Initial Assessment and Management

Committee on Trauma Presents

Abdominal and Pelvic

Trauma

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.

● FAST exam with Ultrasound

● Describe the acute management of abdominal and pelvic injuries.

External Anatomy of Abdomen

Abdominal Injury

When should you suspect abdominal injury?

Abdominal Injury

Blunt

●Speed

●Point of impact

●Intrusion

●Safety devices

●Position

●Ejection

When should you suspect abdominal injury? Penetrating

●Weapon

●Distance

●Number and location of wounds

Can you tell me

• What are the top 3 most commonly injured organs in the abdomen?

Abdominal Injury

●Spleen

●Liver

●Small bowel

Blunt Force MechanismCommonly Injured Organs

Abdominal Injury

●Stab● Low energy, lacerations

●Gunshot● Kinetic energy transfer● Cavitation, tumble● Fragments

Penetrating Mechanism

Any Organ at Risk

Abdominal Injury

How do I determine if there is an abdominal injury?

Abdominal Injury

How do I determine if there is an abdominal injury?

●Inspection

●Auscultation

●Percussion

●Palpation

Assessment: Physical Exam

A missed abdominal injury can cause a preventable death.

Abdominal Injury

Factors that Compromise the Exam

●Alcohol and other drugs

●Injury to brain, spinal cord

●Injury to ribs, spine, pelvis

Caution

Basilar skull / facial fractures

Can induce vomiting / aspiration

Adjuncts

●Relieves distention

●Decompresses stomach before DPL

Caution

Gastric Tube

Adjuncts

●Monitors urinary output

●Decompresses bladder before DPL

●Diagnostic

●If there is blood in meatus, do not place catheter

Caution

Urinary Catheter

Adjuncts

●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)

Blood and Urine Tests

Adjuncts

●Blunt: AP chest and pelvis

●Penetrating: AP chest and abdomen with markers (if hemodynamically normal)

X-ray Studies

Adjuncts

●Abdominal CT

●Urethrogram

●Cystogram

●IVP

●GI studies

Contrast Studies

Don’t delay definitive care!

Caution

Diagnostic Studies

Blunt Trauma

Diagnostic Studies

Penetrating Trauma – Hemodynamically NormalLower 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 triple-contrast CT scan

FAST exam

FAST

• Focused• Assessment using• Sonography for • Trauma

RUQ• 1) RUQ (perihepatic)

view:• Transducer

orientation: In-between pt’s ribs

• Transducer placement: right midaxillary line at level of 9th to 11th intercostal space

• Key Structures: right kidney, liver, diaphragm

• Pathology: fluid in Morison’s pouch, hemothorax

         

 

            

              

Right upper quadrant

• R Kidney

RUQ

Liver

R Kidney

Diaphragm

Morrison’s pouch + fluid

         

 

     

                     

LUQ• LUQ (perisplenic) view:• Transducer orientation:

coronal (indicator towards pt’s head)

• Transducer placement: left posterior axillary line at level of 5th to 8th intercostal space

• Remember “knuckles to the bed” because of posterior location of left kidney

• Key Structures: left kidney, spleen, diaphragm

• Pathology: fluid in splenorenal space or between sleen and diaphragm, hemothorax

       

 

              

            

Left Upper QuadrantLUQ

L Kidney

Spleen

Diaphragm

LUQ +fluid

Pericardial• Subxiphoid view:• Transducer orientation:

indicator towards pt’s right• Transducer placement:

15 degree angle to the chest wall aiming transducer towards the patient’s left shoulder. Key is to lay probe almost parallel to patient

• Key Structures: liver, diaphragm, pericardial space

• Pathology: pericardial effusion

Subxiphoid view

                           

Pericardial Long• 5) Parasternal Long

view:• Transducer placement:

perpendicular to the chest wall at the 3rd or 4th intercostal space immediately left of the sternum with indicator pointing towards pt’s left shoulder

• Key Structures: right ventricle, left ventricle, left atrium, and pericardial space

• Pathology: pericardial effusion

Parasternal Long ViewParasternal Long

LA

RV

LV

Pericardial space

Pelvic views Longitudinal and Transverse

       

 

                       

   

PELVIS• Suprapubic views

(Longitudinal and Transverse):

• Transducer orientation: – longitudinal (indicator

towards pt’s head)– transverse (indicator towards

pt’s right)• Transducer placement: just

above pubic symphysis along midline of abdomen

• Key Structures (males): bladder, retrovesicular space

• Key Structures (females): bladder, uterus, pouch of Douglas

• Pathology: fluid in retrovesicular space or pouch of Douglas

Suprapubic Female (Longitudinal)

Bladder

Pouch of Douglas

Bladder

Suprapubic Male (Transverse)

Retrovesicular space

Longitudinal view +

Transverse +

Explosions

●ABCDE

●Combination mechanism

● Blunt

● Penetrating fragments (multiple)

● BlastConsider 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

●Inspection

● Leg-length discrepancy, external rotation

● Open or closed

●Palpation of pelvic ring, stability

●Rectal / GU / vaginal exam

● Open or closed? Palpate prostate

Assessment of Pelvic Fractures

Pelvic Fractures

How do I manage patients with pelvic fractures?

Pelvic Fractures

●AB, as usual

●C: Control hemorrhage

● Wrap / Binder

● Rule out abdominal hemorrhage

● Angiography, fixation, open surgery

How do I manage patients with pelvic fractures?

Pelvic Fractures

Hemodynamically Abnormal Patients

Surgical consultPelvic wrap Intraperitoneal gross blood?

Yes No

Laparotomy Angiography

Control hemorrhage

Fixation device

● Delayed intervention for abdominal hemorrhage

● Occult intraabdominal / retroperitoneal injuries

● Back and flank wounds

● Repeated manipulation of a fractured pelvis

● Spinal cord injury / altered sensorium

Pitfalls

Pitfalls

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

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?

Thanks to…

• Viam Dinh, MD• http://www.sonoguide.com/FAST.ht

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