radiologic assessment of penetrating abdominal trauma
TRANSCRIPT
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Radiologic Assessment ofRadiologic Assessment of Penetrating Abdominal TraumaPenetrating Abdominal Trauma
John D. Gleason, Harvard Medical School, Year IIIGillian Lieberman, MD
John D. GleasonGillian Lieberman, MD March 2002
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BackgroundBackground
• All penetrating abdominal injuries must be surgically explored.
John D. GleasonGillian Lieberman, MD
• Fact: Based on war experience, surgeons in the 1950s surgically explored all penetrating abdominal trauma. Studies during the 1960s began looking at selective observation of some patients. Today, aided by modern imaging, many patients can be observed.
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Classification of Penetrating TraumaClassification of Penetrating Trauma• Gunshot wound (GSW) vs. stab wound (SW)
– Over 95% of GSWs penetrating the peritoneum require laparotomy
– About 50% of SWs go on to laparotomy
• Anterior vs. posterior stab wounds– 35% of anterior wounds do not have fascial
penetration– Posterior wounds are more likely to cause
retroperitoneal injury
John D. GleasonGillian Lieberman, MD
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Menu of TestsMenu of Tests
• Plain film- useful but insufficient for trauma evaluation
• CT• US• Peritoneal Lavage
John D. GleasonGillian Lieberman, MD
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CTCTPros:
– can evaluate retroperitoneum, pancreas, liver, kidneys, duodenum
– roughly quantify hemoperitoneum– grade injuries to solid organs and follow over time
Cons:– insensitive at detecting bowel and diaphragmatic
injuries (improved with triple contrast and coronal reconstruction)
– requires transporting patient to radiology, time consuming (poor for unstable patients)
John D. GleasonGillian Lieberman, MD
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UltrasoundUltrasound
Pros:– can be done rapidly in the trauma bay
good for detecting free abdominal fluid orpericardial tamponade
Cons:– inferior to CT for identifying and grading
solid organ injury & retroperitoneal trauma– also poor at diagnosing bowel injury
John D. GleasonGillian Lieberman, MD
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Diagnostic Peritoneal Lavage
Pros:– can be done rapidly in the trauma bay– can sometimes detect bowel contents
Cons:– cannot quantify hemoperitoneum (small, self-limited
lacerations may test positive)– no indication of source of bleeding– does not address retroperitoneal injuries
John D. GleasonGillian Lieberman, MD
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AlgorithmAlgorithmAbdominal Stab Wound
Unstable Stable
Anterior Posterior
Local Wound Exploration CTObserve
Discharge DPL or CT
Observe Ex Lap
Ex Lapor
FAST
John D. GleasonGillian Lieberman, MD
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Our Patient, M.R.Our Patient, M.R.
• M.R. is an 18-yo male who presents to the ED with a stab wound to the right back.
• A&O, c/o RLQ and R back pain.• Vitals: 180, 130/80, 18, 100% RA.• Hct 36.• No PMH/PSH.
