Blunt Abdominal Trauma Dr Sean Wilde PGY3 CCFPEM

Blunt Abdominal Trauma Dr. Sean Wilde, PGY-3 (CCFP-EM) Aug 18 2011 Preceptor: Dr. Trevor Langhan

Game Plan • Stepwise approach to BAT – The baseball diamond approach – Adults only • Intra-abdominal & GU trauma • Classification by stability and patient evaluability • Role of FAST • When can you avoid a CT

13% of all injuries are Abdominal Trauma Case mortality is 8% Most deaths are in blunt abdominal trauma Meet the Players…

Motor Vehicle Collisions 50 -75% of BAT

Direct blows to the abdomen 15% (assaults and recreational activities)

Falls from a height 6 -9%

Mechanisms • Abrupt Intraabdominal pressure changes • Compression of abdominal contents • Accelerationdeceleration forces

At Risk • • • Spleen Liver Small bowel Retroperitoneum Kidneys Bladder Colorectal Diaphragm Pancreas

CHALLANGES Often multi-trauma • Altered LOC • Unreliable Physical Exam • Multiple diagnostic tests • Significant miss of intestinal and pancreatic injuries

Develop the BAT reflex Have a simple, step-wise approach to the management of the blunt abdominal trauma victim…

CT ABDO/PELVIS ? Physical YE exam finding S I O s ? +ve FAST N s re ta ? Gross hematuria lia b bl le ? Micro hematuria y pa ev ti w rapid decel injury al en ? peritonitis ua t ? Other CTable injury bl e? O N Consider: ~mech of injury ~associated injury ~clinical gestalt normal abnormal CT result CONSULT BAT Observation Serial exams SEND HOME ? peritonitis ? +ve FAST ? Hematuria d, ion i u Fl fus s n tra le TO THE O. R. ab STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST Beware: hollow viscous, diaphragm, pacreatic inj. (CT poor) UNSTABLE PATIENT ? Unclear exam ? –ve FAST St Consider retrograde urethrogram/ cystogram CT ABDO/PELVIS ? YES STABLE, EVALUABLE PATIENT Y N ARRESTING? ~Consider other sources of blood loss (pelvis, retro. P) ~Consider DPA/DPL

ABC’s in BAT • ABC / OIL • Prioritize the injuries – Airway > Chest > Abdomen > Head > GU • Don’t forget the Abdomen in multi-trauma! • Feel the Belly! – More than once • FAST scan is part of primary survey – Do it BEFORE the log roll.

The Baseball Diamond Approach to BAT 1. Stability • Arresting, unstable or stable? 2. OR Red flags • • In the unstable vs stable patient Initial resuscitation 3. To CT or not to CT • • • Is the patient evaluable? What findings mandate/avoid a CT? When is DPL useful? 4. Reassuring findings • going for home

Case 1 • • • 40 yo male, MVC Restrained driver Passenger fatality Unconscious at scene Cardiac arrest pulling into ambulance bay after 2 litres NS • Diffuse chest and abdominal bruising with distended abdomen • No major open injuries • CPR in progress, asystole on monitor

I would: A) Crack the chest for open cardiac massage B) ATLS/ACLS and 2 fridges of blood C) ED Laparotomy D) Do nothing (“He’s dead Jim”) E)

Plan: Mortality after BAT arrest is dismal; worse than penetrating or chest trauma Doing nothing is a valid option*

However, if you do go there…. 1) Treat emergencies of the chest 2) Open Cardiac resuscitation 3) If you get a pulse: 1) Cross-clamp aorta 2) Straight to OR

Fluid Resuscitation • Colloids – NS, Ringer’s • Blood Early • Massive Transfusion Protocols 6: 6: 1

UNSTABLE PATIENT TO THE O. R. n o si u le ab , tr St Fl d ui sf n a ? BAT Ongoing hemodynamic instability after initial fluid? Stop at 1 st base! Y N ARRESTING? Stable vitals? Head towards 2 nd.

• 29 y F, thrown from bike in motocross accident • GCS 11 -14, fluctuating • Non-ambulatory at scene • Full spinal precautions • HR 135, BP 70/55, O 2 95% on 2 L NP • Cries in pain when transferred to bed • Hurts “everywhere!” • Now what? Case 2

Trauma Survey – – – Chest unremarkable Diffuse mild tenderness to abdomen Pelvis stable but painful FAST –ve Long bones look OK Lots of pain to RLQ/right hip on log roll • Resuscitation – Brief improvement in vitals/GCS with fluid, then rapid decline • Getting more drowsy • Hg 105 on ABG

Unstable BAT patient Fluid/Blood Resuscitation To the OR YES To any Too unstable for CT! ? Peritonitis ? Positive FAST ? Hematuria NO • Exam unclear • FAST negative • Urine bland • Too unstable for imaging Positive Consider DPA/DPL Negative Interventional Radiology Pelvic # Consider other sources of blood loss and shock ? retroperitoneal hematoma

Case cont… • • • FAST is negative No peritonitis Microscopic hematuria after catheter Non displaced pelvic fracture on x-ray But the belly seems more tender than earlier…

FAST Facts • Poor sensitivity – 200 cc fluid for positive scan – Cannot use a negative scan alone to rule out need for surgery • Good specificity – For free abdominal fluid – Blood vs Urine

DPL? 1. Unstable, multi-injured patient with questionable abdominal source 2. Replace serial abdominal exam in head injured patient 3. Post normal CT with ongoing high suspicion of the abdomen 4. Remote area where CT unavailable- i. e. O. R. before transport?

