41-year-old (Male) with Abdominal Trauma

00:01 Alright, guys. We have an absolutely interesting case here.

00:04 Great clinical presentation, high-yield for the USMLE, and you will see it on the wards.

00:09 Let's jump right in.

00:11 A 41-year-old man is admitted to the emergency room after being struck in the abdomen by a large cement plate while transporting it.

00:20 On initial assessment by paramedics at the scene, his blood pressure is a 110/80, heart rate is 85, with no signs of respiratory distress.

00:31 On admission, the patient is alert but in distress.

00:35 He complains of severe, diffuse, abdominal pain and severe weakness.

00:40 Vital signs now are blood pressure 90/50, heart rate 96, respiratory rate 19, and temperature is 37.4°C, and oxygen saturation is 95% on room air.

00:57 His lungs are clear on auscultation.

01:00 The cardiac exam is significant for a narrow pulse pressure.

01:05 Abdominal examination reveals a large bruise over the epigastric and periumbilical regions.

01:13 The abdomen is distended and there is diffuse tenderness to palpitation with rebound and guarding, worst in the epigastric region.

01:22 There is hyperresonance to percussion in the epigastric region and absence of hepatic dullness in the right upper quadrant.

01:32 Aspiration of the nasogastric tube reveals bloody contents.

01:37 Focused assessment with sonography for trauma, FAST, shows free fluid in the pelvic region.

01:44 Evaluation of the perisplenic and perihepatic regions is impossible due to the presence of free air.

01:52 Aggressive intravenous fluid resuscitation is administered but fails to improve the patient's hemodynamics.

02:00 Which of the following is the next best step in management? Answer Choice A: CT scan Answer Choice B: Diagnostic peritoneal lavage Answer Choice C: Abdominal ultrasound Answer Choice D: Emergency laparotomy or Answer Choice E: Emergency laparoscopy Now, take a moment to come to the answer choice by yourself before we go through it together.

02:30 Okay, guys. Like I said, this is a very important question both clinically and for your boards.

02:36 It's going to be tested.

02:38 Now, going through the question characteristics, this is a surgery question.

02:42 We have someone coming in, they have blunt abdominal trauma, they're getting worse for giving fluids, they're not getting better, we're probably gonna be calling in a surgeon.

02:50 Now, this is a 2-step question.

02:52 First thing we have to do is figure out the diagnosis and then we have to figure out what the next step in management is.

02:58 And of course, we need the stem in this case because we need to go through the many complex details and change of events in the question stem to figure out what's going on to figure out a treatment plan.

03:10 So let's walk right through it.

03:11 We have a 41-year-old male presenting.

03:14 He's presenting after trauma.

03:17 You know we're told he's hit in the abdomen by a large heavy item.

03:20 The chief complaint is pain and weakness and general distress.

03:25 The patient has deteriorated vital signs on admission compared to the scene and this is a risk that he may be going into shock.

03:34 So the blood pressure on initial assessment was 110/80 but when he comes to us, it's 90/50 so he has hypotension.

03:43 He also has tachycardia. In the field his heart rate was 85 and now it's 96.

03:50 His clinical exam is suggestive of internal hemorrhage and peritonitis.

03:57 We're also told that he has a narrow pulse pressure.

04:00 A narrow pulse pressure is the difference between the systolic and diastolic pressures.

04:05 Looking at his abdominal exam, he has abdominal distension with tenderness with guarding, he has hyperresonance with epigastric region, and the absence of hepatic dullness.

04:17 Taking into account these findings, our suspicion of internal hemorrhage is actually pretty high and it's even further supported by the fact that there's bloody contents in the nasogastric tube aspiration and there's free fluid detected with the FAST exam with ultrasound.

04:37 Now, there's also the presence of free air which is suggestive of a hollow organ perforation.

