Trauma Blunt Abdominal Trauma Douglas M Maurer DO

Trauma– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH

Learning Objectives • Recognize and respond appropriately to a patient with hemorrhagic shock • Assess via bedside methods the source of hemorrhage • Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition

Introduction • Blunt abdominal trauma is common. • Unknown history, distracting injuries, and altered mental status make these patients difficult to diagnose and manage. • Victims frequently have both abdominal and extraabdominal injuries. • Family physicians need to be able to recognize and treat hemorrhagic shock.

Recognition of Hemorrhagic Shock • Shock: oxygen delivery < tissue demands • Treatment must restore tissue perfusion not just blood pressure • Shock does NOT SBP < 90 mm. Hg • Recognition includes: mechanism of injury, patient’s appearance, vitals, level of mentation, peripheral perfusion and urine output • Clinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.

Practical Diagnosis of Shock • Perform a targeted physical examination • Diagnostic testing should include chest radiography, pelvis radiography, and bedside ultrasound • Objective serum makers of tissue perfusion (serum lactate or base deficit) • Point of care H/H, send CBC, type/cross • DON’T delay resuscitation for lab results

6 Steps to Treat Hemorrhagic Shock • Step 1: Effectively manage the airway and optimize oxygenation. • Step 2: Identify and control immediate threats to central perfusion. • Step 3: Identify and address severe intracranial injuries. • Step 4: Identify and control other potentially lifethreatening thoracic and abdominal injuries. • Step 5: Identify and control potentially limbthreatening injuries. • Step 6: Identify and treat noncritical injuries.

Treatment of Hemorrhagic Shock • Obtain immediate type and crossmatch for 6 -8 units of blood • Massive transfusion defined as > 10 U of PRBCs in 24 hrs • Consider use of PRBC to platelet to FFP ratio of 1: 1: 1 • May result in decreased need for blood products • Give calcium to prevent citrate toxicity

Assessing for Sources of Hemorrhage • Chest radiography: • Tension pneumothorax? Massive hemothorax? Aortic injury? • Pelvis radiography: • Pelvic ring disruption? • Focused Assessment with Sonography for Trauma (FAST): • • • Pneumo/hemothorax? Hemopericardium? Hemoperitoneum? If positive, then emergency laparotomy. If negative, continue resuscitation, treat other causes.

FAST Facts • Reliably identifies 200 -250 ml of intraperitoneal fluid • Cannot reliably evaluate retroperitoneum/hollow viscous injury • Sensitivity/specificity: 75%/98%, NPV: 94%; 86 -97% accurate • Performed using a curvilinear 2. 5 or 3. 5 MHz probe

FAST Views • Cardiac: parasternal or subxiphoid, hepatocardiac interface, pericardial space. • RUQ: hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney. • LUQ: splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleen. • Suprapubic: outline of bladder, silhouette of uterus (females).

FAST Algorithm • Unstable patient: + FAST = OR. • Stable pt: + FAST = abdominal CT. • Stable pt, low mechanism of injury: - FAST = observation, serial exams. • CT is the “Gold Standard”.

What About Diagnostic Peritoneal Aspiration (DPA)? • Can be performed if - FAST in blunt abdominal trauma. • If DPA +, then emergency laparotomy. • If DPA -, then seek and treat other sources. • Perform serial abdominal exams. • Perform serial FAST exams. • If patient stabilizes, then CT. • Get surgery involved!

Indications for Emergency Laparotomy • • • Peritonism Free air under the diaphragm Significant gastrointestinal hemorrhage Hypotension with + FAST scan or + DPA Do NOT keep trauma patients if you lack resources to care for them!

Summary • Recognize and treat hemorrhagic shock aggressively with blood products • Assess for hemorrhage with bedside methods: CXR, pelvis, and FAST • Unstable patient: + FAST = OR. • Stable pt: + FAST = abdominal CT. • Stable pt, low mechanism of injury: - FAST = observation, serial exams.

References 1. Puskarich MA. Initial evaluation and management of blunt abdominal trauma in adults. In: Up. To. Date, Hockberger RS, Moreira ME (Ed), Up. To. Date, Waltham, MA, 2012. 2. Nickson C. “Trauma! Blunt abdominal trauma decision making. ” Weblog entry. Life in the Fastlane Blog. http: //lifeinthefastlane. com/2012/03/trauma-tribulation-023/ 3. Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma. 2010 Edition. Chicago, IL. http: //www. east. org/resources/treatment -guidelines/category/trauma 4. American College of Surgeons. ATLS Textbook, 9 th Edition. 1 September 2012.

Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH, FAAFP

Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma SCENARIO ALGORITHM SET UP: “Rural” ER Simulated Room Bedside US and/or FAST simulator Real patient with simulated skin/abdomen PRE ARRIVAL: FP in rural ER, lab, rad, OR 35 y/o male s/p unrestrained driver MVA arrives via EMS, in c-collar. VS BP 90/50, HR 110, RR 18, Sp. O 2 97% on RA, GCS 15 ARRIVAL: Full spinal precautions, has 1 IV in place. Pt awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHx PRIMARY SURVEY: A – talking initially, then somnolent B – labored, RR 24, nl breath sounds C – BP 85/40, HR 130, cool extremities D – GCS 14, somnolent, oriented to person when responds to voice E – no other trauma, mild abd distension, hypoactive BS SECONDARY SURVEY: Other exam normal, c-spine non tender, pelvis stable, rectal guaiac negative Abdominal exam tense, tender, absent BS LABS & IMAGES: Chest, c-spine, pelvis negative Labs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7. 35/46/40/50%/-8 Positive FAST in RUQ, no CT indicated Blood type and screen/X-match DISPOSITION: Must transfuse blood , call Surgeon and direct to OR, otherwise pt dies of hemorrhage Date: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s): Learning Objectives: 1. Recognize and respond appropriately to a patient with hemorrhagic shock. 2. Assess via bedside methods the source of hemorrhage. 3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition. CRITICAL ACTIONS ME NI M Completes Primary Survey: recognizes shock MK 2 Safety net – IV, oxygen, monitors (2 x 16 G IV) MK 2 Completes Secondary Survey: recognizes abdominal source MK 2 Completes bedside FAST (+ Morrison’s Pouch) PC 5 Recognizes positive FAST: calls surgery PC 5 Bedside labs: POC CBC, lactate, BAL, VBG, blood type/screen/Xmatch MK 2 Bedside rads: port chest, lat Cspine, AP pelvis MK 2 Gives emergency release blood transfusion MK 2 If unstable: no CT, to OR If stabilizes: CT, then OR MK 2 TOTAL SUSTAIN IMPROVE SBP 4 ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)

Perihepatic

Perisplenic

Pelvic

Pericardium