Committee on Trauma Presents

Abdominal and Pelvic Trauma

Initial Assessment and Management

Case Scenario
35-year-old male passenger in high-speed motor vehicle collision BP: 105/80; Pulse: 110; RR: 18 GCS score: 15 Complaining of pain in chest, abdomen, and pelvis

What injuries do you suspect and how would you manage this patient?

Objectives
Identify key anatomical features of the abdomen.
Recognize patients at risk for abdominal and pelvic injuries based on the mechanism of injury. Describe the evaluation of patients with suspected abdominal and pelvic injuries. Describe the acute management of abdominal and pelvic injuries.

External Anatomy of Abdomen

Abdominal Injury
When should you suspect abdominal injury?

Abdominal Injury
When should you suspect abdominal injury? Blunt
Speed Point of impact

Penetrating
Weapon Distance

Intrusion
Safety devices Position

Number and location of wounds

Ejection

Abdominal Injury
Blunt Force Mechanism
Commonly Injured Organs Spleen Liver Small bowel

Abdominal Injury
Penetrating Mechanism
Any Organ at Risk

Stab
Low energy, lacerations

Gunshot
Kinetic energy transfer Cavitation, tumble Fragments

Abdominal Injury
How do I determine if there is an abdominal injury?

Abdominal Injury
How do I determine if there is an abdominal injury? Assessment: Physical Exam Inspection Auscultation Percussion Palpation

Abdominal Injury
Factors that Compromise the Exam Alcohol and other drugs
Injury to brain, spinal cord Injury to ribs, spine, pelvis
Caution

A missed abdominal injury can cause a preventable death.

Adjuncts
Gastric Tube
Relieves distention Decompresses stomach before DPL

Caution

Basilar skull / facial fractures

Can induce vomiting / aspiration

Adjuncts
Urinary Catheter
Monitors urinary output Decompresses bladder before DPL Diagnostic
Caution

Adjuncts
Blood and Urine Tests
No mandatory blood tests before urgent laparotomy

Hemodynamically abnormal: type and crossmatch, coagulation studies

Pregnancy testing Alcohol or other drug testing Hematuria (gross versus microscopic)

Adjuncts
X-ray Studies Blunt: AP chest and pelvis
Penetrating: AP chest and abdomen with markers (if hemodynamically normal)

Adjuncts
Contrast Studies Abdominal CT
Urethrogram Cystogram

IVP
GI studies
Caution

Dont delay definitive care!

Diagnostic Studies
Blunt Trauma

Diagnostic Studies
Penetrating Trauma Hemodynamically Normal Lower chest wounds Serial exams, thoracoscopy, laparoscopy, or CT scan Anterior abdominal stab wounds Wound exploration, DPL, or serial exams

Back and flank stab wounds DPL, serial exams, or double- or triplecontrast CT scan

Explosions
ABCDE
Combination mechanism
Blunt

Penetrating fragments (multiple)

Blast
Consider proximity, enclosed space, multiple fragments and secondary impacts (thrown or fall from height).

Laparotomy
Who requires a laparotomy?

Laparotomy
Who requires a laparotomy?

Laparotomy
Indications for Laparotomy Blunt Trauma

Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)

Free air Diaphragmatic rupture Peritonitis Positive CT

Laparotomy
Indications for Laparotomy Penetrating Trauma

Hemodynamically abnormal
Peritonitis Evisceration

Positive DPL, FAST, or CT

Early operation is usually the best strategy for GSW

Pelvic Fractures
Significant force
Associated injuries Pelvic bleeding
Venous / arterial

Pelvic Fractures
Assessment of Pelvic Fractures

Inspection
Leg-length discrepancy, external rotation

Open or closed

Palpation of pelvic ring, stability

Rectal / GU / vaginal exam
Open or closed? Palpate prostate

Pelvic Fractures
How do I manage patients with pelvic fractures?

Pelvic Fractures
How do I manage patients with pelvic fractures? AB, as usual C: Control hemorrhage

Wrap / Binder Rule out abdominal hemorrhage Angiography, fixation, open surgery

Pelvic Fractures
Hemodynamically Abnormal Patients

Surgical consult Pelvic wrap Intraperitoneal gross blood?

Yes Laparotomy No Angiography

Control hemorrhage Fixation device

Pitfalls
Pitfalls

Delayed intervention for abdominal hemorrhage Occult intraabdominal / retroperitoneal injuries Back and flank wounds Repeated manipulation of a fractured pelvis

Spinal cord injury / altered sensorium

Summary
ABCDEs and early surgical consultation Evaluation and management vary with mechanism and physiologic response Repeated exams and diagnostic studies

High index of suspicion

Early recognition / prompt laparotomy