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Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

GastrointestinalandGenitourinaryTrauma

Presenter:DanielWachter,MD

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Lecture Objectives

  ReviewrelevantGIandGUanatomy  UnderstandpatternsandpathophysiologyoftraumaticGIandGUinjury

  ExplainthediagnosticmodalitiesappropriateforparticulartraumaticGI/GUconditions

  DescribeanalgorithmicapproachtoGIandGUtraumaticinjuryevaluationandmanagement


Potential Injury by Anatomic Region: (Most commonly injured organs in red)

  IntrathoracicAbdomen•  Diaphragm,liver,spleen,stomach.•  Cannotbepalpatedasitliesbehindtheribs.

  PelvicAbdomen:•  Urinarybladder,urethra,rectum,smallintestine,•  Ovaries,fallopiantubes,anduterusinwomen•  Considerextra-peritonealinjuriesinthisregion.

  Retroperitonealabdomen•  Containsthekidneys,ureters,pancreas,aorta,andvenacava•  Usuallyrequireadvancedimagingtoidentifyanddiagnosetheseinjuries.

  Abdomen(proper)•  Containsthesmallandlargeintestines,graviduterus,andthedistendedurinarybladder.

•  Physicalexam,x-raysandDPLareusefulandreliableinthisarea.


Gastrointestinal Anatomy

LadyOfHats(Wikipedia)


Pathophysiology   BluntTraumaticInjury:Threeinjuriespatterns•  RapidDeceleration–shearinginjury

  Injureshollow,solid,visceralorgansorvascularstructures•  Crush

  Abdominalanteriorlyandvertebraeorribsposteriorly.•  ExternalCompression

  Canoccurthroughouttheabdomen  Maycausediaphragmaticorhollowviscousrupture

  PenetratingInjury–stabsandprojectiles


Pathophysiology of Specific Blunt Injuries

  SolidvisceralInjuries•  Liver,Spleen,Pancreas,Kidney

  Gastrointestinal/Hollowviscusinjuries•  Duodenalinjuries•  SmallBowel

  RetroperitonealInjuries  DiaphragmaticInjuries

Pathophysiology


Diagnostic Evaluation of Penetrating Trauma: Stab Wounds

  Unstablepatientsorthosewithperitonitisshouldbeconsideredemergentlyforlaparotomy.

  Stablepatientscanundergolocalwoundexploration.Ifnoperitonealviolationisdetected,serialexaminationsareperformed.


Stab Wound Diagnosis   DiagnosticPeritonealLavage(DPL)orFocusedAbdominalSonographyforTrauma(FAST)•  FASTscanispreferredduetohigherpositivepredictivevalue,butbothareacceptable.•  FurtherdiscussionofDPLandFASTfollows

  PerformAP/LateralChestx-rayfordiaphragmatic,mediastinalorlunginjury.

  CTscancanbeconsidered,butisnotalwaysmandatoryinanteriorabdominalstabwounds

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Stab wound

www.trauma.org


  Unstablepatientssufferingprojectilewoundstotheabdomenshouldproceedemergentlytotheoperatingtheater.

  Thespecificlocationofprojectilefragmentscanbeinvestigatedafterstabilizationisachieved.

  StablepatientssufferingprojectilewoundstotheabdomenshouldundergoCTscanningandserialexaminations.

Diagnostic Evaluation of Penetrating Trauma: Projectile Wounds


GSW to RUQ

www.trauma.org


www.Trauma.org

Blunt Traumatic Injury


Evaluation after Blunt Abdominal/Pelvic Injury

  PhysicalExamination  DiagnosticImaging•  Plainradiography• Ultrasound• CTscan

  DiagnosticProcedures


Physical Exam: Abdomen

 Observefordistension  Listenforbowelsounds  Palpatefortenderness  “GrayTurner”signisecchymosisofflankfromretroperitonealinjury


Grey-Turner Sign

http://en.wikipedia.org/wiki/File:Hemorrhagic_pancreatitis_-_Grey_Turner%27s_sign.jpg


Physical examination: Pelvis

  CompresstheAnteriorSuperiorIliacCreststoassessforpainormovementonPAcompression.