04:45 Taking all of these into account, our diagnosis then is blunt abdominal trauma, which we know pretty quickly, with suspicion for internal hemorrhage given the fact that we have, you know, patient's kind of going into shock, not responding to fluids, abdominal distention regarding hyperresonance in the epigastric, absence of hepatic dullness.

05:07 That all makes you think internal hemorrhage and also peritonitis and hollow organ perforation, given the free air we saw on the exam.

05:18 So now that we know it's blunt abdominal trauma with likely internal hemorrhage, peritonitis, and hollow organ perforation, the question becomes, "What do we do next?" Well, it's very important to appreciate that this patient is in critical situation.

05:31 He's in critical health. He has a decreasing blood pressure and increasing heart rate and we're giving him fluids, he's not getting better, and he has a high suspension of internal organ damage and hemorrhage.

05:43 So really, any diagnostic procedure is really risking an unacceptable delay in his care.

05:50 Immediate treatment is required. We have enough information to want to treat.

05:55 So the answer choice here is Answer Choice D, an emergency laparotomy, and the reason here is that an emergency laparotomy, you know when they open and go into the abdomen provides both a diagnosis because they can look around but also be able to treat surgically in the moment.

06:13 So again, answer choice is Answer Choice D.

06:15 Now let's go through all the answer choices in a bit more detail to find out why some are right and others are wrong.

06:22 Now Answer Choice D, let's talk about it a little bit more.

06:25 The patient's coming in with blunt force abdominal trauma with signs of hollow viscus perforation, hemorrhage, and peritonitis.

06:33 And again, we're seeing abdominal pain, abdominal distension, the evidence of pneumoperitoneum, the evidence of hyperresonance to percussion, and blood being aspirated via the nasal gastric tube.

06:45 So thus, given the condition, emergency laparotomy is indicated because additional diagnostics test or imaging should not delay transportation of the patient to the operation room.

06:58 Blunt abdominal trauma is the most frequent type of abdominal injury seen in the emergency room and it actually accounts for about roughly 80% of cases.

07:09 Now, motor vehicle collisions are the most common cause of blunt abdominal trauma.

07:15 The morbidity and mortality from blunt abdominal trauma tends to be greater than from open penetrating abdominal trauma because although the severity of damage is comparable, proper recognition of blunt abdominal trauma is harder to identify which delays treatment and tends to underestimate the severity of injury.

07:39 The main mechanism of trauma to the hollow internal organs is in blunt abdominal trauma is due to the sudden significant increase in intra-abdominal pressure created by the force of the impact.

07:53 You also have crushing against the rigid bony structures as the main mechanism of trauma to the parenchyma to solid organs in the abdomen in blunt abdominal trauma.

08:04 Now additionally, sheering forces may result in lacerations of the mesentery and the visceral peritoneal ligaments of the abdominal organs as well as disruption to their vascular supply.

08:17 Now, the symptoms commonly seen in blunt abdominal trauma are localized or diffused abdominal pain and signs of peritoneal irritation.

08:27 Now, such as having abdominal rigidity and rebound tenderness, although the absence of pain though does not always mean abdominal injury is not present.

08:36 So you can or you cannot have pain.

08:38 Additional symptoms have suggested internal abdominal injury include referred pain and here's a great example.

08:46 Say you have a hemorrhage from a ruptured spleen leading to accumulation of blood on the left hemidiaphragm which refers then pain to left shoulder.

08:55 This is donned as cure sign. You can also have absence of bowel sounds which is going to be suggestive of peritonitis and paralytic ileus.

09:04 You can have abdominal distension which is due to accumulation of blood, air, or secondary ileus and again, the characteristic findings on abdominal percussion are going to be the absence of hepatic dullness and hyperresonance in the epigastric region due to air accumulation, secondary to hollow viscus trauma.

09:24 Now a focus assessment with sonography for trauma called a FAST exam should be done in all patients who present with blunt abdominal trauma.

