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Necessitate sign

hello again we'll talk about abdominal trauma here so we'll briefly cover some of the anatomy that's relevant for abdominal trauma some of the physical exam signs that you'll want to know when you're confronting the abdominal trauma patient just the most important physical exam signs we'll talk about two of the mechanisms of abdominal trauma both penetrating and blunt abdominal injury important to remember that you can have both mechanisms of injury in the same patient at the same time these aren't mutually exclusive but most of the time you'll have one or the other we'll talk about the indications for exploratory laparotomy which is your surgical management when you have an abdominal trauma patient a lot of patients with abdominal trauma will be managed with an exploratory laparotomy then we'll talk about some of these briefly talk about some of the specific organs so I want to talk about the injury mechanisms first because when you're confronted with a patient on the trauma Bay or in the Eevee you are confronted with a patient you don't necessarily know which which organ is injured you do know however if this is a penetrating injury or a blunt injury so that's going to dictate your initial workup once you get imaging once you worked on the patient then you'll have a better idea of what organ may be damaged and that can dictate further workup but I want to first talk about what's most important and that is when the patient first comes in what do you do for trauma purposes the abdomen is considered anything below the nipple line all the way down as far as the pubic line and the reason is because you have abdominal viscera that go up past the inferior margin of your costal cartilages so a lot of people think okay my abdomen is perhaps where my abdominal rectus muscles are or my abdomen is below my costal cartilages and that may be a fine definition for other purposes but you have abdominal viscera that go up above your costal cartilages up above the inferior margin especially including your liver and spleen which are two of the most common injured organs in abdominal trauma so for our purposes for trauma the abdomen is everything below the nipple line all the way down to the pubic line this includes your peritoneum which is your liver spleen your stomach the last one quarter of your duodenum the small bowel all the rest of it so juju Newman ilium the transverse colon and the sigmoid colon the retroperitoneum is the last three quarters of the duodenum then the pancreas and kidneys the ureters the a sending and descending colon and the major vessels the pelvis includes the bladder urethra the rectum rectum the iliac arteries and veins and then the reproductive organs ovaries uterus prostate so we're not going to talk about pelvis so much here we're not going to talk about kidneys or ureters that's a topic for another section but we will talk about the everything you see in the peritoneum and then the GI stuff of the retroperitoneal some physical exam signs that you will see in abdominal trauma patient so that you may see first off are the seatbelt sign so that's exactly what it sounds like this is an abrasion due to wearing a seat belt one of the most common ways that you get abdominal trauma is motor vehicle accident and so if the patient is wearing their their seat belt as they should if they're involved in a high energy collision you're going to see that abrasion on their chest their abdomen remember that you have both most of the times you have the diagonal belt and then you have the lap belt it's important to ascertain whether the patient was only wearing a lap belt a lot of times that's children are only wearing a lap but you should see both the diagonal and the lap belts if you do see this what you need to consider is a lumbar spinal fracture which is called a chance fracture and this can also be a thoracic spinal fracture or a cervical spinal fracture chance fracture just means that you have a fracture due to due to flexion of the spine due to over flexion of the spine the reason this happens is because of inertia when you come when you crush into something you crash into a wall let's say you have inertia pushing you forward but you also have a force that's stopping you and so you're the the mobile part of your body that's not restrained is going to continue moving forward and the restrained part is going to stay in place and so the you're going to get anterior flexion because of the inertia so that's what causes the chance fracture and then you should also consider bladder and/or bowel perforation from patients with a seatbelt sign so these three things are things that you should consider when you see a patient with the seatbelt sign Cohen sign is periumbilical ecchymosis this points towards hemorrhage in the peritoneum Brae Turner sign is a flank ecchymosis this points to hemorrhage and the retroperitoneum kerosene is pain in the left shoulder and left neck and this is associated with injury to the spleen so just having left shoulder neck pain is not care sign but if you have a patient with abdominal trauma and they have left shoulder or left neck pain especially if it's elicited with palpation of the left upper quadrant you should consider this to be a positive care sign and this is this this is very very very much associated with injury to the spleen the reason being if you have injury to the spleen fluid blood around the spleen this irritates nerves around the diaphragm and that's going to refer to your left shoulder neck so that's somewhat similar to the pain that you get after you have laparoscopic surgery so here's the seatbelt sign you can see