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MEDICAL MANAGEMENT OF ABDOMINAL TRAUMA
LUIS H. TELLO MV, MS, DVM, COS Portland Hospital “Classic”
International Medical Advisor Banfield Pet Hospital
ABDOMINAL TRAUMA
• 70-80% of multiple trauma patients
• 55% of motor vehicle accidents
• Undiagnosed in human trauma patients
• 40% of them are asymptomatic
• The most frequent are • BLUNT TRAUMA
• PENETRATING TRAUMA
ABDOMINAL TRAUMA • PHYSIOPATHOLOGY
– Combining forces :
• Compression
• Extension
• Separation
– Kinetic energy is transferred to abdominal organs
– The transmitted energy overcomes organ resistance
ABDOMINAL TRAUMA
• PHYSIOPATHOLOGY – The energy dissipated in the abdomen is:
KE= MV2 2
KE: Kinetic Energy M : Mass V : Velocity
ABDOMINAL TRAUMA • ASSOCIATED CLINICAL SIGNS:
– Abdomen Haematoma
– Perineal Haematoma (Retroperitoneal)
– Abdominal tenderness (Pain)
– Hemodynamic instability (Hemorrhage)
– Pelvic fractures - Caudal ribs
– Lumbar spine injuries
– Abdominal distention
ABDOMINAL TRAUMA
• ABDOMINAL
DISTENTION:
– Sensitive parameter in
humans
– Associated to pain
– No informatio1n in
Veterinary Medicine
– Each inch of increment in
abdominal perimeter:
500cc of free
intraabdominal blood
Hemoabdomen: Epidemiology • Incidence 11 %
• 71 % are closed trauma cases,
• 29% open or penetrating
• 20 % of patients that are moved to Sx have lesions NO DETECTED PREVIOUSLY
• Humans: 40% is asymptomatic
Cats may have spontaneous hemoabdomen!
• JVECCS 2010, Drobatz, et al • Sixteen cases of feline, non-traumatic hemoperitoneum were
evaluated retrospectively.
• The causes of hemoperitoneum were hepatic neoplasia (31%), hepatic necrosis (19%), hepatic amyloidosis (13%), non hepatic neoplasia (13%), hepatopathy (6%), hepatic rupture (6%), necrotic/hemorrhagic cystitis (6%), and ruptured bladder (6%).
Penetranting Trauma
• Bullets, arrows, impalement, bites,
• Caudal lesions in the thorax may be abdominal
Closed abdominaltrauma: Approach
• PE is difficult and equivocal
• Key: 5 signs – Temperature
– Pulse
– Respiratory rate
– Blood Pressure
– Pain Score
Goals during initial assessment
Determine:
• There is an intraabdominal lesions
• Require medical or surgical Tx
• Find out signs of the TRIADE of DEATH – ACIDOSIS
– HYPOTHERMIA
– COAGULOPATHY
ABDOMINAL TRAUMA
• DIAGNOSTIC
PROCEDURES:
– ABDOMINOCENTESIS
– PERITONEAL LAVAGE
– ABDOMINAL
ECOTOMOGRAPHY
– ABDOMINAL
RADIOGRAPHY
– C.A.T. SCAN
ABDOMINAL TRAUMA
• ABDOMINOCENTESIS:
– 20-22G Needle or Butterfly
catheter+syringe
– Medium line caudal to umbilical scar
– Get inside, infusing saline 0,9%
– Negative: 4 quadrants puncture
– Negative: peritoneal lavage
ABDOMINAL TRAUMA
• PERITONEAL LAVAGE:
– 20 - 22 G needle or butterfly catheter
– Central medium caudal to umbilical scar
– Infuse 20 ml/Kg warm saline NaCl 0,9%
– Rotate or walk the patient
– Obtain a few ml for evaluation
ABDOMINAL TRAUMA
• PERITONEAL LAVAGE : evaluation
– PCV
– PROTEINS
– CITOLOGY
– BUN - CREATININ
– BILIRRUBIN
– “BOYSCOUT” TEST
ABDOMINAL TRAUMA
• BOY SCOUT TEST:
– PUT A DROP OF PERITONEAL LAVAGE
FLUID ON A MICROSCOPE SLIDE
– HEAT TO DIRECT FLAME
– AMMONIA RELEASE? URINE !!
– SCOUTS PUT OUT FIRES WITH URINE
ABDOMINAL TRAUMA
• POSITIVE LAVAGE:
HEMOPERITONEUM
– PCV > than peripherical
– Spleen has a higher PCV
than blood
– The peritoneum absorbs
water and electrolytes
– More than 100.000
erythrocytes/ml
– More than 500 leukocytes/ml
– Can it be read through the
tube??
Lab Data Base
• Hct y Hb
• Glycemia
• Creatinine
• Ca - Mg
• CPL
• Proteines
• UA
• Coagulation profile
• Blood gases- electrolytes
Images
• Radiographs
• Limited value: serosal detail, free gas
• Hernias
• Evidence of bone/joint/soft tissue lesions
JAVMA. 2004 Oct 15;225(8):1198-204
Evaluation of focused assement with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents
Boysen S, Rozanski E, Tidwell ,A
• 4 points
Ultrasound: FAST
Tap the abdomen
• Easy, fast, cheap
• High percentage of false negatives
• Should be more than 5 ml/Kg of free fluid
DPL: Diagnostic
Peritoneal Lavage
Negative Tap
Introduce 20ml/kg warm saline
Very sensitive
Collect fluid in tubes: with and without EDTA
Do not use for
Retroperitoneal lesions,
Pregnant
Dilated GI
Gross examination
RED: Hemorrhage
GREEN:Gallbladder – Biliary tract
YELLOW: Urinary tract
BROWN” GI tract
So….cut or not? • The key seems to be on the patient
– No response to Tx
– Worsening hypotension
– Mentation worsening
– Drop on the Hct (20%)
– If you are not sure…..
No Sx Tx of HEMOBANDOMEN)
• FLUID Tx (NO EXCESSIVELY AGGRESSIVE)
• PLASMA – Coagulation factors
• Pain management
• Sedation
• Oxygen
• ICU MONITORING
Post Sx
• Fluids, Atb, Nutrition
• Check Hct, Proteines, Albumine
• Monitor Blood Pressure
• Monitor ECG
• Monitor Urine production
• DO NOT FEEL SAFE BEFORE 72 HOURS POST SX
UROPERITONEUM • Massive rupture is frequent in blunt
trauma with full bladder
• It can be diagnosed with contrasted
X-rays :
• Excretion Nephrogram
• Contrasted Cystogram
• Pneumocystogram
UROPERITONEUM • Massive rupture is frequent in blunt
trauma with full bladder
• It can be diagnosed with contrasted
X-rays :
• Excretion Nephrogram
• Contrasted Cystogram
• Pneumocystogram
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