  CompresstheAnteriorSuperiorIliacCrestslaterallyforpainormovement.

  Palpateatthepubicsymphisisfortenderness,step-offorcrepitance.

  Pelvicfracturearepainfulandusuallydemonstratetenderness. GhanaEmergencyMedicineCollaborative

AdvancedEmergencyTraumaCourse

Check the Back/Rectal   Log-rollthepatientwhileobservingspinalprecautions.

  Lookandpalpateforstep-offs,abrasions•  Bulletholesorstabwounds

  Performrectalexamforgrossbloodbonypelvicfragmentsor“high-riding”prostate.


www.Trauma.org

CXR – Diaphragmatic Rupture


http://ejournal.afpm.org.my/Assets/factory_worker_chest_radiograph2.jpg

CXR – Viscus Rupture   FreeAirbelowthediaphragm


FAST Exam   FocusedAbdominalSonographyinTrauma

  4viewsoftheabdomentolookforfluid.•  RUQ/Morrison’spouch•  Subxiphoid–viewofheart•  LUQ–viewofsplenorenaljunction•  Bladder–viewofpelvis


FAST   Haslargelyreplaceddeepperitoneallavage(DPL)

  Bedsideultrasoundlookingforbloodcollectioninanunstablepatient.

  Ifthepatientisunstableandabloodcollectionisfound,proceedemergentlytotheoperatingtheater.


FAST   Sensitivityof94.6%  Specificityof95.1%  Overallaccuracyof94.9%inidentifyingthepresenceofintraabdominalinjuries.•  Yoshil:JTrauma1998;45


FAST Right Upper Quadrant -Morrison’s Pouch

  BetweentheliverandkidneyinRUQ.  Firstplacethatfluidcollectsinsupinepatient.


FAST Exam - RUQ

Source: University of Louisville ED website www.louisville.edu/medschool/emergmed/ultrasoundfast.htm



FAST - Subxiphoid

  Evaluateforpericardialfluid  Viewthroughliver•  TranshepaticorParasternal

  Searchesforfluidbetweenheartandpericardium


FAST - Subxiphoid




FAST – Left Upper Quadrant

  Viewbetweenthespleenandkidney  Anotherdependentplacethatfluidcollects  Alsoseediaphragminthisview


FAST - LUQ




FAST – Bladder View

  EvaluatesforfluidinthepouchofDouglas•  Posteriortobladder.

  Dependentpotentialspace.


FAST – Bladder View




Interpret this FAST Image:



Diagnostic Procedures   Diagnostic peritoneal lavage

•  Bedside test for expeditious discovery of free peritoneal blood.

•  Used in multiply injured, altered mentation or to more closely investigate those whose exam is confounded by pelvic or thoracic injuries.

•  Semi-open technique is preferable to percutaneous technique

•  Performed at infraumbilical site unless the patient is pregnant or a large pelvic hematoma is suspected.


Diagnostic Peritoneal Lavage

  DPLmustnotdelaytransporttotheoperatingtheaterwhenemergentlaparotomyisneededregardlessofDPLfindings.

  ComplicationsofDPLinclude:•  Bleeding,•  Infection•  Intra-abdominalinjuries•  False-positiveleadingtounnecessaryexploratorylaparotomy.


DPL: Findings Mandating Surgery

  Greaterthan10mLgrossbloodoncatheterinsertion,orgreaterthan15-20mLonaspiration

  Followingperitoneallavagewithoneliter(1L)crystalloid:•  Greaterthan100,000RBC/mm3,or•  Greaterthan500WBC/mm3,or•  Bile,foodmatter,highamylase,bacteria


Pelvic Fractures   Canbestableorunstable.  Ifunstable,theymustberepairedbyorthopedics.

  Mayhavesignificantbleedingfromvesselsonpelvicfloor.

  Pelvicfracturesshouldbestabilizedwithasheetwrappedtightlyaroundthepelvis.


