Primary Survey and Initial

Resuscitation
Abdominal Trauma

Renato R. Montenegro, MD,

FPSGS
Assistant Professor
UST Faculty of Medicine & Surgery
Multiple Choice:
You are driving along Roxas Blvd when you chanced on a
vehicular accident. You would ...
A. Drive away as quickly as you can

B. Slow down; assess situation; decide there are

enough on-lookers providing help; leave

C. Stop some distance away; call nearest

hospital / police station to report accident; leave
D. Make a dramatic entrance: step on breaks instantly
so everybody sees / hears / smells your burning tires;
push everyone aside, announce you are a UST Medical
senior and that henceforth you are in charged !
Objectives
• For the student to learn that there is a systematic
way of managing trauma
• …to realize that there is no single protocol
applicable to all situations and conditions
• …to be familiar with a protocol in the
management of trauma
• …that as medical students (or paramedics or
laymen), knowledge of the basics in trauma can
spell a significant difference
 Trauma

• leading cause of morbidity and mortality under age 45

• 3rd highest cause of death in all ages
• ages 15-24: accidents claim more lives than all other
causes combined
• 150,000 Americans die each year > # of deaths in
Vietnam; (VA=50%)
• Trauma death rate: 50 / 100,000
• Mortality rates are poor indicators of the problem
 TRAUMA: with a clearly identified beginning which if not
rapidly and properly managed may lead to death of the
victim

TRAUMATIC
EVENT

RECOVERY
GOLDEN
PRODUCTIVE MORBIDITY
MEMBER OF SOCIETY
HOUR MORTALITY

0
TIME
Historical Notes
1945 Atomic bomb dropped at Hiroshima
1965 Diagnostic Peritoneal Lavage (Root, et al)
1967 National Academy of Science milestone
report – “Trauma: The neglected disease
of Modern Society”
1970 Triage, Resuscitation, Fluids, ARDS
1971 Ultrasound
1972 CT Scan
1998 Focused Abd. Sonography for Trauma (FAST)
Diagnostic Laparoscopy for Trauma
2001 911
 150,000 trauma deaths
per year
 50% from vehicular
accidents
 Blunt abdominal
trauma accounts for
majority of deaths
 vehicular accidents
account for majority of
blunt hepatic trauma
Almost 2,000 people are killed and
another 50,000 injured every year in
motorcycle accidents in the United
States.
TRAUMA : The Neglected Disease
of Modern Society

The American Academy of Medicine

 Trauma

TRAUMA: Emergency Management

Basic Assumptions:
1. Patient may have more than 1 injury
2. The obvious injury is not necessarily
the most important
Identify Categories of Injury
Initial Resuscitation - The ABC’s
 Categories of Injury – Identifying Priorities

1. Exigent - most life-threatening - instantaneous intervention

e.g. laryngeal fracture, tension pneumothorax
2. Emergency - immediate intervention within first hour
e.g. ongoing hemorrhage, intracranial injuries
3. Urgent - intervention within first few hours
e.g.- open fractures, ischemic extremity, hollow
viscus injury
4. Deferrable - may or may not be immediately apparent but
will require tx. - e.g. facial fractures, urethral injury
Treatment of Trauma Patients
 Primary Survey (ABC)
 Resuscitation
 Secondary Survey
 Diagnostic Evaluation
 Definitive Care
The ABCs of Resuscitation