09:33 This assessment actually takes about 5 minutes and assesses for the presence of free fluid in 4 anatomical sites: the perihepatic, the hepatorenal space, the perisplenic space, and the splenorenal space, the pelvis, and the pericardium.

09:50 Now the FAST exam can also identify the presence of pneumoperitoneum.

09:54 The following findings are what warrant emergency laparotomy: a positive FAST scan which this patient had, signs of peritonitis which this patient had, hemodynamic instability despite aggressive intravenous fluid resuscitation.

10:10 Hemodynamically stable patients with a negative FAST scan should undergo a CT scan and if it's negative for significant injury, they can be managed conservatively.

10:22 Now let's go through some of the other answer choices and discuss why they're wrong. Answer Choice A is a CT scan.

10:29 A CT scan is not appropriate in this hemodynamically unstable patient with signs of hollow viscus perforation.

10:37 So diagnostic imaging should not delay immediate transport to the OR for an emergency laparotomy.

10:43 Now Answer Choice B, a diagnostic peritoneal lavage should be performed if a FAST is not available or shows negative results despite a high clinical suspicion for intra-abdominal organ trauma.

10:57 But this patient had a FAST scan that was positive so we don't need to do a diagnostic peritoneal lavage and they should undergo emergency laparotomy.

11:05 Answer Choice C is abdominal ultrasound. This is different than a FAST scan.

11:11 If the question stem wants you to think FAST scan, they would say FAST scan.

11:15 When they say abdominal ultrasound, they mean a true complete abdominal ultrasound.

11:19 Now in general, the purpose of the initial examination from patients coming for trauma is merely to confirm the presence of an injury not to determine the specific details.

11:30 A conventional abdominal ultrasound takes too much time for an initial assessment and that time could be better spent actually managing the patient thus it's not indicated in the primary evaluation of any patient with acute trauma.

11:45 Now laparoscopy is option E, is not recommended for the management of patients with a blunt abdominal trauma because of the need to do air insufflation and a limited capacity to visualize the full extent of damage.

11:58 Now, let's go through some high-yield facts for blunt abdominal trauma.

12:04 This is due to a non-penetrating trauma to the abdomen, a motor vehicle accident is the most common cause and it's often due to seat belts.

12:13 The clinical presentation depending on the area involved will include pain, nausea, tenderness, guarding, and diminished bowel sounds.

12:22 The treatment is actually based on an algorithm so let's refer to it now and we'll go through it together and we'll talk about where our patient is.

12:30 So the first question becomes hemodynamic instability.

12:33 Our patient is hemodynamically stable.

12:36 He's becoming hemodynamically unstable though.

12:40 That's why we're worried.

12:41 So he is hemodynamically stable because he is alert and he is answering questions and can tell us he's in distress.

12:47 So let's just imagine though our patient was not hemodynamically stable.

12:52 If they were not, we'd wanna do an abdominal ultrasound with a FAST scan and if it's positive you straight -- you take him straight to the OR.

13:01 If it was negative, you can do a diagnostic peritoneal assessment and if that's positive again, go to the OR and if it's negative do further imaging with the CT or you can take him to the ICU for closer monitoring.

13:14 Now let's go back into what our patient's doing on the other side of this algorithm.

13:18 So, is the patient hemodynamically stable? Yes. Can you clinically evaluate them? Well, yes. If you couldn't, then you have to proceed to the same junction.

13:31 So in our case, you can, so the answer is yes.

13:33 Do they have peritonitis? Yes, and then you take them to the OR.

13:37 Now let's imagine they didn't or do they have abdominal tenderness.

13:40 Yes. Well, then you can get a CT scan and if they don't, you can do an abdominal ultrasound.

13:46 And depending on if it's positive or negative, you can either go to the OR and do further imaging.

13:52 For example if the CT scan is positive, you go OR and do an angiogram and if it's negative you observe.

13:58 And if the abdominal ultrasound is positive, you go back to the junction because then you can consider CT but if it's negative, again you can just observe.