Douglas M Maurer DO MPH Learning Objectives Recognize and respond appropriately to a patient with hemorrhagic shock Assess via bedside methods the source of hemorrhage Respond appropriately to evidence of intraabdominal hemorrhage with regards to initial management and disposition ID: 175763
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Slide1
Trauma– Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPHSlide2
Learning Objectives
Recognize and respond appropriately to a patient with hemorrhagic shock
Assess via bedside methods the source of hemorrhage
Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and dispositionSlide3
Introduction
Blunt abdominal trauma is common.
Unknown history, distracting injuries, and altered
mental
status make
these
patients
difficult to diagnose and manage.
Victims frequently
have both abdominal and
extraabdominal
injuries.
Family physicians need to be able to recognize and treat hemorrhagic shock.Slide4
Recognition of Hemorrhagic Shock
Shock: oxygen delivery < tissue demands
Treatment must restore tissue perfusion not just blood pressure
Shock does NOT SBP < 90mmHg
Recognition includes: mechanism of injury, patient’s appearance, vitals, level of
mentation
, peripheral perfusion and urine output
Clinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.Slide5
Practical Diagnosis of Shock
Perform a targeted physical examination
Diagnostic testing should include chest radiography, pelvis radiography, and bedside ultrasound
Objective serum makers of tissue perfusion (serum lactate or base deficit)
Point of care H/H, send CBC, type/cross
DON’T delay resuscitation for lab resultsSlide6
6 Steps to Treat Hemorrhagic Shock
Step 1: Effectively manage the airway and optimize oxygenation.
Step 2: Identify and control immediate threats to central perfusion.
Step 3: Identify and address severe intracranial injuries.
Step 4: Identify and control other potentially life-threatening thoracic and abdominal injuries.
Step 5: Identify and control potentially limb-threatening injuries.
Step 6: Identify and treat noncritical injuries. Slide7
Treatment of Hemorrhagic Shock
Obtain immediate type and
crossmatch
for 6-8 units of blood
Massive transfusion defined as > 10 U of PRBCs in 24 hrs
Consider use of PRBC to platelet to FFP ratio of 1:1:1
May result in decreased need for blood products
Give calcium to prevent citrate toxicity Slide8
Assessing for Sources
of Hemorrhage
Chest
radiography:
T
ension
pneumothorax
?
M
assive
hemothorax
? A
ortic injury?
Pelvis
radiography:
P
elvic
ring
disruption?
Focused
A
ssessment
with
S
onography
for
Trauma
(FAST
):
Pneumo
/
hemothorax
?
Hemopericardium
?
Hemoperitoneum
?
If positive,
then
emergency
laparotomy
.
If negative, continue
resuscitation, treat
other
causes.Slide9
FAST Facts
Reliably identifies
200-250ml of
intraperitoneal
fluid
C
annot
reliably evaluate
retroperitoneum
/hollow viscous injury
Sensitivity/specificity: 75%/98%, NPV: 94%;
86-97
% accurate
P
erformed
using a curvilinear 2.5 or 3.5 MHz
probeSlide10
FAST Views
Cardiac: parasternal
or
subxiphoid
,
hepatocardiac
interface, pericardial space.
RUQ:
hepatorenal
interface (Morrison’s Pouch), diaphragm, inferior pole of
kidney.
LUQ:
splenorenal
interface, diaphragm, inferior pole of kidney, inferior tip of
spleen.
Suprapubic
:
outline of bladder, silhouette of uterus (females
).Slide11
FAST Algorithm
Unstable patient: + FAST =
OR.
Stable
pt:
+ FAST =
abdominal CT.
Stable pt, low mechanism of
injury:
- FAST =
observation
, serial
exams.
CT
is the
“Gold Standard”.Slide12
What About Diagnostic Peritoneal Aspiration (DPA)?
C
an
be performed
if - FAST in blunt
abdominal
trauma.
If DPA
+
, then emergency
laparotomy
.
