CASE STUDIES
IN ABDOMINAL
TRAUMA
December 5, 2013
MICHAEL SLOAN, MD
Saving Lives By Strengthening Our Region’s Trauma Care System
WHEN TRAUMA IS OBVIOUS…
NO IMAGING IS NECESSARY
WHEN TRAUMA IS UNCERTAIN…
TROUBLE LURKS JUST BELOW THE SURFACE
TRAUMA
• Leading cause of death ages 1-44 years in
most developed countries
• Motor vehicle crashes account for the
majority of injuries and deaths in 70% of the
39 countries for which data is available
• 60 million injuries estimated in the US each
year, resulting in 36.8 million ER visits
TRIMODAL DEATH DISTRIBUTION
ABDOMINAL TRAUMA
Multiple Mechanisms of Injury
1. Crushing – direct application of blunt force
2. Shearing – sudden deceleration of organs
with fixed attachments
3. Bursting – increased intraluminal pressure
from abdominal compression
4. Penetrating – knife/gun/stick/bone
INJURIES
• Solid organ
• Hollow viscus
• Diaphragm
• Retroperitoneal
• Vascular
• Genitourinary
• Pelvic
YOUR TOOL KIT
YOUR DESTINATION
CASE #1
• History
• 72 year old male status post auto versus bicycle
• No LOC (wearing helmet)
• Complaint of rib pain, hip pain, and lower extremity
pain on arrival
• Level 2 Trauma activation
• GCS 15, HR 88, BP 138/66, RR 14, O2 sat 98% 2L NC
INITIAL ASSESSMENT
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Working Diagnosis
• Rib fracture
• Low back pain
• Hip/Femur fracture
INITIAL IMAGING
WHILE AWAITING CT…
• HR 114, BP 114/60, RR 20, O2 sat 98% 2L NC
• Patient complaint of need to void
• “I can’t pee!”
• Nausea => Emesis
• Foley placed – amber urine (<50 mL)
• NG placed
TRAUMA SURGERY AND ORTHOPEDICS AT THE
BEDSIDE
• HR 122, BP 96/52, RR 22, O2 sat 97% 2L NC
• Patient complaint of back pain, need to have
a bowel movement, becoming sedate (4 mg
IV dilaudid at this point)
• Hct 32, plts 156, INR 1.4
• As he rolls out to CT HR 160…
WHAT DO YOU DO NEXT?
• Continue to CT?
• Return to room?
• Transfuse?
• Transfer?
• OR?
• FAST?
• Angio?
RETURN TO ROOM
• 2nd PIV was placed
• NS bolus while transfusion initiated
• Med list confirms ASA and Plavix
• History of cardiac stent 7 months ago
• Platelets ordered
• Draw sheet placed
• FAST exam (suggests pelvic hematoma)
PATIENT IMPROVES…
• Transient or Sustained
• No angiography available
• HR 96, BP 122/54, RR 20 O2 95% 4L NC
• Decision to transfer
ON ARRIVAL
• GCS 14, HR 130, BP 104/50, RR 24 NRB
• 4L crystalloid, 4u pRBC, platelets in the
cooler
• Repeat FAST – suggests free fluid
• Taken to OR
• Ex lap = small amount of free blood, retroperitoneal
and pelvic hematoma (tense), temporary closure
• Binder applied and transfer to Angio suite
ANGIOGRAPHY
• 4.5 hours to selectively access and embolize
the left internal iliac branches (inferior
gluteal/pudendal arteries)
• 7 u pRBC, 10 u platelets, 5 u FFP
• Remember to employ massive transfusion protocol
• Return to OR for 2nd look laparotomy directly
from Angio suite
• External fixator applied at this time
OR – ROUND TWO
• Retroperitoneal/pelvic hematoma has now
begun to bleed from the midline
• Exploration reveals no obvious bleeding and
abdomen is packed and left open with VAC
ABThera
• Two additional trips to the OR for VAC
change
• Definitive abdominal closure on HD#7
RECOVERY
• 13 days ICU
• 27 days hospital
• 2 months LTACH
• 2 months SNF
• Ongoing outpatient rehab for gait
impairment
• Ventral hernia
PELVIC FRACTURES
• Prior to 1900, pelvic fractures with an
associated bleed carried a mortality of 80%
• Today management revolves around early
recognition and minimizing morbidity
• Associated injuries are common
• CHI 50%
• Long Bone Fx 48%
• Thoracic Injury 21%
• Liver/Spleen 7% each
• GI/GU Tract 5% each
Trauma 6th Ed. Feliciano et al. p.781
VASCULAR ANATOMY
•The iliac artery and venous trunks run
ventral to the sacroiliac joint bilaterally
•Lateral compression, anterior compression,
or vertical shear result in ligamentous/bony
injury which are often visible on plain film
•Arterial injury often presents with a
continued hemodynamic decompensation
•Venous injury often will tamponade
EAST GUIDELINES FOR PELVIC FRACTURE
•
•
•
•
•
•
1. Which patients with hemodynamically unstable pelvic
fractures warrant early external mechanical stabilization?
