The Initial Assessment and Evaluation of Abdominal Trauma

The Initial Assessment and Evaluation of Abdominal Trauma Tanya L. Zakrison Trauma & Acute Care Surgery St. Michael’s Hospital Sept. 20 th, 2011

Objectives • How to recognize the trauma patient with an abdominal injury – Anatomy • How to manage the patient with an abdominal injury in the initial stage • Damage control resuscitation • How to evaluate the abdomen – Different modalities & whole body pan scan • Guidelines – European & EAST

Case 1 - Blunt Abdominal Trauma • 45 F, high-speed MVC • Seat-belt sign, HD normal • How would you approach this patient? • How would that change if the pt. is HD abnormal? • What if the patient also had a pelvic fracture?

Case 2 - Penetrating Abdominal Trauma • 23 M, stab wound to anterior abdomen, HD normal • How would you approach this patient? GSW? • How would that change if the patient is HD abnormal? • What if the patient was stabbed in the flank? The back? The thoracoabdominal area? Cardiac box?

ATLS Approach • A – intubation may be required if hypotensive • B – watch H/PTX in both blunt and penetrating TAA injuries • C – start with 2 L crystalloid, may need to activate MTP – MUST FIND & STOP THE BLEEDING • D – may see associated thoracolumbar #s with BAT • E – watch for SBS, other injuries

What is Hemodynamic Normality? Base deficit lactate

Shock? • • Rapid responder (20%) Transient responder (30%) Non-responder (>30%) Hypotension in the field – ATLS - 2 L warmed crystalloid (3: 1) – Blood products as needed – Tranexamic acid (antifibrinolytic) – Follow urine output

The Lethal Triad of Death

More Complicated Than Anticipated – Acute Coagulopathy of Trauma Shock 25% of trauma patients present coagulopathic

Damage Control Resuscitation • Permissive hypotension • 1: 1: 1 resuscitation (p. RBCs, platelets, FFP) • Damage control surgery – Stop the bleeding (pack) – Control the contamination – Definitive surgical anatomical restoration later

Initial Resuscitation – The Bottom Line? • Identify what is bleeding: – “ 4 & on the floor” 1. Chest 1. CXR 2. Intraperitoneal abdomen 1. FAST 3. Retroperitoneal abdomen 1. PXR, CT scan 4. Extremities – (femur #s) 1. XRs • Then stop it: – – OR Angioembolization Tourniquet Reduction & stabilization • Very little to do in the trauma bay prior to OR if HD abnormal: – Intubate – CXR – Group & screen • If crashing: – Bilateral chest tubes • If dying: – ED thoracotomy • Get to OR ASAP

Initial Management of the Bleeding Patient – European Guidelines; CC 2007 • Recommendation 1: – That time elapsed between injury and operation be minimized for pts. In need of urgent surgical control (grade 1 A) • Recommendation 2: – That a grading system be used to assess the clinical extent of hemorrhage (ACS COT) • Recommendation 3: – pts. presenting in hemorrhagic shock AND an identified source of bleeding undergo an immediate bleeding control procedure UNLESS initial resuscitation measures are successful • Recommendation 4: – pts. with an unidentified source of bleeding in hemorrhagic shock should undergo immediate further assessment • Recommendation 5: – Trauma pts. should be resuscitated initially with crystalloid to a BP of 80 -100 mm. Hg in the absence of TBI

Tanya’s guidelines: Find what is bleeding then stop it

Patient in Extremis = ED Thoracotomy

The Abdomen Thoracoabdominal area Transverse nipple line to costal margin Anterior abdomen Costal margin to groin crease to anterior axillary lines bilaterally Flank area Anterior axillary line to posterior axillary line, costal margin to iliac crests Back Medial to posterior axillary lines, tip of scapula to iliac crests Torso All the above

Cardiac Box Mediastinum Thoracoabdominal area

The Abdomen is More Than Just the Abdomen • Abdomen: – Intraperitoneal cavity • • • Clinical exam FAST DPL CT scan Exploratory laparoscopy Exploratory laparotomy – Retroperitoneal cavity & pelvis • Pelvic xray • CT scan • Exploratory laparotomy • Thorax (thoracoabdominal injuries) – CXR • Heart & Great Vessels (cardiac box injuries) – Cardiac FAST – CXR • Diaphragm & Bladder (innocent bystanders) – Diagnostic laparoscopy – CT cystogram