the diagonal abrasions here and then the lap belt here another one lap belt down here diagonal belt here this is a chance fracture so here's anterior here and posterior back here all that happened was you had a portion I will be down here that was that was restrained up here was mobile and the spine flexed too far and it caused the breakage of the spinous process you can also see breakage in the body as well so here's another one so you might not be able to see it very well looking anterior posterior lis but if you look laterally it's much easier to see the fracture call ensign this is ecchymosis on the mellitus and grey Turner site which is a blank ecchymosis you probably won't see these ecchymosis Cullen's or grey Turner's sign right away and the patient is something that develops over time so the two types of injury are penetrating abdominal injury this is most commonly caused from gunshot wound stabbing can also be caused from shrapnel injuries and other less common modes of injury but usually it's gunshot wounds and stabbings the violent problems the organ most commonly damaged is the liver and the reasons because your liver is so big it covers up so much space in your abdomen and it's more superficial so the liver is the most commonly damaged organ in your abdomen when it comes to a penetrating injury with blunt abdominal injury this is usually because of a car accident this can be due to direct blow crush injury deceleration injury the organ most commonly damaged here is the spleen but you can also easily get damage to your liver as well so the penetrating abdominal injury is usually due to gunshot wounds stab wounds gunshot wounds as a rule always penetrate the peritoneum or retroperitoneum I mean it's hard to imagine having a gunshot wound that's a legitimate gunshot wound that doesn't penetrate if it's if it's to the abdomen that isn't penetrating the pear to me I'm a retroperitoneum most of the time even you'll have an exit wound where it actually leaves the body too so it goes in one place and leaves in another place so because of that gunshot wounds because they virtually always penetrate the peritoneum of retroperitoneum they're always going to require surgery exploratory laparotomy and that's not to find a bullet or anything that's to look for viscous injuries and injuries of any organ and to repair that so as a rule gunshot wounds they always penetrate the peritoneum a retroperitoneum and they're going to require exploratory laparotomy that's as a rule for the USMLE and most of the time in real life I'm sure there are very very rare exceptions but we're concerned about the rule not the exception as far as stab wounds that's going to depend on the depth as to whether or not we're going to think about exploratory laparotomy so the severity of stab wounds vary based on the depth as well as the habitus of the patient so if you have a really really thin patient or a child a one-inch stab wound or even a half-inch stab wound maybe enough to penetrate through peritoneum or retroperitoneum and that's necessitate surgery however if you have a morbidly obese patient a one-inch stab wound probably won't even cross the the fat so in that case you may not even need to do surgery you'll probably just do wound repair so debridement and stitches so the severity of stab wounds vary based on the depth so here we need to take into consideration this of the the severity we're not necessarily rushing off to surgery with stab wounds and a good way to deter and how bad it is to just put on a sterile glove use your finger and see if you can palpate any abdominal viscera if you palpate abdominal viscera then it's probably a injury to that penetrated the peritoneum all right so initial management so of course we want to make sure the patient has a secure airway and they're breathing properly the big concern with penetrating abdominal injury it's blood loss you have lots of vessels down there so that's really going to be our biggest problem in patients with penetrating abdominal injuries it's really difficult to get a patient above a hundred or 110 systolic as we normally would want to do just because if they are losing blood it's probably going to be rapid and so there is a problem that can come about if you give the patient too much fluids it's called abdominal compartment syndrome and so we want to be we want to give them enough fluids to make sure that they've got a normal systolic pressure and normal being more than 90 but we don't want to overload them with fluids and so the recommendation is to replace fluids enough to maintain systolic pressure above 90 millimeters of mercury you don't need to go any higher than that as long as you're over 90 in a penetrating abdominal injury you're fine don't overload them with fluids just enough to stay above 90 once you've tended to your ABCs you do a focus physical examination looking at the abdomen making sure that they've got a stable pelvis making sure that there's no long bone injuries try to identify where the bleeding is coming from especially if they came in with shock think of all the areas you can bleed you can bleed from your head you can play from your thorax you can bleed your abdomen you complete from your femur the leg you can bleed from your pelvis so you want to rule out as much of those as possible stable patients should should also mention trauma labs should be ordered so CBC BMP you'll probably want to have cultures with the blood too you'll want to get a coagulation typing and matching and then an abdominal x-ray and a chest x-ray any violation of the peritoneum retroperitoneum is going to require prophylactic antibiotics so you'll want to cover GI flora so what I would use