Lectures

Blunt Abdominal Injuries

by Kevin Pei, MD
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    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.


    About the Lecture

    The lecture Blunt Abdominal Injuries by Kevin Pei, MD is from the course Surgery: Trauma. It contains the following chapters:

    • Blunt Abdominal Injuries
    • Liver
    • Spleen
    • Kidney

    Included Quiz Questions

    1. Flexion injury of the spine
    2. Vertical fracture through the anterior elements of the vertebra
    3. Hyperextension injury of the spine
    4. Transverse fracture through the anterior elements of the vertebra
    5. The anterior portion of the vertebral body.
    1. Upper lumbar spine
    2. Lower thoracic spine
    3. Lower lumber spine
    4. Upper thoracic spine
    5. Cervical spine
    1. Before discharge
    2. 2 weeks after discharge
    3. After surgery
    4. Immediately on presentation
    5. Before starting any procedure
    1. Neisseria Meningitidis
    2. Eikenellacorrodens
    3. Fusobacteriumnucleatum
    4. Actinomycesnaeslundii
    5. Streptococcus sanguinis

    Author of lecture Blunt Abdominal Injuries

     Kevin Pei, MD

    Kevin Pei, MD


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