Blunt Abdominal Trauma

Why investigate? • Unlike penetrating trauma, diagnosis of BAT by clinical exam is unreliable, esp. decreased LOC • Late diagnosis of missed injuries leads to increased mortality rates • Large prospective study- 10% of patients with no clinical signs of injury had injuries found on CT • Consensus guidelines suggest that the threshold for investigation of BAT should be very low – EAST, 2002

Tools Available For Abdominal Trauma • • Physical exam X-Rays Ultrasound (FAST) Computerized Tomography (CT) Magnetic Resonance Imaging (MRI) Diagnostic Laparoscopy Exploratory laparotomy

Tools Available For Abdominal Trauma • Physical exam – bad for blunt, good for penetrating (serial physical exams) • X-Rays • Ultrasound (FAST) – helpful if positive • Computerized Tomography (CT) – not for HVI • Magnetic Resonance Imaging (MRI) • Diagnostic Laparoscopy – for the diaphragm • Exploratory Laparotomy – if needed

What Are We Worried About? • Bleeding: – Liver – Spleen – Kidneys – Mesentery • Bowel: – Contamination • Bladder: – Intraperitoneal rupture • Diaphragm: – Mainly on the left side

How to Investigate Blunt Abdominal Trauma? – BMJ 2008 • Concealed or occult hemorrhage is the 2 nd most common cause of death after trauma • Missed abdominal injuries are a frequent cause of morbidity and mortality • Appropriate and expeditious investigations are important • Non-operative management of solid organ injury now more common

Physical Exam • Neither sensitive nor specific to rule out intraperitoneal hemorrhage (bleeding) • Excellent to watch for the development of peritonitis (contamination) – Less than 24 hours, usually by 13 hours – A modality usually employed in penetrating trauma • Very poor to detect bladder or diaphragmatic injury

Seat Belt Sign – Not Just the Abdomen

Physical Exam Caveat – The Seat Belt Sign • Historically indicative of significant intra-abdominal injury – Especially when accompanied by a Chance fracture (L 2 flexion distraction fracture) (up to 30 -50% pts. ) – Can occur together or in isolation on the neck, chest or abdomen – Indicative of carotid, thoracic or intraabdominal injuries • Hollow viscus injuries • Retroperitoneal injuries (duodenum and pancreas) • Solid organ (tearing of the falciform ligament) – Odds of intraabdominal injury increased 2. 6 x if SBS present on passenger seated in the front seat – Coimbra, 2009

Focused Assessment With Sonography in Trauma (FAST) • Looks for free intra-abdominal fluid (assumed to be blood or gastrointestinal content, may be other) – Also pericardial fluid • Non-invasive, no radiation, repeatable • Highly Sn (79 -100%) and Sp (96 -100%) – Moreso in hemodynamic pts. after BAT – Repeating FAST also increases Sn • May still need other imaging modalities with a negative FAST • Can be performed with equal accuracy by surgeons • Use controversial in penetrating trauma of the abdomen – Only helpful if positive – VERY helpful for detecting intrapericardial blood • UABCDE

FAST

Diagnostic Peritoneal Lavage (DPL) • Described in 1965, standard of care • Open or closed (Seldinger) approach • Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%) – Lead to a non-therapeutic laparotomy rate of 36% • Laparotomy when: – 10 cc gross blood – Enteric contents – 1 L warmed NS: > 100 000 RBC / mm 3 or > 500 WBC / mm 3 • High false positives with pelvic fractures – Do a supraumbilical approach • High Sn for hollow viscus injuries – Moreso than CT • Risk of visceral injury = 0. 6% • Retroperitoneum can’t be assessed

Diagnostic Peritoneal Lavage • In real life: – Good tool if FAST equivocal in the HD abnormal pt. in the setting of a pelvic fracture – FAST unavailable, pt. is HD abnormal