would be cefoxitin in a patient whose non penicillin allergic if they are penicillin allergic you could use something like clindamycin and gentamicin those two would cover the GI flora as well as far as imaging the patient that's going to be important as part of the management however the it's the hemodynamic status that is going to dictate how we image the patient so if the patient is stable yes we can send them off for CT if they're not stable this is more of an urgent scenario then you can do fast exam in reality you're probably going to do fast exam on everybody you'll do fast exam while you're waiting for the radiology crew to come take them down to CT but in urgent scenarios fast exam will be your imaging of choice fast exam is just a set of ultrasound examinations that can easily find bleeding but CT is your best exam and that's what you should choose if it's a stable patient so the ABCs focus physical exam trauma labs and playing films CT or fast your imaging and then antibiotics and a tetanus booster for penetrating abdominal injury is your initial management the surgical management is going to be exploratory laparotomy and that's going to depend on their injury so if it's a gun one to the abdomen you're going to do exploratory laparotomy because it's easy to assume with a gunshot wound that you have penetration of the peritoneum if it's a stab wound you can treat them conservatively if there isn't penetration of the peritoneum however if there is penetration or if there are any other indications for laparotomy then you're sending them off to the or so our diagnostic modalities we can talk about this already plain films are part of our initial management these should be ordered on all abdominal trauma patients the chest x-ray is good if you have an injury to the diaphragm you can see bowel contents in the in the thorax usually it's on the left side so that's something that can easily tip you off to a diaphragm injury if you see that up to the or an abdominal x-ray is also useful cervical and lumbar spinal films should also be added to that as well especially if they are suspected for a chance fracture probably add in there for a sec spinal films as well so you're looking for any kind of problems with the with the spine for CT this is the most common league most commonly done and the most accurate diagnostic modality for any kind of abdominal injury this exceeds any other kind of any other kind of imaging that you could do so if we can send them off for CT we do this is only however performed if the patient is hemodynamically stable if they are unstable you are not going to wait and then have them wheeled down to a CT lab and then have them wheeled back we don't want them dying while they're being imaged so this is only performed at the patient is hemodynamically stable and be careful on the USMLE if they will certainly give you CT and fast exam as choices the patient ASIMO dynamically stable go ahead and choose CT if not you need something quicker now if the patient has an absolute indication for Explorer a laparotomy you don't need to do CT because you're going you're already going to be going in and looking at them surgically anyway so for instance if they have evisceration you're going to be doing a laparotomy on that patient anyway so don't even worry about getting a CT you're going to send them straight to the whole arm the fast exam which stands for focused abdominal sonography for trauma is a series of four ultrasound readings three of which are looking for bleeding in the abdomen so the three places you're looking in the abdomen are the right upper quadrant in between the liver and the kidney that's called Morrison's pouch this is one of the most dependent areas in the entire abdomen with the patient is supine so if you see bleeding there then you know that there's intra-abdominal bleeding so this is looking in between the liver and the kidney right upper quadrant the other place you're going to look is the left upper quadrant and that's at the spleen Oh Reno recess so in between the spleen and the kidney and then another place you're going to look is just above the pubis and you're looking at the pouch of Douglas and that's in between the bladder and the rectum if you see any fluid line then that's considered bleeding and the patient is going to be sent off to the o.r another place that you're going to look with a fast exam that's not abdominal related but you still look anyway is pericardium and so what you do here is you just orient your your ultrasound probe right below the xiphoid process you oriented superiorly and to get a nice image of the pericardium and if there's fluid line these patients are going to need these patients are going to need surgical management as well but it's not going to be these patients won't be getting exploratory laparotomy for their injury they're going to need they're going to need decompression of their pericardium so I just add that because the fast exam wouldn't be complete without looking at the pericardium but that's the parent looking at the pericardium obviously does not does not show abdominal injury so those are the four places you look for fast exam this is ideal for non stable patients because of its relative efficiency it's quick defined bleeding pretty easily however if the patient is stable you send them off for CT because it's much easier to see the bleeding with CT fast exam because it's an ultrasound it's operator dependent diagnostic peritoneal lavage can be used but it's widely replaced by the fast exam because it's less invasive with blunt abdominal injury this is most commonly due to motor vehicle accidents the shearing forces deceleration injury crushing injury