2. Which patients require emergent angiography?
3. What is the best test to exclude extrapelvic bleeding?
4. Are there radiologic findings which predict
hemorrhage?
5. What is the role of noninvasive temporary external
fixation devices?
6. Which patients warrant preperitoneal packing (PPP)?
1. WHICH PATIENTS WITH HEMODYNAMICALLY UNSTABLE PELVIC
FRACTURES WARRANT EARLY EXTERNAL MECHANICAL
STABILIZATION?
•
The use of a pelvic orthotic device (POD) does not seem to
limit blood loss in patients with pelvic hemorrhage. Level III
recommendation
•
The use of a POD effectively reduces fracture displacement
and decreases pelvic volume. Level III recommendation
•
Temporary Pelvic Binders (TPB) reduce 24 and 48 hour
blood transfusion requirements when compared to early
External Pelvic Fixation (EPF)
2. WHICH PATIENTS REQUIRE EMERGENT ANGIOGRAPHY?
•
Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after
nonpelvic sources of blood loss have been ruled out should be considered for pelvic
angiography/embolization. Level I recommendation
•
Patients with evidence of arterial intravenous contrast extravasation (ICE) in the pelvis by CT may
require pelvic angiography and embolization regardless of hemodynamic status. Level I
recommendation
•
Patients with pelvic fractures who have undergone pelvic angiography with or without embolization,
who have signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out,
should be considered for repeat pelvic angiography and possible embolization. Level II
recommendation
•
Patients older than 60 years with major pelvic fracture (open book, butterfly segment, or vertical
shear) should be considered for pelvic angiography without regard for hemodynamic status. Level II
recommendation
•
Although fracture pattern or type does not predict arterial injury or need for angiography, anterior
fractures are more highly associated with anterior vascular injuries, whereas posterior fractures are
more highly associated with posterior vascular injuries. Level III recommendation
•
Pelvic angiography with bilateral embolization seems to be safe with few major complications. Gluteal
muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged
immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct
complication of angioembolization. Level III recommendation
•
Sexual function in males does not seem to be impaired after bilateral internal iliac arterial
embolization. Level III recommendation
3. WHAT IS THE BEST TEST TO EXCLUDE EXTRAPELVIC BLEEDING?
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•
•
•
Focused Assessment with Sonography for Trauma (FAST) is not
sensitive enough to exclude intraperitoneal bleeding in the
presence of pelvic fracture. Level I recommendation
FAST has adequate specificity in patients with unstable vital
signs and pelvis fracture to recommend laparotomy to control
hemorrhage. Level I recommendation
Diagnostic peritoneal tap (DP)/Diagnostic peritoneal lavage (DPL)
is the best test to exclude intra-abdominal bleeding in the
hemodynamically unstable patient. Level II recommendation
In the hemodynamically stable patient with a pelvic fracture, CT
of the abdomen and pelvis with intravenous contrast is
recommended to evaluate for intra-abdominal bleeding
regardless of FAST results. Level II recommendation
4. ARE THERE RADIOLOGIC FINDINGS WHICH PREDICT HEMORRHAGE?
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•
•
•
•
•
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Fracture pattern on pelvic X-ray does not single-handedly predict
mortality, hemorrhage, or the need for angiography. Level II
recommendation
Presence/location of hematoma does not predict or exclude the need
for angiography and possible embolization. Level II recommendation
CT of the pelvis is an excellent screening tool to exclude pelvic
hemorrhage. Level II recommendation
Absence of contrast extravasation on CT does not always exclude
active hemorrhage. Level II recommendation
Pelvic hematoma >500 cm in size has an increased incidence of arterial
injury and need for angiography. Level II recommendation
Isolated acetabular fractures are as likely to require angiography as
pelvic rim fractures. Level III recommendation
If a retrograde urethrocystogram is required, it should be performed
after CT with intravenous contrast. Level III recommendation
5. WHAT IS THE ROLE OF NONINVASIVE TEMPORARY EXTERNAL
FIXATION DEVICES?