Computerized Tomography • Imaging modality of choice only in HD normal patients – Pts crumping in CT a performance indicator in trauma centres • Sn = 92 -97%, Sp = 99% for bleeding – Active arterial contrast extravasation, blush or pseudoaneyurysm – Even with AKI, or in the elderly • Only modality to directly detect retroperitoneal injury • Less accurate for HVI – Still need serial physical exams – If pelvic fluid is present in absence of solid organ injury – exploratory laparotomy is mandated, especially if moderate or large amounts of free fluid – Chen, 2009 – 3% males may have pelvic fluid 2 dary to resuscitation • Poor test to diagnose diaphragmatic injury

Computerized Tomography • Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study – Huber-Wagner et al. , Lancet 2009 – Relative risk of mortality in blunt trauma reduced by 25% according to TRISS – NNT = 17 – Whole-body CT an independent predictor of survival

Hypovolemic Shock Complex

Indications for Laparotomy – Blunt Abdominal Trauma Absolute Indications: 1. 2. 3. 4. 5. Shock Peritonitis Blood out of NG tube or on rectal exam Intraperitoneal bladder rupture Diaphragmatic rupture

Initial Management of the Bleeding Patient – European Guidelines; CC 2007 • Recommendation 6: – Early FAST for the detection of FF in patients with suspected torso trauma • Recommendation 7: – Pts. with significant FF on FAST with hemodynamic instability should undergo urgent surgery • Recommendation 8: – HD normal pts. with suspected head, chest and/or abdominal bleeding following high-energy injuries should undergo further assessment using CT • Recommendation 9: – Single Hct is not helpful; lactate or base deficit is helpful to estimate and monitor the extent of bleeding and shock

BAT & Pelvic # • May have ongoing bleeding from the abdomen, pelvis (retroperitoneum) or both • FAST used for intraabdominal bleeding • PXR for pelvic fractures (APC, VS, LC) • Abdomen trumps pelvis (80 -90% venous bleeding) – Pelvic bleeding should subside with stabilization in the majority of cases – Laparotomy done first if FAST positive

Open Book Pelvic Fracture

Pelvic Fracture has large potential space for hemorrhage

Col (ret) Mark W. Bowyer MD Close Pelvis – Many Devices Available to Close Pelvic Ring

Surgical consult Pelvic wrap Intraperitoneal gross blood? Yes No Laparotomy Angiography Control hemorrhage Fixation device

Initial Management of the Bleeding Patient – European Guidelines; CC 2007 • Recommendation 10: – Pts. in shock with pelvic ring fractures should undergo immediate closure and stabilization • Recommendation 11: – If ongoing instability, proceed to early angioembolization or surgical bleeding control such as packing • Recommendation 12: – Early bleeding control must be achieved by packing, direct surgical bleeding control, the use of local hemostatic procedures. If pt. is exsanguinating, aortic cross-clamping may be employed as an adjunct • Recommendation 13: – Damage control surgery should be employed in the severely injured pt. with signs of shock, ongoing bleeding and coagulopathy

EAST Guidelines – Evaluation of Blunt Abdominal Trauma, 2001 • Level I: – Exploratory laparotomy is indicative for patients with a positive DPL – CT is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT should be admitted for observation (i. e. contamination) – CT is the diagnostic modality of choice for non-operative management of solid visceral injuries (i. e. bleeding) – In HD stable patients, DPL and CT are complementary diagnostic modalities

EAST Guidelines – Evaluation of Blunt Abdominal Trauma, 2001 • Level II: – FAST may be considered as the initial diagnostic modality to exclude hemoperitoneum – Exploratory laparotomy is indicated in HD unstable patients with a positive FAST – If HD stable with a positive FAST, follow up CT permits nonoperative management of select injuries – Surveillance studies (DPL, CT, repeat FAST) are required in HD stable pts. With indeterminate FAST results

Tanya’s Summary - BAT • In stable – go to the OR for a laparotomy – If you are worried about contamination (HVI) • Fluid in the pelvis in absence of SOI – If you are worried about an intraperitoneal bladder injury or large diaphragmatic injury • In unstable – go to the OR for a laparotomy – If the bleeding is in the abdominal cavity – If the bleeding is in the pelvis for packing as still ongoing after stabilizing

Penetrating Abdominal Trauma

ATLS Approach • A – intubation may be required if hypotensive • B – watch H/PTX in both blunt and penetrating TAA injuries • C – start with 2 L crystalloid, may need to activate MTP – MUST FIND & STOP THE BLEEDING • D – may see associated thoracolumbar #s with BAT • E – watch for SBS, other injuries

