Blunt Abdominal Injuries

00:01 Now, let’s discuss blunt abdominal injuries.

00:04 Lots of organs are in the abdomen clearly and anything can be injured in a blunt, particularly high-speed motor vehicle accident.

00:11 So we’ll just limit it to the most common and high-yield information.

00:16 We’ll talk about duodenal injuries, liver injuries, spleen injuries, kidney injuries.

00:22 Let’s start with the duodenum.

00:26 Now, in this image, you see a clear classic seat belt sign.

00:31 There was a time that many of us don’t remember where there was only a waist belt when you sat in a car.

00:37 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.

00:48 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.

00:58 Now, let’s talk about very high-yield topic, a chance fracture.

01:03 A chance fracture is a hyperflexion injury, kind of like when you’re only wearing a waist belt.

01:09 It’s associated with a proximal, usually L1 spine fracture as you see highlighted in this image.

01:16 Now, do you remember what bowel injury might be associated with a chance fracture? These are some classic associations.

01:22 I’ll give you a few moments to think about this.

01:27 That’s right, duodenal injury and small bowel injury, and in fact the pancreas as well.

01:34 Remember, anatomically, that the duodenum is fixed in the retroperitoneum in certain portions.

01:39 The pancreas is completely retroperitoneal.

01:42 These organs abut the upper lumbar lower thoracic spine.

01:46 Therefore, a chance fracture is associated with these injuries.

01:52 Now, here’s an image of a traumatic duodenal perforation.

01:56 It can only be found on exploratory laparotomy or exploration.

02:01 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.

02:11 Depending on the severity of the duodenal injury, multiple surgeries can be performed, either primary repair or some sort of a bypass surgery.

02:19 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.

02:28 Another common scenario you may encounter on examinations is a young patient who is riding their bicycle or an ATV.

02:36 They may flip over and hit their upper abdomen on the handlebar.

02:40 This is called the handlebar injury.

02:42 Usually, these patients don’t present right away.

02:45 They pick themselves up, dust themselves off and just keep going.

02:48 But days later, they may come in with nausea, vomiting, abdominal pain.

02:55 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.

03:04 This is likely because the handlebar injury when they made impact cause swelling or injury to the duodenum.

03:11 Subsequent edema because of the injury has now caused a gastric outlet obstruction.

03:17 Very importantly, your next step in management should not be surgery.

03:21 Many, many of these patients resolve completely with a trial of non-operative management.

03:26 So that’s what you should choose.

03:28 Now, let’s move on to the liver.

03:33 Here, on this cross-sectional image, you can see a pre-macerated liver in the right lobe.

03:42 But despite its appearance, we’re quite successful on non-operative management.

03:47 Why is non-operative management so important in liver? Well, unlike some other organs like the spleen, you can’t remove the liver.

03:55 Therefore, if the patient is stable and responsive to blood transfusion, try non-operative management.

04:01 Particularly if there is a blush or active bleeding, you can try IR embolization.

04:07 However, if your patient is hypotensive and deteriorating, that’s not a patient that goes to the interventional suite or tries non-operative management.

04:16 Always choose surgery in exploratory laparotomy.

04:19 Pack the liver and depending on the actual injury, there are multiple mechanisms to stop bleeding.

04:26 It’s likely to be beyond the scope of the USMLE examination.

04:32 Now, let’s move on to spleen, a favorite topic.

04:37 The spleen of course is in the left upper quadrant of your abdomen.

04:40 On this cross-sectional image of the abdomen and pelvis, you not only see a major hematoma laceration 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.

04:54 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.

05:03 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.

05:15 Just as a side up, remember, any time you see an image of the patient, it’s presumed that the patient was hemodynamically stable.

05:22 Because again, a very important high-yield fact is you never want to take an unstable patient to the radiology suite.

05:31 So, how do we manage spleen injuries? Well, for hemodynamically stable patients, we have had great success with non-operative management and we continue pushing the envelope for even higher grade splenic injuries.

05:45 So splenic salvage rates are incredibly good.

05:49 This is what you should offer your patient if they’re stable.

05:53 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.

06:08 Now, I’d like to pose a question.

06:10 After splenectomy, vaccines are needed.

06:13 I’ll give you that.

06:14 But do you know what the vaccines are? I’ll give you a second to think about this.

06:22 Before I give you the answer, remember vaccinations are most ideal two weeks prior to surgery, clearly not possible in a trauma patient.

06:29 Therefore, practically speaking, we give it right before discharge.

06:34 Vaccinations are again encapsulated organisms.

06:37 I hope you got these answers.

06:39 The specific organisms that we’re trying to cover is Haemophilus influenzae, Streptococcus, and Neisseria meningitidis also known as meningococcus.

06:52 We’ve discussed spleen, let’s move on to kidney.

06:58 Kidney injury noted here in a coronal section is usually found on the CT scan.

07:03 Unfortunately, neither hematuria or flank pain or necessarily the mechanism of injury usually gives you enough information.

07:11 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.

07:21 Remember, sometimes observation alone is okay for patients who are hemodynamically stable.

07:26 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.

07:35 Remember, though, embolization of the kidney can cause ischemia.

07:40 Sometimes urologists actually need to place stents because your urethral system or the kidney itself may be obstructed with a clot.

07:47 This can lead to renal failure or acute kidney injury.

07:51 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.

07:59 We get a blood draw and look at the hemoglobin and hematocrit every few hours.

08:04 Unfortunately, in a small patient population, nephrectomy is necessary, but make sure you check that there’s another kidney first and it’s functional prior to removing the kidney.

08:16 In the emergency situations with massive hemorrhage, you do what you have to do.