Now, let’s discuss blunt
Lots of organs are in the abdomen
clearly and anything can be
injured in a blunt, particularly
high-speed motor vehicle accident.
So we’ll just limit it to the most
common and high-yield information.
We’ll talk about duodenal injuries, liver
injuries, spleen injuries, kidney injuries.
Let’s start with the duodenum.
Now, in this image, you see a
clear classic seat belt sign.
There was a time that many
of us don’t remember
where there was only a waist
belt when you sat in a car.
That was actually more dangerous than
not having a belt at all because
oftentimes the patient had
these hyperflexion injuries
because their chest and their backs
were not belted into the car.
With the seat belt sign, however, you
have to be suspicious that there may
be intra-abdominal injury, whatever
the viscous or solid injury may be.
Now, let’s talk about very
high-yield topic, a chance fracture.
A chance fracture is a
kind of like when you’re
only wearing a waist belt.
It’s associated with a
proximal, usually L1 spine
fracture as you see
highlighted in this image.
Now, do you remember what bowel injury might
be associated with a chance fracture?
These are some classic
I’ll give you a few moments
to think about this.
That’s right, duodenal
injury and small bowel
injury, and in fact
the pancreas as well.
that the duodenum is fixed
in the retroperitoneum
in certain portions.
The pancreas is completely
These organs abut the upper
lumbar lower thoracic spine.
Therefore, a chance fracture is
associated with these injuries.
Now, here’s an image of a
traumatic duodenal perforation.
It can only be found on exploratory
laparotomy or exploration.
In fact, if your patient has pneumoperitoneum
on work-up during the trauma,
you should take the patient to the operating
room as your next step in management.
Depending on the severity of the duodenal
injury, multiple surgeries can be performed,
either primary repair or some
sort of a bypass surgery.
What I mean by bypass surgery is how the
stomach juice is drained into a small bowel by
making another connection, leave lots of
drains around the duodenum and let it heal.
Another common scenario you
may encounter on examinations
is a young patient who is
riding their bicycle or an ATV.
They may flip over and hit their
upper abdomen on the handlebar.
This is called the
Usually, these patients
don’t present right away.
They pick themselves up, dust
themselves off and just keep going.
But days later, they may come in with
nausea, vomiting, abdominal pain.
And if you have a suspicion of a
duodenal injury, you might get an
upper GI swallow study which will
show a gastric outlet obstruction.
This is likely because the
handlebar injury when they
made impact cause swelling
or injury to the duodenum.
Subsequent edema because of the injury has
now caused a gastric outlet obstruction.
Very importantly, your next step in
management should not be surgery.
Many, many of these
patients resolve completely
with a trial of
So that’s what you
Now, let’s move on to the liver.
Here, on this
you can see a pre-macerated
liver in the right lobe.
But despite its appearance, we’re quite
successful on non-operative management.
Why is non-operative management
so important in liver?
Well, unlike some other organs like the
spleen, you can’t remove the liver.
Therefore, if the patient is stable
and responsive to blood transfusion,
try non-operative management.
Particularly if there is a blush or active
bleeding, you can try IR embolization.
However, if your patient is
hypotensive and deteriorating,
that’s not a patient that
goes to the interventional
suite or tries
Always choose surgery in
Pack the liver and depending
on the actual injury,
there are multiple
mechanisms to stop bleeding.
It’s likely to be beyond the
scope of the USMLE examination.
Now, let’s move on to
spleen, a favorite topic.
The spleen of course is in the left
upper quadrant of your abdomen.
On this cross-sectional image
of the abdomen and pelvis,
you not only see a major
of the spleen in the
left upper quadrant,
you also see a fair amount
of intraperitoneal fluid
around the liver as well
as around the spleen.
Remember when I made a comment that when you
do a FAST examination and you see blood or
fluid in a certain quadrant doesn’t always
mean that the injury was in that quadrant.
In this scenario had you
done a right upper quadrant
ultrasound, you would’ve found
blood in the hepatorenal
space and yet the injury
is demonstrated by the CT
abdomen and pelvis was
actually a spleen injury.
Just as a side up, remember, any time
you see an image of the patient,
it’s presumed that the patient
was hemodynamically stable.
Because again, a very important
high-yield fact is you never
want to take an unstable patient
to the radiology suite.
So, how do we manage
Well, for hemodynamically
we have had great success with
non-operative management and we
continue pushing the envelope for
even higher grade splenic injuries.
So splenic salvage rates
are incredibly good.
This is what you should offer
your patient if they’re stable.
If, however, the patient is hypotensive
like our patient and has a positive FAST,
your next step in management
should be exploratory
laparotomy and in this
situation a splenectomy.
Now, I’d like to
pose a question.
vaccines are needed.
I’ll give you that.
But do you know what
the vaccines are?
I’ll give you a second
to think about this.
Before I give you the answer,
remember vaccinations are most ideal
two weeks prior to surgery, clearly
not possible in a trauma patient.
Therefore, practically speaking,
we give it right before discharge.
Vaccinations are again
I hope you got these answers.
The specific organisms that we’re trying
to cover is Haemophilus influenzae,
and Neisseria meningitidis
also known as meningococcus.
We’ve discussed spleen,
let’s move on to kidney.
Kidney injury noted here
in a coronal section
is usually found on the CT scan.
Unfortunately, neither hematuria
or flank pain or necessarily
the mechanism of injury usually
gives you enough information.
Fortunately, the vast majority of the
time, unless it’s a hilar avulsion,
doesn’t result in hemodynamic instability
and can be treated non-operatively.
observation alone is okay
for patients who are
We oftentimes contact our
interventional radiology colleagues
to give the patient a shot of
contrast to see whether or not
there’s active bleeding and a
potential for embolization.
Remember, though, embolization of
the kidney can cause ischemia.
Sometimes urologists actually
need to place stents because your
urethral system or the kidney itself
may be obstructed with a clot.
This can lead to renal failure
or acute kidney injury.
Typically, given this likelihood of
bleeding, we put these patients in the
intensive care unit for close monitoring
and what’s called a serial H and H.
We get a blood draw and look at the
hemoglobin and hematocrit every few hours.
Unfortunately, in a small
nephrectomy is necessary,
but make sure you
check that there’s
another kidney first and
it’s functional prior
to removing the kidney.
In the emergency situations with massive
hemorrhage, you do what you have to do.