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Objectives

Identify key anatomic features of the


abdomen.
Describe blunt and penetrating injury
patterns.
Describe the evaluation of the patient with
suspected abdominal injury.
Objectives

Objectives
Identify and apply the most appropriate
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diagnostic and therapeutic procedures.


Discuss
Huruf acutetimes
management of pelvic
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fracture.
Key Questions

What priority is abdominal trauma in the


management of the multiply injured
patient?
Why is the mechanism of injury important?
How do I know if shock is the result of an
intraabdominal injury?
Key Questions

How do I determine if there is an


abdominal injury?
Who warrants a celiotomy (laparotomy?)
How do I manage patients with pelvic
fractures?
External Anatomy
Lower peritoneal
cavity

Pelvic cavity
Abdominal Trauma

What is one of the leading cause of


preventable mortality?

Unrecognized
intraabdominal
injury
Abdominal trauma priority?

Head and abdominal trauma?


Head, chest, and abdominal trauma?
Head, chest, abdominal and extremity
trauma?
Head, chest, abdomen, extremity, and
pelvic trauma?
Mechanism of Injury

Why is it important to know?

It determines what
organs are probably
injured.
Blunt Force Mechanism

How does it injure?


Compression
Crushing
Shearing
Deceleration (fixed organs)
Blunt Force Mechanism

What organs are commonly injured?

Spleen
Liver
Small bowel
Penetrating Mechanism?

How does it injuries?


Stab
Transfer of
Low energy kinetic energy
Lacerations Cavitation
Gunshot Tumble
High energy Fragments
Penetrating Mechanism

Common injuries?
Low Energy High Energy
Liver Small bowel
Small bowel Colon
Diaphragm Liver
Colon Vascular structures
Assessment: History

Blunt Penetrating
Speed Weapon
Point of impact Distance
Intrusion Number of wounds
Safety devices
Position
Ejection
Assessment: Physical Exam

Inspection
Auscultation
Percussion
Palpation
Abdominal Trauma

What can compromise the exam?


Alcohol or other drugs
Injuries to brain, spinal cord
Injury to ribs, spine, pelvis
Assessment: Stab Wound

How do I evaluate and manage the


abdomen of a patient with an anterior
abdominal, lower chest, flank, or back
stab wound?
What is a positive local wound
exploration performed by a surgeon?
Assessment: Penetrating Injury

How do I evaluate and manage perineal,


rectal, vagina, or gluteal penetrating
injuries?
Assessment: Gunshot Wound

How do I evaluate and manage the


abdomen of a patient with a possible
abdominal GSW?
Tangential? X-rays?
Exit wound? Lab
Likely injuries? determinations?
Management: Gunshot Wound

Early operation usually is


the best strategy..
Abdominal injury causes shock?

Evidence of abdominal injury by


mechanism, history, or evaluation
Hypotension
Positive FAST or grossly positive DPL
Absence of massive hemothorax on
chest x-ray
Adjunct: Gastric Tube

Relieves distention
Decompresses stomach before DPL

Basilar skull / facial fractures


May induce vomiting /
aspiration
Adjunct: Urinary Catheter

Monitors urinary output


Decompress bladder before DPL
Diagnostic
Adjuncts: Blood / Urine Tests

No mandatory blood tests


Injury Severity and likely injuries
Hemodynamically abnormal: type &
crossmatch
Pregnancy testing
Alcohol or other drug testing
Gross hematuria vs microscopic
Adjuncts: X-ray Studies

Routine
Blunt: AP Chest and Pelvis
Penetrating: AP chest and abdomen
with markers (if hemodinamically
normal)
Adjuncts: Contrast Studies

Urethrogram
Cystogram
IVP
GI
Abdominal CT
Diagnostic Studies: Penetrating

Lower chest wounds: Serial exams,


thoracoscopy, laparoscopy, or CT scan
Anterior abdominal stab wounds:
wound exploration, DPL, or serial
exams
Back and flank stab wound: DPL,
serial exams, or double- or triple
contrast CT scan
Indication for celiotomy?

Blunt Trauma
BP, suspect visceral injury
Free air
Diaphragmatic rupture
Peritonitis
+ DPL, FAST, or contrast CT
Indications for celiotomy?

Penetrating Trauma
Hypotension
Peritoneal / retroperitoneal injury
Peritonitis
Evisceration
+ DPL, FAST, or contrast CT
Remember

a missed abdominal
injury is a common
cause of a potentially
preventable death.
Pelvic Fractures

Mechanism
AP compression
Lateral
compression
Vertical shear
Pelvic Fractures

Classification
Open
Closed
Pelvic Fractures

Significant force
applied
Associated
injuries
Pelvic bleeding
Bone ends
Pelvic muscles Veins / arteries
Pelvic Fractures

Assessment
Inspection
Palpate prostate
Pelvic ring
Leg-length discrepancy, external rotation
Pain on palpation of bony pelvic ring
Pelvic Fractures

Emergency Management
Fluid resuscitation
Determine if open or closed fracture
Determine associated perineal / GU injuries
Determine need for transfer
Splint pelvic fracture
ABCDEs and early surgical consultation
Evaluation and management vary with a
mechanism and physiologic response
Repeated exams and diagnostic studies
High index of suspicion
Early recognition / prompt celiotomy

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