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Resuscitation
Abdominal Trauma
TRAUMATIC
EVENT
RECOVERY
GOLDEN
PRODUCTIVE MORBIDITY
MEMBER OF SOCIETY
HOUR MORTALITY
0
TIME
Historical Notes
1945 Atomic bomb dropped at Hiroshima
1965 Diagnostic Peritoneal Lavage (Root, et al)
1967 National Academy of Science milestone
report – “Trauma: The neglected disease
of Modern Society”
1970 Triage, Resuscitation, Fluids, ARDS
1971 Ultrasound
1972 CT Scan
1998 Focused Abd. Sonography for Trauma (FAST)
Diagnostic Laparoscopy for Trauma
2001 911
150,000 trauma deaths
per year
50% from vehicular
accidents
Blunt abdominal
trauma accounts for
majority of deaths
vehicular accidents
account for majority of
blunt hepatic trauma
Almost 2,000 people are killed and
another 50,000 injured every year in
motorcycle accidents in the United
States.
TRAUMA : The Neglected Disease
of Modern Society
A - Airway
B - Breathing
C - Circulation
D - Disability / Neurologic Assessment
E - Exposure for Complete Examination
Airway Management
Assess mental status / verbal output
Inspect oropharyngeal cavity
Methods for establishing airway
Problems: altered MS, foreign body, neck injuries,
maxillofacial trauma, edema to air passages
Breathing
Oxygenation and
ventilation
Problems: tension / open
pneumothorax, flail chest,
pulmonary contusion
Diagnosis: clinical, chest
x-ray
Thoracostomy
• Needle thoracentesis
• Closed Tube
thoracostomy
• Water-sealed
drainage bottle
Circulation
Assumption: hypotension is caused by
bleeding
Assess pulses:
Radial = 80 mmHg
Femoral = 70 mmHg
Carotid = 60 mmHG
Vital Signs: BP, PR, RR
Methods to control hemorrhage
Hypovolemic shock vs Cardiogenic shock
Cardiac Tamponade
Index of suspicion: unexplained hypotension
Diagnosis: increased venous pressure,
decreased pulse pressure, decreased heart sounds
Dx procedures: Pericardiocentesis, Chest x-ray,
FAST, 2-D ECHO
Pitfall in dx: waiting for a complete diagnostic
triad
Treatment : Pericardiocentesis, Pericardiostomy
FAST for Cardiac Tamponade
Pericardiocentesis
•Index of suspicion:
unexplained
hypotension
•A temporizing
therapeutic procedure
which may be life-
saving
Resuscitation
Establish airway / oxygenate patient
Insert large-bore IV lines
Draw blood for typing and cross-matching;
consider universal donor transfusion
Volume resuscitation with crystalloid solution
Definitive treatment for non-responders
Diagnostic work-up for responders
Abdominal Trauma: Mechanism and
Pattern of Injury
BLUNT PENETRATING
Energy transfer to a wide Injury localized to path
area
of SW or GSW
Vehicular accident,
steering wheel injury, fall, Easy to diagnose
More delays in dx Better outcome
Higher mortality rates
Range of P.E. Findings in Abdominal Trauma
I. BLUNT ABDOMINAL INJURY
Observe/
Diagnostic
discharge
To OR for surgery peritoneal
pt
lavage (DPL)
+ DPL - DPL
STAB
Indications for
WOUND
immediate surgery
-Unstable VS
-evisceration
-Peritomitis
Negative
- signs of bleed LWE
To OR for surgery
STAB Local wound
WOUND exploration
Positive Negative
LWE LWE
Diagnostic
peritoneal
lavage (DPL)
STAB Local wound
Indications for
WOUND exploration
immediate surgery
-Unstable VS
-evisceration
-Peritomitis
Positive Negative
- signs of bleed LWE LWE
Observe/
Diagnostic
discharge
To OR for surgery peritoneal
pt
lavage (DPL)
+ DPL - DPL
Diagnostic Peritoneal Lavage
(Root et al, 1965) The first serious departure from
mandatory laparotomy for suspected blunt
abdominal injury
Fast, very sensitive (97-98%)
Specialized training not required
May be done in a variety of locations
Results are quantitative, objective, operator
independent
Diagnostic Peritoneal Lavage
Abdominal paracentesis
Peritoneal catheter
Infuse lavage fluid (NSS/LRS)
Drain after 20-30 minutes
Analysis of effluent fluid
Positive results are indications for
explore laparotomy
Positive (DPL)
SW , back
GSW
Blunt Abdominal Trauma
Trauma remains the leading cause of death in 1 – 44
year old age group
Most deaths caused by blunt injury
VA accounts for most blunt hepatic injury
Diagnosis is a challenge and continues to evolve
Non-therapeutic laparotomy weighed against
delayed / missed diagnosis
Range of PE findings
Normal P.E. Equivocal P.E. Unstable patients
/obvious indications
for surgery
Diagnosis of B.A.T.
1. Physical Exam
2. Lab. Studies (serial Hb/Hct)
3. Diagnostic Peritoneal Lavage
4. Ultrasound
5. CT Scan
6. FAST (Focused Abdominal Sonography for
Trauma)
7. Diagnostic Laparoscopy
Diagnosis of B.A.T.
Physical Exam
Most useful in primary survey to identify life-
threatening injuries and to set priorities
Useful in secondary survey to identify patients
with E/N physical exam who may not require any
work-up
In equivocal cases: wide variabilty in sensitivity
50-60 % sensitive
Plain radiographs
Abdomen x-ray: unreliable due to uniform fluid
density of abdomen
Chest x-ray mandatory
Lab Studies
Serial Hb/Hct – useful monitor of hemorrhage
over a period of time
rapid hemorrhage - false negative
crystalloid hemodilution - false positive
Arterial Base Deficit
- index of metabolic acidosis in setting of
hemorrhage
Chest x-ray
Mandatory procedure
May show
pneumoperitoneum
To document problems
in the lungs and pleura
Traumatic Diaphragmatic Hernia
Diagnosis of Blunt Abdominal Trauma
Highly sensitive