Pelvic Fracture   PelvicRingFractureshaveahighassociationwithabdominal/pelvicinjuries

  PelvicFracture–“OpenBook”

http://emedicine.medscape.com/article/394515-overview


www.Trauma.org

Pelvic Fracture


Improvised Pelvic Binder

  Maximalcompressionisattheheightofthegreatertrochanters

http://www.aaos.org/news/aaosnow/jul09/clinical8-3.gif


After Binder Application

www.trauma.org


Management Algorithm   ABC,IV,O2,monitor  Primaryandsecondarysurveywhile2Lofcrystalloidinfuses  Ifremainsunstableafterbolus,transfuseblood•  Startwith2Unitsofpackedredbloodcells

  FASTScanforintraperitoneal,pericardiachemorrhage  IfFASTisnegativeandpatientisunstableconsiderDPL  IfFASTisnegativeandpatientisstable,considerserialexamsand/orCTscan

  IfFASTispositiveandpatientisunstable,proceedtoemergentexploratorylaparotomy

  IfFASTispositiveandpatientisstable,performCTscan  IfCTscanisnegativeandpatientishypotensive,considerarteriographyorlaparotomy


When to Consult Surgery Following Abdominal Trauma

  Clinicallyunstable•  Abnormalvitalsignsorpoorgeneralappearancewithoutexternalhemorrhagetoaccountforinstability

  Peritonealfindingsonexam•  Severetenderness,reboundorguarding

  Highriskofassociatedsignsandinjuries•  Pelvicfractures,lumbarspinefractures,lowerribfractures,“Grey-Turner”or“Cullen”Sign,Seat-BeltSign

  Patientcannotbeadequatelyevaluated:•  Alteredmentalstatus,languagebarrier,age(youngoradvanced),significantheadorneckinjury.

  PositiveDPL,FASTscanorfree-aironplainradiographs


Penetrating Abdominal Trauma Miscellaneous Points

  Evisceration•  Proceedtotheoperatingtheaterorreducetheomentumwithemergentsurgicalconsultation.

  Penetratingobjectsshouldnotberemovedexceptinproximitytodefinitivecare.•  Pre-maturelyremovingtheobjectmayleadtoexsanguinationifitistamponadingapotentialvasculardisaster.


Genitourinary Trauma

  GeneralAnatomyReview•  UpperGU:kidneys,pelvocalicealsystem,andureters•  LowerGU:bladder,urethra,externalgenitalia

  PathophysiologyofTraumaticInjury•  BluntTraumaticInjury

  RapidDecelerationConsideration  PediatricConsiderations

•  PenetratingInjuryGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

GU Trauma Physical Examination

  Examineforbloodattheurethralmeatus.  Bloodpresentshouldraiseconcernforpelvicfracture.

  Foleyshouldnotbeplaceduntilaretrogradeurethrogramhasbeenperformed.

  Aretrogradeurethrogramorcystograminastablepatientwhohasbloodattheurethralmeatusorevidenceofurethralorbladderinjuryfrompenetration.


Evaluation for Traumatic GU Injury   PhysicalexamforGUinjuriesisoflimitedvalueinobtainingdetailedoroperative-planninginformation•  Urinedipandmicroscopy•  RectalExamforbonyprotrusion,tenderness,high-ridingprostate,boggyprostate

•  Examineforbloodattheurethralmeatus,scrotalhematomaandperinealecchymosis

  Indicationsforimaging•  Grosshematuria•  Microscopichematuriawithhemodynamicinstability•  Persistentmicroscopichematuria(serialurineanalysis)•  Hemodynamicinstabilitywithhistoryofsignificantdecelerationmechanism•  However,microscopichematuriainaclinicallystablepatientisrarelyassociatedwithfindingsonimaging.


CT Scanning in GU Trauma   CTscanoftheabdomenandpelviswithIVcontrast•  CTscanispreferredoverintravenouspyelogram(IVP)inrenalinjuries•  Imagingismoredetailed,sensitiveandmaydetectotherintraabdominalinjuriesorurinecollections

  InthepresenceofpenetratingflanktraumaIV/PO/PR,“triplecontrast”CTscanisthepreferredmodality

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourseGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Further GU Trauma Imaging   Intravenouspyelogram(IVP)•  Contrastdyeclearedviathekidneysprovidesagoodindicationofbilateralrenalfunctionifureteralinjuryisconsidered.