John D. GleasonGillian Lieberman, MD
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AlgorithmAlgorithmAbdominal Stab Wound
Unstable Stable
Anterior Posterior
Local Wound Exploration CTObserve
Discharge DPL or CT
Observe Ex Lap
Ex Lapor
FAST
John D. GleasonGillian Lieberman, MD
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AlgorithmAlgorithmAbdominal Stab Wound
Unstable Stable
Anterior Posterior
Local Wound Exploration CTObserve
Discharge DPL or CT
Observe Ex Lap
Ex Lapor
FAST
John D. GleasonGillian Lieberman, MD
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Chest FilmChest Film
Limited evaluation asRight costophrenicangle cut off
Limited evaluation asRight costophrenicangle cut off
Findings
• No PTX• No left-sided
effusion• Normal
mediastinum• No abdominal
free air
John D. GleasonGillian Lieberman, MD
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
Fluid consistent with
Hematoma
Fluid consistent with
Hematoma
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleedingActiveBleeding
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleedingActiveBleeding
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleedingActiveBleeding
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleedingActiveBleeding
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleedingActiveBleeding
BIDMC PACS
Kidney displaced anteriorly
Kidney displaced anteriorly
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
HematomaHematoma
ActiveBleeding
- vs -Collecting duct injury
ActiveBleeding
- vs -Collecting duct injury
BIDMC PACS
Kidney displaced anteriorly
Kidney displaced anteriorly
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
ActiveBleeding
- vs -Collecting duct injury
ActiveBleeding
- vs -Collecting duct injury
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
ActiveBleeding
- vs -Collecting duct injury
ActiveBleeding
- vs -Collecting duct injury
BIDMC PACS
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Abdominal CTAbdominal CT
John D. GleasonGillian Lieberman, MD
BIDMC PACS
Path of stab wound
Path of stab wound
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Pelvic CTPelvic CT
John D. GleasonGillian Lieberman, MD
BIDMC PACS
UretersUreters
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Initial CT FindingsInitial CT Findings
• Lacerations to liver and right kidney• Intra-abdominal and retroperitoneal
hemorrhage• Active extravasation of contrast• Patient clinically stable so nothing
warranted immediate surgery
John D. GleasonGillian Lieberman, MD
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AlgorithmAlgorithmAbdominal Stab Wound
Unstable Stable
Anterior Posterior
Local Wound Exploration CTObserve
Discharge Diagnostic Peritoneal Lavage
Observe Ex Lap
Ex Lapor
FAST
John D. GleasonGillian Lieberman, MD
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Further Evaluation of Renal InjuryFurther Evaluation of Renal Injury
• A CT urogram was ordered to determine whether the perirenal fluid was blood versus urine from a collecting duct injury
• To determine the source of the perirenal contrast extravasation, a CT urogram was performed 12 hours later.
John D. GleasonGillian Lieberman, MD
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CT CT UrogramUrogram: 12 hours later: 12 hours laterJohn D. GleasonGillian Lieberman, MD
R KidneyR Kidney
BIDMC PACS
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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD
R KidneyR Kidney
UreterUreter
BIDMC PACS
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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD
R KidneyR Kidney
UreterUreter
Collecting system Collecting system
BIDMC PACS
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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD
R KidneyR Kidney
UreterUreter
Collecting system Collecting system
BIDMC PACS
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CT CT UrogramUrogramJohn D. GleasonGillian Lieberman, MD
R KidneyR Kidney
Collecting system Collecting system
BIDMC PACS
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CT CT UrogramUrogram FindingsFindings
• Large right perirenal organizing hematoma• No evidence of extravasation of contrast
material• No injury to right collecting system
John D. GleasonGillian Lieberman, MD
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M.R.M.R.’’ss Hospital CourseHospital Course
• His Hct stabilized at 26, tolerated regular diet.
• Hepatobiliary scan revealed no leakage.• Discharged on hospital day 4 with follow-
up in trauma clinic in one week.
John D. GleasonGillian Lieberman, MD
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FollowFollow--up CTup CTOriginal CT Follow-up CT at 11 days
John D. GleasonGillian Lieberman, MD
BIDMC PACSBIDMC PACS
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Ultrasound Approach to the Ultrasound Approach to the Unstable PatientUnstable Patient
John D. GleasonGillian Lieberman, MD
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FASTFAST
• Focused Assessment with Sonography for Trauma• Performed early during resuscitation only to
identify evidence of injury (hemoperitoneum).• Four areas of attention: perihepatic, perisplenic,
pelvic and pericardial.• Well established for detecting surgical
hemoperitoneum in patients with blunt trauma (Sn 81-88%, Sp 97-100%). A recent study for penetrating trauma showed Sn 46% and Sp 94%.
John D. GleasonGillian Lieberman, MD
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PerihepaticPerihepatic FASTFAST
John D. GleasonGillian Lieberman, MD
• Hepatorenal space (Morison’s Pouch) is the most dependent area of the right upper quadrant.
• Look for hypoechoic stripe between capsule of liver and Gerota’s fascia of kidney.