A - Airway
B - Breathing
C - Circulation
D - Disability / Neurologic Assessment
E - Exposure for Complete Examination
Airway Management
 Assess mental status / verbal output
 Inspect oropharyngeal cavity
 Methods for establishing airway
 Problems: altered MS, foreign body, neck injuries,
maxillofacial trauma, edema to air passages
Breathing
 Oxygenation and
ventilation
 Problems: tension / open
pneumothorax, flail chest,
pulmonary contusion
 Diagnosis: clinical, chest
x-ray
 Thoracostomy
• Needle thoracentesis
• Closed Tube
thoracostomy
• Water-sealed
drainage bottle
Circulation
 Assumption: hypotension is caused by
bleeding
 Assess pulses:
Radial = 80 mmHg
Femoral = 70 mmHg
Carotid = 60 mmHG
 Vital Signs: BP, PR, RR
 Methods to control hemorrhage
 Hypovolemic shock vs Cardiogenic shock
Cardiac Tamponade
 Index of suspicion: unexplained hypotension
 Diagnosis: increased venous pressure,
decreased pulse pressure, decreased heart sounds
 Dx procedures: Pericardiocentesis, Chest x-ray,
FAST, 2-D ECHO
 Pitfall in dx: waiting for a complete diagnostic
triad
 Treatment : Pericardiocentesis, Pericardiostomy
FAST for Cardiac Tamponade
 Pericardiocentesis

•Index of suspicion:
unexplained
hypotension

•50 % false negative

•A temporizing
therapeutic procedure
which may be life-
saving
Resuscitation
 Establish airway / oxygenate patient
 Insert large-bore IV lines
 Draw blood for typing and cross-matching;
consider universal donor transfusion
 Volume resuscitation with crystalloid solution
 Definitive treatment for non-responders
 Diagnostic work-up for responders
Abdominal Trauma: Mechanism and
Pattern of Injury
BLUNT PENETRATING
 Energy transfer to a wide  Injury localized to path
area
of SW or GSW
 Vehicular accident,
steering wheel injury, fall,  Easy to diagnose
 More delays in dx  Better outcome
 Higher mortality rates
Range of P.E. Findings in Abdominal Trauma
I. BLUNT ABDOMINAL INJURY

Normal P.E. Equivocal P.E. Unstable patients

/obvious indications
for surgery

II. PENETRATING ABDOMINAL INJURY

Equivocal P.E. Unstable patients

/obvious indications
for surgery
 STAB Local wound
Indications for
WOUND exploration
immediate surgery
-Unstable VS
-evisceration
-Peritomitis
Positive Negative
- signs of bleed LWE LWE

Observe/
Diagnostic
discharge
To OR for surgery peritoneal
pt
lavage (DPL)

+ DPL - DPL
 STAB
Indications for
WOUND
immediate surgery
-Unstable VS
-evisceration
-Peritomitis
Negative
- signs of bleed LWE

To OR for surgery
 STAB Local wound
WOUND exploration

Local Wound Exploration

Negative
 For stable SW patients LWE
 To determine penetration
beyond the peritoneum
Observe/
 Positive LWE: peritoneum is
discharge
violated pt
 (+) LWE: reasonable
likelihood of intraperitoneal
injury
STAB Local wound
WOUND exploration

Positive Negative
LWE LWE

Diagnostic
peritoneal
lavage (DPL)
 STAB Local wound
Indications for
WOUND exploration
immediate surgery
-Unstable VS
-evisceration
-Peritomitis
Positive Negative
- signs of bleed LWE LWE

Observe/
Diagnostic
discharge
To OR for surgery peritoneal
pt
lavage (DPL)

+ DPL - DPL
Diagnostic Peritoneal Lavage
 (Root et al, 1965) The first serious departure from
mandatory laparotomy for suspected blunt
abdominal injury
 Fast, very sensitive (97-98%)
 Specialized training not required
 May be done in a variety of locations
 Results are quantitative, objective, operator
independent
Diagnostic Peritoneal Lavage

 Abdominal paracentesis
 Peritoneal catheter
 Infuse lavage fluid (NSS/LRS)
 Drain after 20-30 minutes
 Analysis of effluent fluid
 Positive results are indications for
explore laparotomy
 Positive (DPL)

•Aspiration of 10 ml free blood

•Effluent drains in NGT, Chest
tube, Foley catheter
•RBC > 100,000/cu ml
•Bile, bacteria, vegetable
fibers, fecal material detected
•Amylase, alkaline
phosphatase detected
Diagnostic Peritoneal Lavage
INDICATIONS: NOT RECOMMENDED:
 closed head injury / altered
 previous abdomial
consciousness / SC injuries
surgery
 equivocal abdominal
 presence if dilated
findings
bowels
 Pregnancy

