1/24/2008

Multiple Choice:
You are driving along Roxas Blvd when you chanced on a
Primary Survey and Initial vehicular accident. You would ...
A. Drive away as quickly as you can
Resuscitation
B. Slow down; assess situation; decide there are
Abdominal Trauma enough on-lookers providing help; leave

C. Stop some distance away; call nearest

Renato R. Montenegro, MD, FPSGS
Assistant Professor
UST Faculty of Medicine & Surgery
hospital / police station to report accident; leave
D. Make a dramatic entrance: step on breaks instantly
so everybody sees / hears / smells your burning tires;
push everyone aside, announce you are a UST Medical
senior and that henceforth you are in charged !

Objectives
• For the student to learn that there is a systematic
way of managing trauma
• …to realize that there is no single protocol
applicable to all situations and conditions
• …to be familiar with a protocol in the
management of trauma
• …that as medical students (or paramedics or
laymen), knowledge of the basics in trauma can
spell a significant difference
Trauma
• leading cause of morbidity and mortality under age 45
• 3rd highest cause of death in all ages
• ages 15-24: accidents claim more lives than all other
causes combined
• 150,000 Americans die each year > # of deaths in
Vietnam; (VA=50%)
• Trauma death rate: 50 / 100,000
• Mortality rates are poor indicators of the problem

TRAUMA: with a clearly identified beginning which if not Historical Notes

rapidly and properly managed may lead to death of the
victim
1945 Atomic bomb dropped at Hiroshima
1965 Diagnostic Peritoneal Lavage (Root, et al)
TRAUMATIC
EVENT 1967 National Academy of Science milestone
report – “Trauma: The neglected disease
of Modern Society”
1970 Triage, Resuscitation, Fluids, ARDS
1971 Ultrasound
GOLDEN 1972 CT Scan
PRODUCTIVE
MEMBER OF SOCIETY 1998 Focused Abd. Sonography for Trauma (FAST)
HOUR RECOVERY
Diagnostic Laparoscopy for Trauma
MORBIDITY 2001 911
MORTALITY

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 150,000 trauma deaths per

year
 50% from vehicular accidents
 Blunt abdominal trauma
accounts for majority of
deaths
Almost 2,000 people are killed and
 vehicular accidents account
another 50,000 injured every year in
for majority of blunt hepatic motorcycle accidents in the United
trauma States.

Trauma

TRAUMA : The Neglected Disease TRAUMA: Emergency Management

Basic Assumptions:
of Modern Society
1. Patient may have more than 1 injury
2. The obvious injury is not necessarily
the most important
Identify Categories of Injury
Initial Resuscitation - The ABC’s

The American Academy of Medicine

Categories of Injury – Identifying Priorities Treatment of Trauma Patients

1. Exigent - most life-threatening - instantaneous intervention  Primary Survey (ABC)

e.g. laryngeal fracture, tension pneumothorax  Resuscitation
2. Emergency - immediate intervention within first hour  Secondary Survey
e.g. ongoing hemorrhage, intracranial injuries
 Diagnostic Evaluation
3. Urgent - intervention within first few hours
 Definitive Care
e.g.- open fractures, ischemic extremity, hollow
viscus injury
4. Deferrable - may or may not be immediately apparent but
will require tx. - e.g. facial fractures, urethral injury

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Airway Management
The ABCs of Resuscitation
 Assess mental status / verbal output
A - Airway  Inspect oropharyngeal cavity
B - Breathing  Methods for establishing airway
C - Circulation  Problems: altered MS, foreign body, neck injuries,
D - Disability / Neurologic Assessment maxillofacial trauma, edema to air passages
E - Exposure for Complete Examination

Breathing Thoracostomy
 Oxygenation and ventilation
 Problems: tension / open • Needle thoracentesis
pneumothorax, flail chest, • Closed Tube
pulmonary contusion thoracostomy
 Diagnosis: clinical, chest x-
• Water-sealed
ray
drainage bottle

Circulation Cardiac Tamponade

 Assumption: hypotension is caused by  Index of suspicion: unexplained hypotension
bleeding  Diagnosis: increased venous pressure,
 Assess pulses: decreased pulse pressure, decreased heart sounds
Radial = 80 mmHg  Dx procedures: Pericardiocentesis, Chest x-ray,
Femoral = 70 mmHg
FAST, 2-D ECHO
Carotid = 60 mmHG  Pitfall in dx: waiting for a complete diagnostic triad
 Vital Signs: BP, PR, RR  Treatment : Pericardiocentesis, Pericardiostomy
 Methods to control hemorrhage
 Hypovolemic shock vs Cardiogenic shock

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FAST for Cardiac Tamponade Pericardiocentesis

Abdominal Trauma: Mechanism and

Resuscitation Pattern of Injury
 Establish airway / oxygenate patient
BLUNT PENETRATING
 Insert large-bore IV lines
 Energy transfer to a wide  Injury localized to path of
 Draw blood for typing and cross-matching; area SW or GSW
consider universal donor transfusion  Vehicular accident, steering  Easy to diagnose
 Volume resuscitation with crystalloid solution wheel injury, fall,  Better outcome
 Definitive treatment for non-responders  More delays in dx
 Diagnostic work-up for responders  Higher mortality rates

