Trauma
Question 103 of 216
A 32 year old woman is brought to the Emergency Department following a road traffic collision. She was the unrestrained driver of a car travelling at 50 mph that collided with a stationary lorry. Her obs are: BP 73/42, HR 145, RR 25. The focused assessment with sonography in trauma (FAST) scan of the patient shows a hypoechoic stripe in the pouch of Douglas. Which of the following is correct?
Answer:
The pouch of Douglas is one of the areas of ultrasound inspection for a FAST examination. If free fluid is present and the patient is haemodynamically unstable, the patient should forego computed tomography (CT) scanning for the operating room. FAST examinations are effective in detecting as little as 100 mL of free fluid in the abdominal cavity.Abdominal Trauma: Assessment
Trauma
Last Updated: 13th February 2021
In hypotensive patients, the goal is to rapidly identify an abdominal or pelvic injury and determine whether it is the cause of hypotension. The patient history, physical exam, and supplemental diagnostic imaging can establish the presence of abdominal and pelvic injuries that require urgent haemorrhage control. However, when indications for patient transfer already exist, do not perform time-consuming tests, including abdominal CT.
Haemodynamically normal patients without signs of peritonitis may undergo a more detailed evaluation to determine the presence of injuries that can cause delayed morbidity and mortality. This evaluation must include repeated physical examinations to identify any signs of bleeding or peritonitis that may develop over time.
X-ray
- An AP chest-x-ray is recommended for assessing patients with multisystem blunt trauma
- Haemodynamically abnormal patients with penetrating abdominal wounds do not require screening x-rays in the emergency department
- If the patient is haemodynamically normal and has penetrating trauma above the umbilicus or a suspected thoracoabdominal injury, an upright chest x-ray is useful to exclude an associated hemothorax or pneumothorax, or to determine the presence of intraperitoneal air
- With radiopaque markers or clips applied to all entrance and exit wounds, a supine abdominal x-ray may be obtained in haemodynamically normal penetrating trauma patients to demonstrate the path of the missile and determine the presence of retroperitoneal air; obtaining two views (i.e. AP and lateral) may allow for spatial orientation of foreign bodies
- An AP pelvic x-ray may help to establish the source of blood loss in haemodynamically abnormal patients and in patients with pelvic pain or tenderness; an alert, awake patient without pelvic pain or tenderness does not require a pelvic radiograph
Focused Assessment with Sonography for Trauma (FAST)
- FAST is an accepted, rapid, repeatable, and reliable study for identifying intraperitoneal fluid; it can also detect cardiac tamponade
- FAST includes the examination of four regions: the pericardial sac, the hepatorenal fossa, the splenorenal fossa and the pelvis or pouch of Douglas
- For more information on FAST, see separate article
Diagnostic peritoneal lavage (DPL)
- DPL is another rapidly performed study to identify haemorrhage
- The technique is most useful in patients who are haemodynamically abnormal with blunt abdominal trauma or in penetrating trauma patients with multiple cavitary or apparent tangential trajectories
- Haemodynamically normal patients who require abdominal evaluation in settings where FAST and CT are not available may benefit from the use of DPL; in settings where CT and/or FAST are available, DPL is rarely used because it is invasive and requires surgical expertise
- Relative contraindications to DPL include previous abdominal operations, morbid obesity, advanced cirrhosis, and preexisting coagulopathy; note that DPL requires gastric and urinary decompression for prevention of complications
- An open, semi-open, or closed (Seldinger) infraumbilical technique is acceptable in the hands of trained clinicians; in patients with pelvic fractures, an open supraumbilical approach is preferred to avoid entering an anterior preperitoneal pelvic hematoma; in patients with advanced pregnancy, use an open supraumbilical approach to avoid damaging the enlarged uterus
- Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage catheter mandates laparotomy; aspiration of 10 cc or more of blood in haemodynamically abnormal patients requires laparotomy
