Abdominal Abdominal TraumaTrauma

Nestor Nestor, M.D., M.Sc.Nestor Nestor, M.D., M.Sc.

January 17, 2007January 17, 2007

The PlanThe Plan

Abdominal AnatomyAbdominal Anatomy Mechanisms of Mechanisms of

InjuryInjury Common PathologyCommon Pathology EvaluationEvaluation ManagementManagement

Part 1:Part 1:Abdominal Abdominal AnatomyAnatomy

Abdominal Anatomy Abdominal Anatomy BasicsBasics

ABC’sABC’s Many organs receiving substantial Many organs receiving substantial

blood flowblood flow Potential spaces that can hide Potential spaces that can hide

hemorrhagehemorrhage Hollow organ damageHollow organ damage > Peritonitis> Peritonitis

Abdominal Anatomy Abdominal Anatomy BasicsBasics

ABC’sABC’s Many organs receiving substantial Many organs receiving substantial

blood flowblood flow Potential spaces that can hide Potential spaces that can hide

hemorrhagehemorrhage Hollow organ damageHollow organ damage > Peritonitis> Peritonitis

Abdominal Anatomy Abdominal Anatomy BasicsBasics

ABC’sABC’s Many organs receiving substantial Many organs receiving substantial

blood flowblood flow Potential spaces that can hide Potential spaces that can hide

hemorrhagehemorrhage Hollow organ damage > PeritonitisHollow organ damage > Peritonitis

Abdominal Anatomy Abdominal Anatomy BasicsBasics

ABC’sABC’s Many organs receiving substantial Many organs receiving substantial

blood flowblood flow Potential spaces that can hide Potential spaces that can hide

hemorrhagehemorrhage Hollow organ damage > PeritonitisHollow organ damage > Peritonitis

Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants

Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants

Abdominal AnatomyAbdominal Anatomy

Abdominal AnatomyAbdominal Anatomy

Abdominal AnatomyAbdominal Anatomy

Abdominal AnatomyAbdominal Anatomy

Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants

Alternative DivisionsAlternative Divisions

Intraperitoneal Intraperitoneal StructuresStructures

Retroperitoneal Retroperitoneal StructuresStructures

Upper Abdomen CTUpper Abdomen CT

Lower Abdomen CTLower Abdomen CT

Retroperitoneal Retroperitoneal

Part 2:Part 2:Mechanisms andMechanisms and

PathologyPathology

Abdominal InjuriesAbdominal Injuries

Blunt vs. PenetratingBlunt vs. Penetrating

Often both occur simultaneouslyOften both occur simultaneously

Blunt is the most common Blunt is the most common mechanism in USmechanism in US

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Liver LacerationsLiver Lacerations

I. I. Subcapsular Hematoma <10% Subcapsular Hematoma <10% Surface AreaSurface Area

II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50%

III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50%

IV. Parenchymal Disruption of 25-75%IV. Parenchymal Disruption of 25-75%

V. Parenchymal Disruption of >75%V. Parenchymal Disruption of >75%

VI. Liver AvulsionVI. Liver Avulsion

Splenic LacerationsSplenic Lacerations

I. I. Subcapsular Hematoma <10% Subcapsular Hematoma <10% Surface AreaSurface Area

II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50%

III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50%

IV. Laceration producing IV. Laceration producing devascularization of devascularization of >25% of >25% of the spleenthe spleen

V. Shattered SpleenV. Shattered Spleen

Evaluation: Evaluation: Be SuspiciousBe Suspicious

MechanismMechanism VitalsVitals SymptomsSymptoms Associated InjuriesAssociated Injuries Elderly or co-morbiditiesElderly or co-morbidities Distracting injuriesDistracting injuries Decreased MS/intoxicationDecreased MS/intoxication

Techniques for Techniques for EvaluationEvaluation

Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and

reliable ptreliable pt

Plain FilmsPlain Films Abd films little or no use, pelvic are the Abd films little or no use, pelvic are the

standardstandard

ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound:Ultrasound: FAST (serial exams)FAST (serial exams)

Techniques for Techniques for EvaluationEvaluation

Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and

reliable ptreliable pt

Plain FilmsPlain Films Abd films little or no use, pelvis are the Abd films little or no use, pelvis are the

standardstandard

ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound:Ultrasound: FAST (serial exams)FAST (serial exams)

Techniques for Techniques for EvaluationEvaluation

Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and

reliable ptreliable pt

Plain FilmsPlain Films Abd films little or no use, pelvis are the Abd films little or no use, pelvis are the

standardstandard

ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams)Ultrasound: FAST (serial exams)