•
TPBs effectively reduce unstable pelvic fractures as well as
definitive stabilization and decrease pelvic volume. Level III
recommendation
•
TPBs may limit pelvic hemorrhage but do not seem to
affect mortality. Level III recommendation
•
TPBs work as well or better than emergent EPF in
controlling hemorrhage. Level III recommendation
6. WHICH PATIENTS WARRANT PREPERITONEAL PACKING (PPP)?
• Retroperitoneal pelvic packing is effective in
controlling hemorrhage when used as a salvage
technique after angiographic embolization. Level III
recommendation
• Retroperitoneal pelvic packing is effective in
controlling hemorrhage when used as part of a
multidisciplinary clinical pathway including a
POD/C-clamp. Level III recommendation
CASE #2
• History
• 49 year old female passenger, restrained, MVC
• Possible brief LOC
• Complaint of left chest/breast pain, mild right
abdominal pain
• Level 2 Trauma activation
• GCS 15, HR 71, BP 154/94, RR 20, O2 sat 100% 6L
INITIAL ASSESSMENT
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Working Diagnosis
• ?LOC
• Breast pain
• Abdominal pain (mild)
INITIAL IMAGING
WHILE IN CT…
• Increased agitation = CT head negative
• GCS 14, HR 77, BP 51/35
• CT chest/abd/pelvis in progress
WHILE IN CT…
• Scan stopped, IV bolus provided
• HR 74, BP 102/52
• Delayed images show increased free fluid
• HR 74, BP 88/40
• Taken to OR from CT scanner for exploration
• Shearing injury of abdominal wall
• Avulsion of 30 cm of distal ileum requiring resection
• Active bleeding from branch of ileocolic artery
BLUNT VISCERAL INJURY
• Sir McCormack in 1900 was the first to
advocate “A man wounded in war in the
abdomen dies if he is operated upon and
remains alive if he is left in peace”
• Nonoperative Management has reported
success rates of ~90% in properly selected
patient populations – regardless of age,
grade of injury, multivisceral injury, and
mechanism of injury
FAST, DPL, DIAGNOSTIC LAPAROSCOPY
•
Overall, FAST has a sensitivity between 73% and 88%,
a specificity between 98% and 100% and is 96% to 98%
accurate
•
The accuracy of DPL has been reported between 92%
and 98%
•
Although there are no randomized, controlled studies
comparing Diagnostic Laparoscopy (DL) to more
commonly utilized modalities, experience at one
institution using minilaparoscopy demonstrated a 25%
incidence of positive findings on DL, which were
successfully managed nonoperatively and would have
resulted in nontherapeutic laparotomies
OTHER ITEMS OF INTEREST
• Damage Control Surgery
• Abdominal Compartment Syndrome
DAMAGE CONTROL
• Traditional thinking = The best operation for
a patient is a single, definitive procedure
ER => OR => ICU
• Unfortunately, severely injured patients
(ISS>35) are more likely to die from intraoperative metabolic failure, than from failure
to complete a definitive procedure
DEATH TRIAD
Hypothermia
Coagulopathy
Acidosis
OR POSSIBLY A LITTLE MORE COMPLEX
DAMAGE CONTROL IN PRACTICE
• Control hemorrhage
• Contain/Stop contamination
• Avoid further injury
ER => OR => ICU => OR => ICU
GUIDELINES FOR INSTITUTING DAMAGE CONTROL
• pH < 7.2
• Serum bicarbonate < 15
• Core temp < 34 C
• Transfusion > 4 L pRBC
• Total blood products > 5 L
• Total fluid > 12 L
If all of the above = death
If one or more = damage control
ABDOMINAL COMPARTMENT SYNDROME
https://www.wsacs.org/
QUESTIONS