•  CanbeusedwhenrenalinjuryissuspectedandCTscanisnotavailable,buttestcharacteristicsareinferiortoCTscanning.

•  AbnormalIVPisanindicationforCTscan,angiographyorsurgery.  Ultrasonography•  UltrasonographyisoftenreadilyavailablebutdoesnotofferthesensitivityofCTscanning

•  RenalimagingisperformedroughlybytheFASTexaminationbutmightdetectrenallacerationswithhematomaformationorurinomas.

  Radionuclideimagingisnotindicatedintheinitialevaluationforrenaldamage.

  Retrogradeureterogramisnotperformedintheemergencysetting.


Normal Bladder vs. Ruptured Bladder

http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-821994-828251-1375001.jpg

http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-821994-828251-1374998.jpg


Genitourinary Injuries   UrethralInjuries•  Almostexclusivelyinmales•  Anteriorurethrainjuryusuallycausedbystraddleinjury•  Posteriorurethrainjuryusuallycausedbypelvicfracture•  Urologyconsultation,bladderdrainagewithsuprapubiccatheteranddelayedrepair

  TesticularandScrotalInjuries–radionuclidestudyfortesticularviability.Considersurgicalexploration

  PenileInjuries–associatedwithurethralinjuries,causedbyrupturedBucks’fasciaandcorpuscallosumfromtraumaduringerection•  90%resolvespontaneously•  10%requiresurgeryforhematomaevacuation


Genitourinary injuries   RenalInjuries–frequentlydiagnosedbyCTandlikelynotanisolatedinjury•  Managementinvolvessurgery,urologyandangiography•  RenalContusion•  RenalLaceration•  PedicleInjury•  RenalRupture•  RenalPelvicRupture

  UreteralInjuries–rareduetowell-protectedlocation


Bladder Injuries   Ifimagingisunavailable,canbesuspectedbyinabilitytoaspirateafterbladderirrigation• CTcystoscopyisreplacingtraditionalcystoscopyastheimagingmodalityofchoice• Usuallytheresultofbluntabdominaltrauma•  Bladdercontusion–conservativemanagementashematuriaresolves


Bladder Rupture   Intraperitoneal•  Lesscommon•  Notusuallyassociatedwithpelvicfractures•  Requiressurgicalrepair

  Extraperitoneal•  Morecommon•  Associatedwithpelvicfractures•  Initialconservativemanagementisacceptable•  Delayedcystogramin7-10daysaslongaspatientisabletovoidwithorwithoutfoleycatheter  Unlesshematuriacontinuesorpelvichematomaforms


Key Points of GU Trauma   GUinjuriesarehighlyassociatedwithadditionalabdominal/pelvicinjuries

  Lookforlowerabdominal/flank/genital/backecchymosisoredema

  Elicitahistoryofinabilitytovoidfollowinginjury  Exploreforhematuria  Consideradvancedimaging  Involvegeneralandspecialistsurgeonsfordefinitivemanagementandtoguidethediagnosticevaluation


Special Cases   PenetratingTraumatotheFlank•  Scapulartiptoiliaccrest,betweenanteriorandposteriorAxillarylines•  Pathophysiology–canviolateretro-andintra-peritonealspaces•  ClinicalFeatures–

  Flankecchymosis,hematuria,abdominaltenderness,CVAtenderness,orUNDIFFERENTIATEDHYPOTENSION

•  Diagnosis–triplecontrastCT(IV/PO/PRcontrast)•  Treatment–

  Surgery,angiographyorconservativemeasureareallpossible.


Special Cases   PenetratingTraumatotheButtocks•  Pathophysiology

  Canviolateretro-,intra-andextra-peritonealspacesandstructures

  GI/GU,vascular,neurologicalandmusculoskeletalstructuresareallatrisk

•  Diagnosis–Negativerectalexamdoesnotexcludethediagnosis

  CTscanshouldbestronglyconsidered  Endoscopyshouldbeavoidedduetopossiblehollowviscusinjuryworseninginthefaceofinsufflation

•  Management–  Surgicalconsultation  Angiographymayalsoberequired.



Questions?

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