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Trauma– Blunt Abdominal Trauma Trauma– Blunt Abdominal Trauma

Trauma– Blunt Abdominal Trauma - PowerPoint Presentation

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Trauma– Blunt Abdominal Trauma - PPT Presentation

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

abdominal fast shock trauma fast abdominal trauma shock hemorrhage blunt blood hemorrhagic patient treat injuries step bedside perfusion stable

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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)Slide18
Slide19

PerihepaticSlide20

PerihepaticSlide21

PerisplenicSlide22

PerisplenicSlide23

PelvicSlide24

PelvicSlide25

PericardiumSlide26

Pericardium