Trauma Abdominal Injury ================ þ Duodenal Rupture: þ Examination of the Abdomen after Trauma þ Renal Trauma and Hematuria þ Liver and Spleen Injury: þ Diagnostic Peritoneal Lavage (DPL) þ Ultrasound for Trauma þ Do Patients Require Abdominal CT after Left Lower Chest Injury? - Yes - Prospective observational study – Documented variables considered risk for IAI – 875 patients with left lower chest injury – 63 (7.2%) had splenic injuries + 54 had other indications for imaging – 301 had left lower chest injury as only risk: + 9 (3%) patients with splenic injury and all had a pleuritic component to their rib pain/tenderness [Holmes, J. F., H. Ngyuen, et al. (2005). "Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury?" Ann Emerg Med 46(3): 232-236.] STUDY OBJECTIVE: We determine whether all patients with pain or tenderness to the left lower ribs after blunt traumatic injury require abdominal computed tomography (CT) scanning for the detection of splenic injury. METHODS: This was a prospective, observational cohort of all blunt-trauma patients who had pain or tenderness to the left lower ribs and presented to the emergency department (ED) of a Level I trauma center. Patients were enrolled if they had a Glasgow Coma Scale (GCS) score greater than 13 and pain or tenderness to the left lower ribs (ribs 7 to 12). Patients with pain or tenderness to the left lower ribs were considered to have pleuritic pain if the pain increased with inspiration or cough. All hemodynamically stable patients underwent abdominal CT scanning for detection of intraabdominal injuries. Data forms collecting information on the medical history and physical examination of all patients were completed before radiographic imaging. Patients with left lower rib pain or tenderness were considered to have "isolated" left lower rib injury if they were without all of the following: ED or out-of-hospital systolic blood pressure less than 90 mm Hg, abdominal or flank tenderness, pelvic or femur fractures, and gross hematuria. RESULTS: Eight hundred seventy-five patients had left lower rib pain or tenderness, 63 (7.2%; 95% confidence interval [CI] 5.6% to 9.1%) patients had splenic injuries, and 20 (2.3%; 95% CI 1.4% to 3.5%) patients had left renal injuries. Five hundred seventy-four patients had additional indications for abdominal imaging, leaving 301 patients with "isolated" left lower rib injury. Of the 301 patients, 9 (3.0%; 95% CI 1.4% to 5.6%) had splenic injuries. All 9 patients had a pleuritic component to their rib tenderness, and 3 (33%) patients underwent splenectomy. CONCLUSION: A small but important percentage of patients with pain or tenderness to the left lower ribs has splenic injuries. All patients with splenic injury had pleuritic pain. þ Which patients with abdominal trauma to CT and DC from ED? - never hypotensive - no other signficant injuries - normal mental status - nontender abdomen [Brasel 1996] þ Which patients to CT? - Decision Rule: + Hypotension + GCS <14 + Costal margin tenderness + Abdominal tenderness + Hematuria > 25 rbc/hpf + Hematocrit < 30% - Validation of the Decision Rule: + 1,595 patients: - 143 with IAI (44 with intervention) + Test performance - Sensitivity for IAI = 137/143; 95.8% (95% CI 91.1, 98.4%) - Specificity = 434/1452; 29.9% (95% CI 27.5, 32.3%) - NPV for IAI = 434/440; 98.6% (95% CI 97.1, 99.5%). - Sensitivity for IAI with intervention: 44/44; 100% (95% CI 93.4% to 100%) [Holmes, J. F., D. H. Wisner, et al. (2009). "Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma." Ann Emerg Med 54(4): 575-584.] STUDY OBJECTIVE: We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma. METHODS: We prospectively enrolled adult patients (>or=18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients. RESULTS: In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra- abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra- abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%). CONCLUSION: These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning. þ Children with Abdominal Trauma: - if negative abdominal exam AND negative dip UA for miscroscopic hematuria, then OK to send home. - microscopic hematuria highly associated with splenic injuries in kids [Isaacman, 1993] þ Comatose Patients and Abdominal Trauma: - Up to 25% of comatose patients with nondistended belly and normal VS have a surgically correctable lesion in belly. [Prall 1994] [Butterworth 1980] þ Associated Injury and Abdominal Trauma - Chance fractures (transverse lumbar fx): high association with abdominal injury þ CT in Abdominal Blunt Trauma - Oral contrast not needed. [Clancy TV et al. Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography. Am J of Surg 1993;166;680-685.] Abstract: [Tsang BD, Panacek EA, Brant WE, Wisner DH. Effect of oral contrast administration for abdominal computed tomography in the evaluation of acute blunt trauma Ann Emerg Med, July, 1997;30:1.] Abstract: - Mercy protocol: IV, no PO - Prospective studies: slight decrease in sensitivity for bowel injury with PO contrast - ACEP policy: oral contrast doesn't hurt, no evidence it helps þ Blunt Abdominal Trauma - Most likely to be injured: spleen } liver } retropertoneum } small bowel } kidney } bladder þ Ruptured Diaphragm - when from blunt trauma, 95% on the left side þ Retroperitoneal Injury - rare to see elevated amylase initially; rises slowly over 24 hours - intramural hematoma of duodenum: diagnosis usually late (48 hours to days) when have negative abdominal ultrasound despite symptoms of obstruction; diagnosed with UGI series - [Boulanger BR, Milzman, DP, Rosati C, Rodriguez A. The clinical significance of acute hyperamylasemia after blunt trauma. Can J Surg 1993;36(1):63-9.] þ Indications for immediate surgery in blunt trauma - Unstable despite resuscitation when abdominal injury likely - clear peritoneal signs - free air on abdominal film (get decubitus if on backboard) - evidence of ruptured diaphragm (e.g, on CXR) - gross blood from NG tube or rectum - positive DPL þ blunt trauma--} stable--} serial examinations and/or CT scan if positive --} OR if negative --} observe, continue w/u unstable--} US scan, if positive --} OR if negative --} DPL, if pos --} OR if neg --} CT* positive meaning positive for the need for laparotomy, not just "a finding" * to look for extraperitoneal injuries causing the instability. }Gun shot wounds require mandatory local exploration. But, what is the opinion }regarding the method used to rule out peritoneal perforation---- } }#1 --Is anyone using DPL? OR do these patients go straight to the OR? Here's the current approach at Shock Trauma in Baltimore, where we occasionally see such things: If, after local exploration, it is still unclear whether peritoneal penetration has occurred, there are essentially three choices: 1) Observe. (This is uncommon.) 2) Laparotomy. (This is very common, and arguably the safest choice.) 3) Something in between - used to be DPL, now is becoming Laparoscopy. (After inserting the laparoscope, insufflating and inspecting the peritoneum, if there is penetration a full laparotomy is done. It's tough to run the bowel with the laparoscope.) DPL is becoming quite uncommon in these parts nowadays. }AND }#2 --what's your current choice of antibiotics in cases of possible bowel }perforation--- Cephasomethin' - currently Cefotetan. (Bill Bozeman, Shock-Trauma, Baltimore) ------------------------------------------------------ With respect to the string on GSW/SW to abdomen, we here at the Medical College of Wisconsin take a more conservative route. If the patient is hemodynamically stable and the abdomen is non-tender (this is sometimes hard to determine from local wound tenderness) the patient is observed. We sometimes do bedside Ultrsound looking for hemoperitoneum. Certainly, penetrating wounds to the rt thoracoabdomen can be watched and managed conservatively (depending on chest tube output etc.). J. Trauma 1994;5:737-744 Initially I was skeptical with this approach but I have become a believer. The surgical residents would rather explore the patient so they don't have to watch them so closely on the floor but I think it saves the patient an unnecessary or non-therapeutic laparotomy. Daniel J. DeBehnke M.D. Associate Professor of Emergency Medicine Director of Research Director Resuscitation Research Laboratory Medical College of Wisconsin ------------------------------------------------------------------ Chmielewski GW, Nicholas JM, Dulchavsky SA, Diebel LN. Nonoperative management of gunshot wounds of the abdomen. American Surgeon 1995; 61: 665-668. Small study (n=12), tight entry criteria (single GSW, RUQ, stable VS, reliable exam with minimal abd tenderness), no complications. Worth reading, but not the definitive word. ----------------------------------------------------------------------