Med On The Go episode 16: Abdominal Trauma

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Med On The Go episode 16: Abdominal Trauma

Abdominal Trauma

As always, today's post is available in podcast form, available at www.medonthego.podbean.com. Subscribe on iTunes, Google Play, or Podbean to make sure you never miss an episode. Want to get to know us better? Check out our Facebook page at www.facebook.com/drolimedonthego/. Wanna support the podcast? See www.patron.podbean.com/medonthego.

Let’s open with a bit of trivia: what kind of injuries can you receive from a seatbelt?

A.     Retroperitoneal duodenal trauma

B.     Intraperitoneal bowel transection

C.     Mesenteric injury

D.    L-spine injury

E.     All of the above

If you chose D like me, you would be wrong! The answer is “all of the above”. Who knew seatbelts can cause so many abdominal injuries?!

Two main types of injuries can cause abdominal trauma: blunt (causing solid organ injury, with the spleen most commonly affected followed by the liver) and penetrating (causing hollow organ or liver injury). Penetrating injuries are most common.

Blunt trauma of the abdomen can result in two types of hemorrhage: intraperitoneal and retroperitoneal. When a patient presents with multi-system trauma, be extra suspicious of blunt trauma damage in the abdomen. A history focused on the mechanism of injury should be included in the general medical history.

Physical examination is often unreliable in multi-system trauma, with a wide spectrum of presentations; sometimes abdominal symptoms may be masked by other injuries—therefore serial examinations need to be done. Common findings include tachycardia, tachypnea, oliguria, febrile, and hypotension; signs of slow blood loss may not be apparent right away.

·      Inspect: contusions, abrasions, seatbelt sign, distention

·      Auscultate: bruits, bowel sounds

·      Palpate: tenderness, rebound tenderness, rigidity, guarding

·      DRE: rectal tone, blood, bone fragments, prostate position

·      Placement of NG tube and Foley catheter should be considered part of the abdominal exam. Foley catheter should be inserted in unconscious patient or patient with multiple injuries who cannot void spontaneously. NG tube can be used to decompress the stomach and proximal small bowel; but it’s contraindicated for patients with suspected facial fractures or basal skull fractures.

Investigations

·      Laboratory—CBC, electrolytes, coagulation profile, cross and type, glucose, creatinine, creatinine kinase, lipase, amylase, liver enzymes, ABG, blood alcohol levels, toxicology screen, and beta HCG (where applicable).

·      Urinary analysis

Imaging MUST be done if:

·      Equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia).

·      Unexplained shock/hypotension

·      Multiple trauma patients who must undergo GA for orthopedic, neurosurgical, or other injuries

·      Fracture of lower ribs, pelvis, spine

·      Positive FAST

*Criteria for positive lavage:

·      > 10cc gross blood

·      Bile, bacteria, foreign material

·      RBC count > 100,000 x 10⁶/L

·      WBC count > 500 x 10⁶/L

·      Amylase > 175IU

Management

·      General—ABCs, fluid resuscitation, and stabilization

·      Surgical—watchful waiting vs. laparotomy

·      Solid organ injuries—decision based on hemodynamic stability, not the specific injuries

·      Hollow organ injuries—laparotomy

·      Even if low suspicion of injury—admit and observe for 24hrs

Penetrating trauma of the abdomen has a high risk of gastrointestinal perforation and sepsis. It’s important to note the size of blade, caliber/distance from gun, and route of entry in the history. Local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable in inexperienced hands) with exception to thoraco-abdominal region (may cause pneumothorax) and wounds of the back or flanks (muscles too thick).

Remember the Rule Of Thirds:

1/3 do not penetrate peritoneal cavity

1/3 penetrates but are harmless

1/3 cause injury requiring surgery

Laparotomy is mandatory if penetrating trauma and one or more of the following:

·      Shock

·      Peritonitis

·      Evisceration

·      Free air in abdomen

·      Blood in NG tube, Foley catheter, or DRE

Management

·      General—ABCs, fluid resuscitation, and stabilization

·      Gunshot wounds—ALWAYS require laparotomy

Med On The Go episode 15: Chest Trauma

Med On The Go episode 15: Chest Trauma



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Chest Trauma: The List of Deadlies

Trauma to the chest accounts for 50% of trauma deaths. Ironically 80% of all chest injuries can be managed non-surgically with simple measures such as intubation, chest tubes, and pain control. Chest trauma can be divided into two categories—those found in the primary survey and those found during secondary survey.

*3-way seal for open pneumothorax (i.e. sucking chest wound)—allows air to escape during the expiratory phase (so that patient does not get a tension pneumothorax) but seals itself to allow adequate breaths during the inspiratory phase.

**Pulsus paradoxus—a drop in blood pressure of > 10mmHg with inspiration. Recall that blood pressure normally drops with inspiration, but what’s “paradoxical” about this is that it drops more than it should.

***Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction. Kussmaul sign is not to be confused with Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.

Mnemonic to remember signs that indicate aortic tear: ABC WHITE. These are present in 85% of cases but absence cannot rule out diagnosis.

Aortic tear on x-ray

Bronchus pleural Cap

Wide mediastinum (most consistent)

Haemothorax

Indistinct aortic knuckle

Tracheal deviation to right side

Esophagus (NG tube) deviated to right

Other potentially life-threatening injuries related to the chest include penetrating neck trauma:

·      Includes all penetrating trauma to the three zones of the neck

·      Management: injuries deep to the platysma require further evaluation by angiography, contrast CT, or surgery.

·      DO NOT insert NG tube

·      DO NOT remove weaponry/impaled object

·      DO NOT clamp or explore open neck wounds except in surgery

Anatomy reminder: 3 zones of the neck I~III

Zone I: sternal notchà cricothyroid membrane

Zone II: cricothyroid membraneà angle of mandible

Zone III: angle of mandibleà skull base

Always have a high suspicion of airway injury. Two major organs involved are the larynx and trachea/bronchus.

Trachea

·      History: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma

·      Triad: hoarseness, subcutaneous emphysema, palpable fracture

·      Other symptoms: hemoptysis, dyspnea, dysphonia

·      Investigations: CXR, CT scan, arteriography (if penetrating injury)

·      Management

o   Airway—manage early because of edema

o   C-spine may also be injured, consider mechanism of injury

o   Surgical—tracheotomy vs. repair

Larynx/bronchus

·      Frequently missed

·      History: deceleration, penetration, increased intra-thoracic pressure, complaints of dyspnea, hemoptysis

·      Examination: subcutaneous air, Hamman’s sign (crunching sound synchronous with heart beat)

·      CXR: mediastinal air, persistent pneumothorax or persistent air leak after chest tube insertion for pneumothorax

·      Management: surgical repair if > 1/3 circumference

As always, this post is available in audible form through our podcast www.medonthego.podbean.com; subscribe on iTunes, Google Play, and Podbean so that you'll never miss an episode. If you want to get to know us better (or just have a laugh at nerdy medical jokes) check out our Facebook page www.facebook.com/drolimedonthego/. If you wish to support us, please see www.patron.podbean.com/medonthego for more details!