TO THE O. R. ? peritonitis ? +ve FAST ? Hematuria on i us f s n ra t , id ab St ? BAT ? Unclear exam ? –ve FAST le u Fl UNSTABLE PATIENT Y N ARRESTING? ~Consider other sources of blood loss (pelvis, retro. P) ~Consider DPA/DPL

Rounding 1 st base STABLE, EVALUABLE PATIENT • Hemodynamically stable BAT patient • ASK: Can I reliably evaluate this patient? • YES = arrive at base! ab BAT St • NO = go to CT d, ion i u Fl fus s n tra le re sta lia b bl le y pa ev ti al en ua t bl e? GCS Head injury Intoxication Distracting injury Drugs 2 nd NO Is ? – – – YE S CT ABDO/PELVIS

Case 3 • 45 y M kicked in the stomach 7 hours ago • Ongoing discomfort • Vitals normal and stable • Generalized abdo pain on palpation – No peritonitis – No guarding – No visible bruising • Urine clean • Next?

FAST To CT Scan- Lacerated Spleen

CAT Scan in BAT Very good sensitivity and specificity Normal CT scan be considered very reassuring Critical management decisions

Oral Contrast? • Does not increase detection of HVI • Impractical/Risky (NG feeds on spine board) • Local trauma surgeons rarely use it • Negative CT- Consider missed: – GI (hollow viscous) injuries – Diaphragmatic injuries – Pancreatic injuries • Serial exams and CT Scans as indicated will catch most.

Stable BAT patient with reliable exam Surgery (+/- CT) Abdo CT Scan Diffuse Peritonitis Any +ve Physical Exam Finding OR Positive FAST OR Gross hematuria OR Deceleration injury with Microscopic hematuria OR Any other injury requiring CT Consider retrograde urethrogram * Physical exam * FAST * Check Urine * Consider mechanism Normal physical exam Negative FAST Normal urine Low risk Mech of injury Observation vs Discharge

Abdominal seatbelt sign: IA injury rate 23% with, 3% without

Vertebral (Chance) #, mesenteric tears

BAT Physical Exam +ves • Abdominal Seatbelt sign • Pain with guarding • Any peritoneal findings • Remember value of repeat exams!!!

CT ABDO/PELVIS YES Consider retrograde urethrogram/ cystogram STABLE, EVALUABLE PATIENT ? Physical exam finding ? +ve FAST ? Gross hematuria ? Micro hematuria w rapid decel injury ? Other CTable injury O N STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST • Rounding 2 nd base to 3 rd • Avoiding a CT so far… • What’s between you and home plate?

Case 3 the remix… • As before, kicked in stomach, ongoing pain. • Vitals stable • This time all investigations negative, including FAST • What now?

3 rd Base to Home Plate • Consider mechanism, clinical gestalt • Not worried? – D/C with FU • Worried? STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST – Can still CT Consider: ~mech of injury ~associated injury ~clinical gestalt CONSULT Observation Serial exams SEND HOME – Or Observation: serial abdominal exams, FAST, blood work – Second opinion

Holmes, 2009. Low risk Clin Pred Rules in BAT If none of: • GCS <14 • Abdominal/costal margin tenderness • Hematuria • Hematocrit < 30% • Femur fracture • CHXR trauma findings Negative predictive value of 99% for intraabdominal injury

The Bare Minimum… Serial abdominal exams (at least 2) Negative FAST Clean Urine

Case 4 • 29 y M fell 12 ft off “scissor lift. ” • Landed on his bottom • Stable, alert, c/o sore buttocks • Head/spines cleared • Abdomen non-tender • FAST negative • Urine dips 3+ blood

GU Trauma • Blood at meatus • High riding/boggy prostate • Unable to void • Hematuria (esp gross)

Retrograde Urethrogram in suspected GU trauma (Pre-catheter) Post cath: Follow-up CT and Cystogram (Upper GU Trauma)

CT ABDO/PELVIS ? Physical YE exam finding S I O s ? +ve FAST N s re ta ? Gross hematuria lia b bl le ? Micro hematuria y pa ev ti w rapid decel injury al en ? peritonitis ua t ? Other CTable injury bl e? O N Consider: ~mech of injury ~associated injury ~clinical gestalt normal abnormal CT result CONSULT BAT Observation Serial exams SEND HOME ? peritonitis ? +ve FAST ? Hematuria d, ion i u Fl fus s n tra le TO THE O. R. ab STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST Beware: hollow viscous, diaphragm, pacreatic inj. (CT poor) UNSTABLE PATIENT ? Unclear exam ? –ve FAST St Consider retrograde urethrogram/ cystogram CT ABDO/PELVIS ? YES STABLE, EVALUABLE PATIENT Y N ARRESTING? ~Consider other sources of blood loss (pelvis, retro. P) ~Consider DPA/DPL