Rosen & Barkin's 5-Minute Emergency Medicine Consult (17 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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SIGNS AND SYMPTOMS
  • Spectrum from abdominal pain, signs of peritoneal irritation to hypovolemic shock
  • Nausea or vomiting
  • Labored respiration from diaphragm irritation or upper abdominal injury
  • Left shoulder pain with inspiration (Kehr sign) from diaphragmatic irritation owing to bleeding
  • Delayed presentation possible with small-bowel injury
ESSENTIAL WORKUP
  • Evaluate and stabilize airway, breathing, and circulation (ABCs).
  • Primary objective is to determine need for operative intervention.
  • Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation.
  • Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation.
  • Remember that the limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference.
  • Abrasions or ecchymoses may be indicators of intra-abdominal injury:
    • Roll the patient to assess the back.
    • Lap-belt abrasions can be indicative of significant intra-abdominal injuries.
  • Bowel sounds may be absent from peritoneal irritation (late finding).
  • Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
  • Plain film of the pelvis:
    • Fracture of the pelvis and gross hematuria may indicate genitourinary injury.
    • Further evaluation of these structures with retrograde urethrogram, cystogram, or IV pyelogram
  • CT most useful in assessing need for operative intervention and for evaluating the retroperitoneal space and solid organs:
    • Patient must be stable enough to make trip to scanner.
    • Also useful for suspected renal injury
  • Focused abdominal sonography for trauma (FAST) to detect intraperitoneal fluid:
    • US is rapid, requires no contrast agents, and is noninvasive.
    • Operator dependent
  • Diagnostic peritoneal lavage (useful for revealing injuries in the intrathoracic abdomen, pelvic abdomen, and true abdomen) primarily indicated for unstable patients:
    • Positive with gross blood, RBC count of >100,000/mm
      3
      , WBC count of 500/mm
      3
      , or presence of bile, feces, or food particles
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • Hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
  • Type and screen is essential. Cross-match PRBC units for unstable patients.
  • Urinalysis for blood:
    • Microscopic hematuria in the presence of shock is an indication for genitourinary evaluation.
  • ABG:
    • Base deficit may suggest hypovolemic shock and help guide the resuscitation.
Imaging

See “Essential Workup.”

Diagnostic Procedures/Surgery

See “Essential Workup”

DIFFERENTIAL DIAGNOSIS

Lower thoracic injury may cause abdominal pain.

TREATMENT
PRE HOSPITAL
  • Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg
  • Normal vital signs do not preclude significant intra-abdominal pathology.
INITIAL STABILIZATION/THERAPY
  • Ensure adequate airway:
    • Intubate if needed.
    • O
      2
      100% by nonrebreather face mask
  • 2 large-bore IV lines with crystalloid infusion
  • Begin infusion of PRBCs if no response to 2 L of crystalloid.
  • If patient is in profound shock, consider immediate transfusion of O-negative blood.
ED TREATMENT/PROCEDURES
  • Continue stabilization begun in field.
  • Nasogastric tube to evacuate stomach, decrease distention, and decrease risk of aspiration:
    • May relieve respiratory distress if caused by a herniated stomach through the diaphragm
MEDICATION
  • Tetanus toxoid booster: 0.5 mL IM for patients with open wounds
  • Tetanus immunoglobulin: 250 U IM for patients who have not had complete series
  • IV antibiotics: Broad-spectrum aerobic with anaerobic coverage such as a 2nd-generation cephalosporin
Pediatric Considerations
  • Crystalloid infusion is 20 mL/kg if patient is in shock.
  • PRBC dose is 1 mL/kg.
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Postoperative cases
  • Equivocal findings on diagnostic peritoneal lavage, FAST exam, or CT
  • Many blunt abdominal trauma patients benefit from admission, monitoring, and serial abdominal exams.
Discharge Criteria

No patient in whom you suspect intra-abdominal injury should be discharged home without an appropriate period of observation, despite negative exam or imaging studies.

PEARLS AND PITFALLS
  • Do not delay blood products when patient is in obvious shock despite normal Hct.
  • Avoid overaggressive resuscitation with crystalloids.
  • Obtain a pregnancy test in all females of childbearing age.
  • Do not transport unstable patients to CT for diagnostic imaging.
ADDITIONAL READING
  • Amoroso TA. Evaluation of the patient with blunt abdominal trauma: An evidence based approach.
    Emerg Med Clin North Am
    . 1999;17:63–75.
  • Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries.
    Ann Emerg Med
    . 2004;43(1):120–128.
  • Kendall JL, Faragher J, Hewitt GJ, et al. Emergency department ultrasound is not a sensitive detector of solid organ injury.
    West J Emerg Med
    . 2009;10(1):1–5.
  • Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma.
    Br J Surg
    . 2001;88:901–912.
CODES
ICD9
  • 459.0 Hemorrhage, unspecified
  • 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
  • 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ
ICD10
  • R58 Hemorrhage, not elsewhere classified
  • S36.00XA Unspecified injury of spleen, initial encounter
  • S36.90XA Unspecified injury of unspecified intra-abdominal organ, initial encounter
ABDOMINAL TRAUMA, IMAGING
Alfred A. Joshua
BASICS
DESCRIPTION

Diagnostic procedures: Use of these imaging and procedure modalities will be based on history and physical exam.

DIAGNOSIS
SIGNS AND SYMPTOMS
  • Abdominal trauma can be seen in a variety of patients ranging from those with isolated abdominal injury to multisystem trauma.
  • Abdominal trauma is divided into blunt and penetrating injuries. Penetrating abdominal injuries can further be divided into stab wounds and gunshot wounds.
  • Hemodynamic status should be the primary initial focus of evaluation. Most unstable patients will require early surgical management, while many stable patients with abdominal trauma may be managed nonoperatively.
History
  • History should include mechanism of injury, restraint use and type, airbag or helmet use, prehospital vital signs, initial mental status, and change in mental status.
  • AMPLE history (
    a
    llergies-to-medications and radiographic contrast agents,
    m
    edications taken,
    p
    ast medical and surgical history,
    l
    ast meal,
    e
    vents leading up to the injury)
Physical-Exam
  • A comprehensive physical exam should start with ABCDE survey and include full exposure of the patient and careful palpation of all abdominal quadrants.
  • Abdominal injury in only 45–50% of cases.
  • The abdominal physical exam is frequently misleading in intoxicated, uncooperative, and multisystem trauma patients.
ESSENTIAL WORKUP
  • See “Abdominal Trauma (Blunt)” and “Abdominal Trauma (Penetrating).”
  • All trauma patients initially managed with:
    • ABCDE survey (Airway, Breathing, Circulation, Disability, Exposure)

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