If
DPA
-
,
then
seek and treat other sources.
Perform serial abdominal exams.
Perform serial FAST exams.
If patient
stabilizes,
then CT.
Get surgery involved!Slide13
Indications for Emergency
Laparotomy
Peritonism
Free air under the
diaphragm
Significant gastrointestinal
hemorrhage
Hypotension with +
FAST scan or +
DPA
Do NOT keep trauma patients if you lack resources to care for them!Slide14
Summary
Recognize and treat hemorrhagic shock aggressively with blood products
Assess for hemorrhage with bedside methods: CXR, pelvis, and FAST
Unstable patient: + FAST = OR.
Stable pt: + FAST = abdominal CT.
Stable pt, low mechanism of injury:
- FAST = observation, serial exams.Slide15
References
Puskarich
MA. Initial evaluation and management of blunt abdominal trauma in adults. In:
UpToDate
,
Hockberger
RS,
Moreira
ME (Ed),
UpToDate
, Waltham, MA, 2012.
Nickson
C. “Trauma! Blunt abdominal trauma decision making.” Weblog entry. Life in the
Fastlane
Blog.
http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/
Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma. 2010 Edition. Chicago
, IL.
http://
www.east.org/resources/treatment-guidelines/category/trauma
American College of Surgeons. ATLS Textbook, 9
th
Edition. 1 September 2012.Slide16
Simulation Training Assessment Tool (STAT)–
Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPH, FAAFPSlide17
CRITICAL
ACTIONS
ME
NI
M
SUSTAIN
IMPROVE
Completes
P
rimary
Survey: recognizes shock
MK2
Safety
net – IV, oxygen, monitors (2 x 16G IV)
MK2
Completes Secondary
Survey: recognizes abdominal source
MK2
Completes bedside FAST
(+
Morrison’s Pouch)
PC5
Recognizes positive FAST:
calls surgery
PC5
Bedside
labs: POC CBC, lactate, BAL, VBG, blood type/screen/X-match
MK2
Bedside
rads
: port chest, lat C-spine, AP pelvis
MK2
Gives emergency release blood transfusionMK2If unstable: no CT, to ORIf stabilizes: CT, then ORMK2TOTALSBP4
SCENARIO ALGORITHMSET UP:“Rural” ER Simulated RoomBedside US and/or FAST simulatorReal patient with simulated skin/abdomenPRE ARRIVAL:FP in rural ER, lab, rad, OR35 y/o male s/p unrestrained driver MVA arrives via EMS, in c-collar. VS BP 90/50, HR 110, RR 18, SpO2 97% on RA, GCS 15 ARRIVAL:Full spinal precautions, has 1 IV in place. Pt awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHxPRIMARY SURVEY:A – talking initially, then somnolent B – labored, RR 24, nl breath soundsC – BP 85/40, HR 130, cool extremitiesD – GCS 14, somnolent, oriented to person when responds to voiceE – no other trauma, mild abd distension, hypoactive BSSECONDARY SURVEY:Other exam normal, c-spine non tender, pelvis stable, rectal guaiac negativeAbdominal exam tense, tender, absent BSLABS & IMAGES:Chest, c-spine, pelvis negativeLabs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7.35/46/40/50%/-8Positive FAST in RUQ, no CT indicatedBlood type and screen/X-matchDISPOSITION:Must transfuse blood , call Surgeon and direct to OR, otherwise pt dies of hemorrhage
Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma
Date: 1 May 2013
Instructor(s): Clark, Maurer, Cuda
Learner(s):
Learning Objectives:
1. Recognize and respond appropriately to a patient with hemorrhagic shock.2. Assess via bedside methods the source of hemorrhage.3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition.
ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)Slide18Slide19
PerihepaticSlide20
PerihepaticSlide21
PerisplenicSlide22
PerisplenicSlide23
PelvicSlide24
PelvicSlide25
PericardiumSlide26
Pericardium