- If gross blood or gastrointestinal contents are not aspirated initially, lavage is performed by instilling 1 L of warmed isotonic crystalloid solution (10 mL/kg in a child) into the peritoneum; after ensuring adequate mixing of peritoneal contents with the lavage fluid, the effluent is drained from the abdomen and sent to the laboratory for quantitative analysis (adequate fluid return is >20% of the infused volume); a positive test (and thus the need for surgical intervention) is indicated by > 100,000 RBC/mm³, > 500 WCC/mm³ or a positive Gram stain
- Complications (although rare) include bleeding secondary to injection of local anaesthetic or incision of the skin or subcutaneous tissues, peritonitis secondary to intestinal perforation from the catheter, laceration of the urinary bladder (if bladder not evacuated prior to procedure), injury to other abdominal and retroperitoneal structures and wound infection at the lavage site
Computed tomography (CT)
- CT is a diagnostic procedure that requires transporting the patient to the scanner (i.e. removing the patient from the resuscitation area), administering IV contrast, and radiation exposure
- CT is a time-consuming (although less so with modern CT scanners) procedure that should be used only in haemodynamically normal patients in whom there is no apparent indication for an emergency laparotomy; do not perform CT scanning if it delays transfer of a patient to a higher level of care
- CT scans provide information relative to specific organ injury and extent, and they can diagnose retroperitoneal and pelvic organ injuries that are difficult to assess with a physical examination, FAST, and DPL
- Relative contraindications for using CT include a delay until the scanner is available, an uncooperative patient who cannot be safely sedated, and allergy to the contrast agent
- CT can miss some gastrointestinal, diaphragmatic, and pancreatic injuries
- In the absence of hepatic or splenic injuries, the presence of free fluid in the abdominal cavity suggests an injury to the gastrointestinal tract and/or its mesentery, and many trauma surgeons believe this finding to be an indication for early operative intervention
Diagnostic laparoscopy or thoracoscopy
- Diagnostic laparoscopy is an accepted method for evaluating a haemodynamically normal, penetrating trauma patient with potential tangential injury and without indication for laparotomy.
- Laparoscopy is useful to diagnose diaphragmatic injury and peritoneal penetration
- The need for general anaesthesia limits its usefulness
Contrast studies
Contrast studies can aid in the diagnosis of specifically suspected injuries, but they should not delay the care of haemodynamically abnormal patients. These studies include:
- Urethrography
- Urethrography should be performed before inserting a urinary catheter when a urethral injury is suspected
- Cystography
- A cystogram or CT cystography is the most effective method of diagnosing an intraperitoneal or extraperitoneal bladder rupture
- Intravenous pyelogram
- Suspected urinary system injuries are best evaluated by contrast-enhanced CT scan but if CT is not available, intravenous pyelogram (IVP) provides an alternative
- Gastrointestinal contrast studies
- Isolated injuries to retroperitoneal gastrointestinal structures (e.g. duodenum, ascending or descending colon, rectum, biliary tract, and pancreas) may not immediately cause peritonitis and may not be detected on DPL or FAST
- When injury to one of these structures is suspected, CT with contrast, specific upper and lower gastrointestinal intravenous contrast studies, and pancreaticobiliary imaging studies can be useful
- However, the surgeon who ultimately cares for the patient will guide these studies
Indications for laparotomy
Surgical judgment is required to determine the timing and need for laparotomy. The following indications are commonly used to facilitate the decision-making process in this regard:
- Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding
- Hypotension with an abdominal wound that penetrates the anterior fascia
- Gunshot wounds that traverse the peritoneal cavity
- Evisceration
- Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
- Peritonitis
- Free air, retroperitoneal air, or rupture of the hemidiaphragm
- Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma
- Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers, or bile from DPL, or aspiration of 10 cc or more of blood in haemodynamically abnormal patients
Comparison of DPL, FAST and CT in abdominal trauma
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