that happens with blunt with motor vehicle accidents your initial management is going to be pretty similar so we're looking at the ABCs you want to do a focused physical examination here we're going to be very concerned about the possibility of peritoneal science if there are peritoneal signs this automatically is going to warrant exploratory laparotomy remember that with a blunt abdominal injury patient you're not going to see any knife or bullet wound and so if there is guarding or rigidity or rebound tenderness that's peritoneal science that's going to send them off to the Oh are you shouldn't see that in a patient with blunt abdominal injury unless they've got something really wrong going on in their abdomen trauma labs and plain films are ordered as per usual and just like in penetrating injury stable patients will go to a CT to assess damage unstable patients will get fast and then the operative management it's going to be exploratory laparotomy as indicated not all patients with blunt abdominal injury need exploratory laparotomy some do some don't what are the indications for exploratory laparotomy so if the patient has abdominal trauma and they have had hemodynamic instability they're going to get an exploratory laparotomy but the first thing you do before you operate on the patient is stabilize them so when I say abdominal trauma plus hemodynamic instability I mean that they have had hemodynamic instability and why does this indicate exploratory laparotomy if the patient has hemodynamic or has had hemodynamic instability they have to be bleeding somewhere and we're concerned with abdominal trauma that they're bleeding somewhere in the abdomen that would make sense unless they've got somewhere else that they're bleeding from that you can see it's going to be abdominal bleeding until proven otherwise so he Medina hemodynamic instability in the setting of abdominal trauma will require exploratory laparotomy once they've been stabilized if there's peritoneal irritation that's going to go to the O R if there's a Visser a ssin as mentioned earlier that's going to go to the O R if they're suspected or known diaphragmatic injury that's going to go to the O R so part of that chest x-ray can help us determine if there is an injury to the diaphragm a normal chest x-ray doesn't rule out injury to the diaphragm but if you do see bowel in the thorax that's a diaphragmatic injury so those patients will go out to the O R rectal perforation lead / stomach this you can often get by placing an NG tube if you aspirate blood you can be pretty confident that this is bleeding from the stomach if there's three intraperitoneal retroperitoneal air you can see this either on abdominal or chest x-ray you can also see this on CT that's going to indicate laparotomy and if there's a positive diagnostic peritoneal lavage or a positive fast exam that's going to indicate exploratory laparotomy so these are some of the indications I can't say that these are all things of the top ones that I came across so some specific notes for the diaphragm some signs of injury chest pain dyspnea respiratory distress decreased breath sounds remember that the diaphragm is what allows you helps you breathe it's your major muscle for breathing so if there are respiratory problems you may suspect a diaphragmatic injury so other things you can see our abdominal pain and tenderness that's just because it where the diaphragm sits you should have an increase index of suspicion in patients with an upper abdominal injury so just go by your Anatomy if the patient has a stab wound in its left upper quadrant you're concerned of diaphragmatic injury if they were shot and if it's left upper quadrant or you have a if you have a let's say an exit wound that's in the thorax on the left side you're considered a diaphragmatic injury so increase index of suspicion for patients with upper abdominal injury another thing where you'd be concerned of diaphragmatic injury is if you flat out see signs on your on your chest x-ray so if you see air below the diaphragm that may be a sign of diaphragmatic injury as well the left hemidiaphragm is more frequently injured why because you have the liver insulating your right diaphragm so look at the chest x-ray which in 50% of patients will show abdominal viscera and the Hemi thorax elevated hemidiaphragm other abnormal signs this will necessitate laparotomy or laparoscopy for repair and a delayed diagnosis is associated with hernia strangulation increased morbidity and mortality the problem with diaphragmatic injury is depending on how bad it is some patients are not diagnosed with diaphragmatic injury because there's nothing that points to it either on imaging or symptom wise and so if they wind up not getting a laparotomy or they do get laparotomy and the surgeon misses it they can wind up with delayed signs and that would be things like hernia so the liver in general penetrating trauma involving the liver will get an exploratory laparotomy blunt trauma involving the liver can be managed with observing if all of these are true if the patient is hemodynamically stable and there's no peritoneal signs and there's no injuries requiring laparoscopy and there's no need for excessive transfusions really this just goes with our indications for laparotomy so the patient was hemodynamically unstable they're going to be sent off for laparotomy if the patient has peritoneal signs they're going to be sent off for laparotomy if the patient has injuries requiring laparotomy or laparoscopy they're going to be sent off for laparotomy so kind of get the picture here so some patients with one trauma to the liver can be managed with observation however they should be