STAB Local wound

Range of P.E. Findings in Abdominal Trauma Indications for
WOUND exploration
immediate surgery
-Unstable VS
I. BLUNT ABDOMINAL INJURY
-evisceration
-Peritomitis
Normal P.E. Unstable patients Positive Negative
Equivocal P.E.
/obvious indications - signs of bleed LWE LWE
for surgery

Observe/
II. PENETRATING ABDOMINAL INJURY Diagnostic
discharge
To OR for surgery peritoneal
pt
lavage (DPL)

Equivocal P.E. Unstable patients

/obvious indications
for surgery
+ DPL - DPL

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Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage

 (Root et al, 1965) The first serious departure from

mandatory laparotomy for suspected blunt  Abdominal paracentesis
abdominal injury  Peritoneal catheter
 Fast, very sensitive (97-98%)  Infuse lavage fluid (NSS/LRS)
 Specialized training not required  Drain after 20-30 minutes
 May be done in a variety of locations  Analysis of effluent fluid
 Results are quantitative, objective, operator  Positive results are indications for
independent explore laparotomy

Diagnostic Peritoneal Lavage

Positive (DPL)

•Aspiration of 10 ml free blood INDICATIONS: NOT RECOMMENDED:

 closed head injury / altered  previous abdomial surgery
•Effluent drains in NGT, Chest
consciousness / SC injuries  presence if dilated bowels
tube, Foley catheter
 equivocal abdominal  Pregnancy
•RBC > 100,000/cu ml findings  SW , back
•Bile, bacteria, vegetable  GSW
fibers, fecal material detected
•Amylase, alkaline
phosphatase detected

Blunt Abdominal Trauma Diagnosis of B.A.T.

 Trauma remains the leading cause of death in 1 – 44
year old age group 1. Physical Exam
 Most deaths caused by blunt injury 2. Lab. Studies (serial Hb/Hct)
 VA accounts for most blunt hepatic injury 3. Diagnostic Peritoneal Lavage
 Diagnosis is a challenge and continues to evolve 4. Ultrasound
 Non-therapeutic laparotomy weighed against 5. CT Scan
delayed / missed diagnosis 6. FAST (Focused Abdominal Sonography for Trauma)
 Range of PE findings 7. Diagnostic Laparoscopy

Normal P.E. Equivocal P.E. Unstable patients

/obvious indications
for surgery

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Diagnosis of B.A.T.
Plain radiographs
Physical Exam
 Abdomen x-ray: unreliable due to uniform fluid
 Most useful in primary survey to identify life- density of abdomen
threatening injuries and to set priorities  Chest x-ray mandatory
 Useful in secondary survey to identify patients
with E/N physical exam who may not require any Lab Studies
work-up  Serial Hb/Hct – useful monitor of hemorrhage
 In equivocal cases: wide variabilty in sensitivity over a period of time
 50-60 % sensitive rapid hemorrhage - false negative
crystalloid hemodilution - false positive
 Arterial Base Deficit
- index of metabolic acidosis in setting of
hemorrhage

Chest x-ray Traumatic Diaphragmatic Hernia

 Mandatory procedure
 May show
pneumoperitoneum

Diagnosis of Blunt Abdominal Trauma DPL: disadvantages

 Physical exam lacks sensitivity
 Invasive (<1% complication rate)
 Not all patients with BAT require studies
 Not very specific
 All patients with abdominal SW require some
 May miss retroperitoneal, diaphragm injuries
type of objective evaluation
 Highly sensitive
 Utilize studies to arrive at dx early at the same
time minimize non-tx laparotomy increases incidence of non-therapeutic laparotomy
NON-THERAPEUTIC ADJUST CELL COUNT THRESHOLD
LAPAROTOMY

MISSED / DELAYED
DIAGNOSIS

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DPL Abdominal CT Scan

 Recommended cell count threshold = 100,000 cells/cu
mm  Very specific (95-100%)
 Institutions / practitioners must evaluate their own  Good sensitivity (85-99%)
tolerance for and consequences of delayed diagnosis  Can evaluate the
vs. non therapeutic laparotomy retroperitoneum
 Indications have diminished with use of CT and FAST  Allows staging of blunt
 Still useful in intra-op evaluation of trauma patient organ injuries
undergoing emergency surgery at a site remote from  Most major injuries are
the abdomen (eg. Craniotomy) operator (reader)
independent
 Dx modality of choice for
hemodynamically stable
patients with suspected
blunt abdominal injury

CT scan: BAT CT scan: BAT

 Computed tomography
demonstrating a focal
 Computed tomography splenic laceration involving
scan identifying an the posterior aspect of the
intraparenchymal liver spleen
hematoma with overlying
 Small amounts of blood
rib fracture
associated with solid organ
injury is not an independent
indication for exploration

Focused Abdominal Sonography for Trauma

Abdomen CT Scan: disadvantages
(FAST)
 Requires time and patient
transport  Diagnostic procedure of
choice in the unstable
 Has some degree of
patient
operator dependence
 Fast, simple, portable,
 May miss blunt intestinal
readily available
injuries
 Short learning curve
 Positive finding: fluid
(blood) in peritoneal cavity

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Blunt Abdominal Injury

 22 y/o, male fell off his
motorcycle (?20 mph)
 Ambulatory, in pain,
BP=90/min, PR=120
 Hematoma in mid abdomen
 Diagnostic procedure ?