Penetrating Abdominal Trauma • Violation of peritoneum – Therefore risk of intraabdominal injury that requires surgery • • Caused by stab wounds Caused by gun shot wounds Caused by shot gun wounds Caused by other penetrating objects

How common are injuries that require surgical repair? Anterior abdominal stab wounds: 25 -33% will need a laparotomy Posterior or flank stab wounds: 15% will need a laparotomy Anterior gun shot wounds: 58 -75% will need a laparotomy Posterior gun shot wounds: 33% will need a laparotomy

Indications for Laparotomy – Penetrating Abdominal Trauma Absolute Indications: 1. 2. 3. 4. 5. 6. Shock Peritonitis Evisceration Weapon still in situ Blood out of NG tube or on rectal exam Gross hematuria

Penetrating Abdominal Trauma – When to Operate in Stab Wounds? 1. Shock PPV = 80% for therapeutic laparotomy – 2. Peritonitis PPV = 85% for therapeutic laparotomy – • • Local (50%) Diffuse (81%) 3. Evisceration PPV = 75% for therapeutic laparotomy – • • Intestinal (100%) Omental (76%)

Stab Wounds – Anterior Abdominal Wall Not all stab wounds to the anterior abdominal wall (AAW) will have: Violated the peritoneum Caused intraabdominal injury requiring operative repair Up to 50% of stab wounds to the AAW will not violate the peritoneum Up to 50% that violate the peritoneum do not cause injury requiring operative repair

Stab Wounds – Anterior Abdominal Wall 1. Local Wound Exploration (LWE) – Sterile procedure with local anesthetic 2. Serial Physical Examinations (SPE) – Done by same clinician to assess for the development of peritonitis 3. Focused Assessment with Sonography for Trauma (FAST) – ‘Not indicated’ in penetrating trauma 4. Diagnostic Peritoneal Lavage (DPL) – Not done in many centers

Stab Wounds – Anterior Abdominal Wall 5. Computerized Tomography (CT) Historically not used for anterior abdominal stab wounds ▪ More useful in penetrating injury to the flank and back 6. Diagnostic Laparoscopy Used to rule out: ▪ ▪ Peritoneal penetration Diaphragmatic injury on left side 7. Exploratory Laparotomy Still the gold standard in ruling out intra-abdominal injury

Pitfalls 1. DPL: – Cumbersome – Sensitivity poor for hollow viscus injury – Different criteria for positive tests in different centers – Positive test for RBC’s does not equate to needing a therapeutic laparotomy • Many solid organ injuries managed non-operatively now 2. FAST (Soffer, 2004): – Very limited role in penetrating abdominal trauma – Rarely changes management, even if positive (1. 7%)

Pitfalls 3. Diagnostic laparoscopy: – Only identifies peritoneal violation – Not sensitive for hollow viscus or retroperitoneal injury – Automatic conversion to laparotomy will still result in a high non-therapeutic rate – Still largely reserved to rule out diaphragmatic injury with left thoracoabdominal SWs • 30% will have an injury to the diaphragm – Caution: 10% develop a tension pneumothorax intraoperatively if no chest tube in place

Non-Operative Management of Stab Wounds – EAST 2010 1. 2. 3. 4. Hemodynamically stable No peritonitis or diffuse abdominal pain In a center with surgical expertise Patient is evaluable* *Evaluable: absence of brain or spinal cord injury, intoxication or need for sedation or anesthesia • 20% of patients selected for NOM will fail (Clarke et al. , 2010)

Stab Wounds Flank and Back Laparotomy used to be standard of care Phillips, 1986 CT first reported for SWs to flank & back Fletcher, 1989 Non-operative management with 3 CT in 76% of patients with SWs to flank & back Jurkovich et al, 2009 Triple contrast CT scan has replaced DPL Evaluates retroperitoneum as DPL cannot Now mandatory laparotomy replaced with triple contrast CT scan for stab wounds to flank and back Some centers advocate IV contrast only is necessary