FAST: RUQFAST: RUQ

FAST: RUQFAST: RUQ

FAST: RUQFAST: RUQ

Techniques for Techniques for EvaluationEvaluation

Organ Specific DxOrgan Specific Dx Only CT Only CT Also evaluates retroperitoneumAlso evaluates retroperitoneum ExpensiveExpensive RadiationRadiationEx LapEx Lap Laparotomy gold standard for evaluation Laparotomy gold standard for evaluation Concomitant treatmentConcomitant treatment Retroperitoneum difficult to Retroperitoneum difficult to

explore/assessexplore/assess

Techniques for Techniques for EvaluationEvaluation

Organ Specific DxOrgan Specific Dx Only CT Only CT Also evaluates retroperitoneumAlso evaluates retroperitoneum ExpensiveExpensive RadiationRadiationEx LapEx Lap Laparotomy is the gold standard for Laparotomy is the gold standard for

evaluation evaluation Concomitant treatmentConcomitant treatment Retroperitoneum difficult to Retroperitoneum difficult to

explore/assessexplore/assess

Penetrating Trauma Penetrating Trauma EvaluationEvaluation

Mandatory exploration abandonedMandatory exploration abandoned No digital exploration or contrast No digital exploration or contrast

studiesstudies Inspect wound to determine if there Inspect wound to determine if there

is violation of the fasciais violation of the fascia Difficult to assess stab wound Difficult to assess stab wound

trajectorytrajectory Determine if gunshot traversed the Determine if gunshot traversed the

peritoneal cavityperitoneal cavity

ManagementManagement

ABC’sABC’s Fluid resuscitateFluid resuscitate To lap or not to lap?To lap or not to lap? Unstable (with no other reason)Unstable (with no other reason) Free air/peritonitis (antibiotics)Free air/peritonitis (antibiotics) Unexplained free fluidUnexplained free fluid Many splenic/liver lacs managed Many splenic/liver lacs managed

non-operatively or by VIRnon-operatively or by VIR

Penetrating Flank and Penetrating Flank and Buttock InjuriesButtock Injuries

Potential for peritoneal Potential for peritoneal and/or retroperitoneal and/or retroperitoneal injuryinjury

Similar evaluation and Similar evaluation and management to management to abdominalabdominal

Buttock injuries may also Buttock injuries may also reach peritoneal and/or reach peritoneal and/or retroperitonal structuresretroperitonal structures

Genitourinary Genitourinary TraumaTrauma

GU TraumaGU Trauma

2-5% of adult traumas2-5% of adult traumas Vast majority blunt mechanismsVast majority blunt mechanisms 80% renal injuries80% renal injuries 10% bladder injuries10% bladder injuries Abnormalities (tumor, hydro) Abnormalities (tumor, hydro)

increase susceptibility increase susceptibility Rarely require immediate Rarely require immediate

interventionintervention

EvaluationEvaluation

Rectal - high riding prostateRectal - high riding prostate Perineum - ecchymosis, lacsPerineum - ecchymosis, lacs Genitals - meatal/vaginal bloodGenitals - meatal/vaginal blood Difficult catheter placement (may Difficult catheter placement (may

need suprapubic)need suprapubic) UA – hematuria (poor correlation to UA – hematuria (poor correlation to

degree of injury)degree of injury)

EvaluationEvaluation

U/S and Plain films of little useU/S and Plain films of little use CT is the superior imaging modalityCT is the superior imaging modality Careful with contrast (nephropathy)Careful with contrast (nephropathy) Angiography remains the gold Angiography remains the gold

standard standard IVP/Cystoscopy less useful in the EDIVP/Cystoscopy less useful in the ED

GU Injuries: The KidneysGU Injuries: The Kidneys

Kidneys are well protectedKidneys are well protected Most commonly bruisedMost commonly bruised Pts with a shattered kidney become Pts with a shattered kidney become

rapidly unstablerapidly unstable Renal vascular injuries may result in Renal vascular injuries may result in

thrombosed vesselsthrombosed vessels

GU Injuries: The KidneysGU Injuries: The Kidneys

Operative management for:Operative management for: uncontrolled hemorrhageuncontrolled hemorrhage Penetrating injuriesPenetrating injuries Multiple lacsMultiple lacs Shattered kidneyShattered kidney Avulsed vesselsAvulsed vessels

GU Injuries: The BladderGU Injuries: The Bladder

ContusionContusion Rupture: Intra vs. ExtraperitonealRupture: Intra vs. Extraperitoneal Extraperitoneal presents with pain, Extraperitoneal presents with pain,

hematuria and inability to voidhematuria and inability to void Urethral injuries: Anterior vs. Urethral injuries: Anterior vs.

posteriorposterior No Foley for urethral injuriesNo Foley for urethral injuries

Retroperitoneal Retroperitoneal StructuresStructures

In Summary...In Summary...

Basic knowledge of anatomy Basic knowledge of anatomy necessary for initial assessment of necessary for initial assessment of abdominal traumaabdominal trauma

Peritoneal vs. RetroperitonealPeritoneal vs. Retroperitoneal Blunt vs. PenetratingBlunt vs. Penetrating Don’t miss GU injuriesDon’t miss GU injuries

Thank YouThank You