managed with observation in the hospital in preferably a surgical ICU setting and they need to get a repeat CT after two to three days technically however operative management is required for a ast that's American Association for surgery of trauma a liver injury grade three or higher and I didn't want to complicate things by giving all of the criteria for how you grade liver injuries or splenic injuries but that's the that's what trauma surgeons will probably use if they decide they need to do a if they want to do surgery on a patient with one liver injury this the ast indications are primarily focused on the the length of the laceration and the size simply Mottola if there is one as far as the spleen remember that this is the number one most injured organ and blunt abdominal injury you should also suspect this if there are injuries to the thorax so if there's seventh eighth ninth or tenth left rib fractures that can penetrate the spleen and cause bleeding 30% of splenic injury patients will present with hypotensive shock either in the field or as they're wheeled into the hospital immediately Parata me is going to be required if there is ongoing hemodynamic instability if there an expanding hematoma if the patient has a coagulopathy or if there is an ast spleen injury grade 3 or greater which just means a hematoma greater than 50% or a surface area or sorry or a laceration greater than 3 centimeters so don't commit this stuff to memory the ast stuff I don't think the USMLE is going to require you to remember that but as far as the spleen if there's ongoing hemodynamic instability expanding hematoma or a patient has played gallopping you'll do a laparotomy to assess the damage now I say assess the damage because it is now recommended that impossible you don't remove the entire explain it used to be that if you had splenic injury we would just take the spleen out that's not preferred now it's preferred now to remove the damaged portions and leave as much of the spleen in as possible however if you do need to remove this in the entire spleen please remember for board questions that the patient will subsequently need vaccinations against encapsulated bacteria pneumococcus meningococcus and homoplasy influenza type B if the patient is managed non-operatively so they fulfilled those criteria or they didn't fulfill any of these criteria for media laparotomy and they're stable you should admit them and they should be on strict bed rest for two to three days you're going to have this patient prepared as if they need surgery so they're going to be NPO you want ng decompression so they're all ready for surgery in case they need it in case they go unstable you'll also want to get serial hematocrit to see if the bleeding is stopped that's a good indicator to see if bleeding is stopped and then at three days you'll get a follow-up CT and at this point they can resume light activity will go off bed rest and they can also resume their diet because at three days if they're still stable at this point it's highly unlikely that they're going to need surgery however for the next three months they should be on light activity because the spleen is still somewhat fragile so this is the non operative approach for splenic injury but it can only be undertaken in stable patients who don't require laparotomy if they are in this category ongoing humid I am against ability expanding hematoma or they have a quite you op a--they and within that category of coagulopathy I would probably include patients who are on blood thinners they should have an immediate laparotomy to remove as much of the spleen as needed then some other organs so with the stomach if you place an NG tube in many cases you will as part of your initial management if you get a bloody ass for it from the NG tube that suggests damage to the stomach other things that can suggest damage this to the stomach are sub diaphragmatic Freire on chest x-ray as well as free abdominal fluid on CT these patients should get antibiotics to cover gut flora and then you should have repair these are prophylactic antibiotics for the most part again I would just use either cefoxitin or clindamycin gentamicin bowel injury will show up on the CT as a bowel this hollow viscus injury again here you'll have some diaphragmatic free air on chest x-ray because you have air within your bowel you also see free abdominal fluid on CT and then you'll give a patient antibiotics to cover the gut flora and repair injuries to the pancreas due to trauma are rare and they're very difficult to diagnose typically the way these present especially in a vignette our patients who come back several weeks two months later with feelings of fullness in their stomach and when you look at them with ultrasound or CT you see a pseudocyst of the pancreas and that is managed as itself that's not a trauma topic but this is something to consider though when you're thinking of the pancreas this is a patient that may not come in due to trauma probably won't come in due to trauma but they'll have a history of trauma in many cases may I even be severe trauma may not even be trauma where they went and got checked for anything they may have gotten punched in the gut didn't go to the hospital but then several weeks later they developed this fullness and in the stomach area and so just as a side when you're thinking of possible pancreatic pseudocyst one of the things you've got to ask the patient is have you had any history of trauma have you had anything who had a blow to your stomach anybody hit you got in a car accident or anything and or is it that's positive then you're concerned for pancreatic pseudocyst and with that that's it for trauma to the abdomen