Thoracoabdominal Stab Wounds • Historically, 33% of patients with left thoracoabdominal stab wounds with have a diaphragmatic injury • Murray, 1998 – Prospective study of left throacoabdominal SWs – Diaphragmatic injury in 26% of patients who had no indication for laparotomy – Patients with left thoracoabdominal stab wounds may be observed for 12 hours • If no need for laparotomy by that time, may repair diaphragm using laparoscopic techniques

CT Scan for Anterior Abdominal Wall Stab Wounds Not well defined, evolving modality Does not add much to serial physical exams Poor test for: Hollow viscus injuries Diaphragm injuries Use if: 1. High suspicion of solid organ injury (liver, spleen, kidney) based on wound location (R or LUQ) 2. Positive FAST exam 3. Hematuria

• While selective management of anterior abdominal stab wounds is appropriate. . . • Selective management of anterior abdominal GSWs is still controversial • But this can reduce the rate of nontherapeutic laparotomy from 30 -50% to 5 -10%

Non Operative Management of Gun Shot Wounds – Guidelines (EAST) 2010 1. Hemodynamically stable 2. Tangential wound 3. No peritoneal signs 4. Consider only if patient is evaluable 5. Exception if GSW to RUQ

Non Operative Management of Gun Shot Wounds to Right Upper Quadrant (Non-Tangential) - Guidelines • Absolute indications: 1. 2. 3. Hemodynamically stable Patient is evaluable* Minimal to no abdominal tenderness * Evaluable: absence of brain or spinal cord injury, intoxication or need for sedation or anesthesia

EAST Guidelines 2010 • Patients with GSWs who are selected for initial non-operative management should have other diagnostic tests • This should be an abdominal pelvic CT scan to facilitate initial management decisions

Is a Non-Therapeutic Laparotomy Bad? • Ventral incisional hernia rate 5 - 20% • Lowe et al. , 1972 – 245 pts. with negative or non-therapeutic laparotomies after mainly penetrating trauma • 20. 4% complication rate (evisceration in 4 pts. ) • 1. 6% mortality rate related to unnecessary laparotomy • Demetriades, 1993 – 11% of non-therapeutic laparotomies with major complications – LOS = 4. 1 days if no complications vs. 21. 2 days if complicated • Renz & Feliciano, 1995 – Complications in 41. 3% of 254 pts. with laparotomies for trauma • Velmahos et al, 2001 – $ 9. 5 million saving with NOM over 8 years, 1856 pts. with GSW

How long to observe? • Patients with penetrating abdominal injuries selected for NOM should be observed for 24 hours • They may be discharged after 24 hours in the presence of a reliable physical exam and minimal to no tenderness • The majority of asymptomatic patients who failed NOM after SWs did so within 12 hours Alzamel et al, 2005 • 24 hours still recommended by most centers

Inaba & Demetriades, 2007

Summary – Stab Wounds to Abdomen • Non-operative management if no: – Shock, peritonitis, evisceration & patient evaluable • LWE as per clinician preference – May discharge patient home if no fascial violation • Serial physical exams by same clinician X 24 hours – Watch for peritonitis, discharge home if minimal or no pain

Summary – Stab Wounds to Abdomen • CT scan if – SW to R or LUQ to rule out solid organ injury – SW to flank or back as CT may rule out peritoneal violation • May send home after or. . – May observe patient after CT for 24 hours nonetheless • Delayed laparoscopy after 12 hours of observation if – TAA SW to left upper quadrant to identify and repair any diaphragmatic injury

Summary – GSW to Abdomen • Non-operative management if no: – Shock, peritonitis, evisceration & evaluable • All patients undergo CT scanning – Anterior abdomen, flank or back – If GSW tangential (no peritoneal breach) & no peritoneal signs, patient may be discharged home – If solid organ injury, may manage non-operatively • Consider repeat imaging in 7 days to manage asymptomatic complications in 50% – If hollow viscus injury, proceed with laparotomy – If no apparent injury, observe for 24 hours

Summary – Penetrating Abdominal Trauma • Low threshold to operate • Don’t forget trauma to thoracic structures if TAA • FAST only helpful with bleeding if positive – Always do a pericardial FAST if close to the box • CT only helpful with bleeding – Less so with HVI • Serial physical exams helpful in all

Thank you! zakrisont@smh. ca