Transducer in the right mid- to posterior axillary line at the level of the 11th and 12th ribs.
http://www.trauma.org/radiology/FASTruq.html
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PerihepaticPerihepatic FASTFAST
John D. GleasonGillian Lieberman, MD
Normal Perihepatic FAST Positive Perihepatic FAST
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PerihepaticPerihepatic FASTFAST
http://www.trauma.org/radiology/FASTruq.html
Normal Perihepatic FAST Positive Perihepatic FAST
John D. GleasonGillian Lieberman, MD
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PerisplenicPerisplenic FASTFAST
John D. GleasonGillian Lieberman, MD
• In the LUQ, the perisplenic area is dependent.
• Look for hypoechoic area near the spleen and kidney.
Transducer in the left posterior axillary line region between the 10th and 11th ribs.
http://www.trauma.org/radiology/FASTluq.html
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PerisplenicPerisplenic FASTFAST
Normal Perisplenic FAST Positive Perisplenic FAST
John D. GleasonGillian Lieberman, MD
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PerisplenicPerisplenic FASTFAST
Normal Perisplenic FAST Positive Perisplenic FAST
http://www.trauma.org/ortho/fastluq.html
John D. GleasonGillian Lieberman, MD
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Pelvic FASTPelvic FAST
John D. GleasonGillian Lieberman, MD
• In the pelvis, the rectovesicular or rectouterine area is most dependent (pouch of Douglas).
• Look for hypoechoic area near the bladder or uterus.Transducer is midline just superior to the
symphysis pubis.
http://www.trauma.org/radiology/FASTpelvis.html
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Pelvic FASTPelvic FAST
John D. GleasonGillian Lieberman, MD
Normal Perihepatic FAST Positive Perihepatic FAST
“Mickey Mouse ears”
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Pelvic FASTPelvic FAST
Normal Pelvic FAST Positive Pelvic FAST
http://www.trauma.org/ortho/fastpelvis.html
John D. GleasonGillian Lieberman, MD
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SubxiphoidSubxiphoid FASTFAST
John D. GleasonGillian Lieberman, MD
• The subxiphoid view inspects the heart for tamponade.
• Pericardial tamponade will appear as a hypoechoic region within the pericardial space between the visceral and parietal pericardia.
Transducer is to the left of the xiphoid process and angled upward under the costal margin.
http://www.trauma.org/radiology/FASTpericardium.html
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SubxiphoidSubxiphoid FASTFAST
John D. GleasonGillian Lieberman, MD
Normal Subxiphoid FAST Positive Subxiphoid FAST
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SubxiphoidSubxiphoid FASTFAST
Normal Subxiphoid FAST Positive Subxiphoid FAST
http://www.trauma.org/radiology/FASTpericardium.html
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SummarySummary
• CT is the test of choice for assessing the degree of abdominal injury in a stable patient with penetrating abdominal trauma.
• US can be helpful in detecting free abdominal fluid in an unstable patient.
• Some patients can be successfully observed based on clinical and radiologic findings.
John D. GleasonGillian Lieberman, MD
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ReferencesReferences• Brant WE, Helms CA: Fundamentals of Diagnostic Radiology, ed 2. Baltimore, Williams &
Wilkins, 1999, pp 831-858.• Chiu WC, Shanmuganathan K, et al. Determining the need for laparotomy in penetrating torso
trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma. 2001;51:860-869.
• Exsanguinating pelvic trauma. http://www.trauma.org/ortho/pelvis.html• Feliciano DV, Moore EE, Mattox KL: Trauma, ed 3. Stamford, Appleton & Lange, 1995, pp
441-459, • Ng A. Trauma ultrasonography: the FAST and beyond.
http://www.trauma.org/radiology/FASTintro.html• Scalea TM, Rodriguez A, et al. Focused assessment with sonography for trauma (FAST):
results from an international consensus conference. J Trauma. 1999;46:466-472.• Shatz DV, Kirton OC, et al: Manual of Trauma and Emergency Surgery. Philadelphia, W.B.
Saunders Company, 2000, pp 119-143.• Udobi KF, Rodriguez A, et al. Role of ultrasonography in penetrating abdominal trauma: a
prospective clinical study. J Trauma. 2001;50:475-479.
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AcknowledgementsAcknowledgements
• Maria-Candida Albano, MD• Ravi Thakur, MD• Wayne Monsky, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras and Cara Lyn D’amour
our Webmasters
John D. GleasonGillian Lieberman, MD