 SW , back

 GSW
Blunt Abdominal Trauma
 Trauma remains the leading cause of death in 1 – 44
year old age group
 Most deaths caused by blunt injury
 VA accounts for most blunt hepatic injury
 Diagnosis is a challenge and continues to evolve
 Non-therapeutic laparotomy weighed against
delayed / missed diagnosis
 Range of PE findings
Normal P.E. Equivocal P.E. Unstable patients
/obvious indications
for surgery
Diagnosis of B.A.T.
1. Physical Exam
2. Lab. Studies (serial Hb/Hct)
3. Diagnostic Peritoneal Lavage
4. Ultrasound
5. CT Scan
6. FAST (Focused Abdominal Sonography for
Trauma)
7. Diagnostic Laparoscopy
Diagnosis of B.A.T.
Physical Exam
 Most useful in primary survey to identify life-
threatening injuries and to set priorities
 Useful in secondary survey to identify patients
with E/N physical exam who may not require any
work-up
 In equivocal cases: wide variabilty in sensitivity
 50-60 % sensitive
Plain radiographs
 Abdomen x-ray: unreliable due to uniform fluid
density of abdomen
 Chest x-ray mandatory

Lab Studies
 Serial Hb/Hct – useful monitor of hemorrhage
over a period of time
rapid hemorrhage - false negative
crystalloid hemodilution - false positive
 Arterial Base Deficit
- index of metabolic acidosis in setting of
hemorrhage
Chest x-ray
 Mandatory procedure
 May show
pneumoperitoneum
 To document problems
in the lungs and pleura
Traumatic Diaphragmatic Hernia
Diagnosis of Blunt Abdominal Trauma

 Physical exam lacks sensitivity

 Not all patients with BAT require studies
 All patients with abdominal SW require
some type of objective evaluation
 Utilize studies to arrive at dx early at the
same time minimize non-tx laparotomy
NON-
THERAPEUTIC
LAPAROTOMY
MISSED /
DELAYED
DIAGNOSIS
DPL: disadvantages
 Invasive (<1% complication rate)
 Not very specific

 May miss retroperitoneal, diaphragm injuries

 Highly sensitive

increases incidence of non-therapeutic laparotomy

ADJUST CELL COUNT THRESHOLD

 DPL
 Recommended cell count threshold = 100,000 cells/cu
mm
 Institutions / practitioners must evaluate their own
tolerance for and consequences of delayed diagnosis
vs. non therapeutic laparotomy
 Indications have diminished with use of CT and FAST
 Still useful in intra-op evaluation of trauma patient
undergoing emergency surgery at a site remote from
the abdomen (eg. Craniotomy)
Abdominal CT Scan
 Very specific (95-100%)
 Good sensitivity (85-99%)
 Can evaluate the
retroperitoneum
 Allows staging of blunt
organ injuries
 Most major injuries are
operator (reader)
independent
 Dx modality of choice for
hemodynamically stable
patients with suspected blunt
abdominal injury
CT scan: BAT
 Computed tomography
scan identifying an
intraparenchymal liver
hematoma with overlying
rib fracture
CT scan: BAT
 Computed tomography
demonstrating a focal
splenic laceration
involving the posterior
aspect of the spleen
 Small amounts of blood
associated with solid organ
injury is not an
independent indication for
exploration
Abdomen CT Scan: disadvantages
 Requires time and patient
transport
 Has some degree of
operator dependence
 May miss blunt intestinal
injuries
Focused Abdominal Sonography for Trauma
(FAST)
 Diagnostic procedure of
choice in the unstable
patient
 Fast, simple, portable,
readily available
 Short learning curve
 Positive finding: fluid
(blood) in peritoneal cavity
Blunt Abdominal Injury
 22 y/o, male fell off his
motorcycle (?20 mph)
 Ambulatory, in pain,
BP=90/min, PR=120
 Hematoma in mid abdomen
 Diagnostic procedure ?
Seat Belt Sign
Thank You.