Abdominal and GU Trauma - Exam 4

What does this refer to

Diagnostics for abdominal and GU trauma

What does this refer to

• Accurate, sensitive and specific

• Rapid (< 4 mins)

• Non-invasive

• Repeatable

• Portable

• No nephrotoxic contrast

• No radiation exposure

• Can be used in cardiothoracic exam

FAST exam

What does this refer to

• Precisely locate abdominal lesions

• Can evaluate retroperitoneum better

• Identify injuries that can be managed non-operatively

• Non-invasive

CT

What does this refer to

• Indications for use

  • Hypotension in the setting of blunt force abdominal trauma

• Sensitivity and availability are good

Diagnostic Peritoneal Lavage (DPL)

What does this refer to

• Blunt and/or penetrating

• Solid or hollow abdominal organs

• Evisceration

• Often external trauma may be a distracting injury

• Look for other abd trauma as well

• Lower left rib fx increase suspicion for splenic injury

Abdominal trauma

What does this refer to

• Produce sx by blood loss and peritoneal contamination

• Perforation

  • Stomach

  • Small bowel

  • Colon

• Blow-out injury of the antimesenteric border

• Penetrating trauma

  • Small bowel & colon

Hollow Visceral trauma

What does this refer to

• Bucket-handle tear of

• Suppurative peritonitis may develop from small bowel and colonic injuries

• 6-8 hours post accident

Deceleration trauma

What does this refer to

• MC organs are spleen followed by liver, and small bowel.

Blunt Abdominal Trauma

What does this refer to

• Subcutaneous emphysema

• Peritoneal irritation

• Pain throughout abdomen

  • Radiating to neck, chest and shoulders

Esophageal injruy

What does this refer to

• Severe epigastric or abdominal pain, LUQ pain

• Tenderness

• Signs of peritonitis secondary to release of gastric contents.

Gastric injury

What does this refer to

• Mesenteric injury of the intestine

• Intestine itself separates from the mesentery

  • Leaves a devascularized segment of bowel that looks like the handle on a bucket

• MVC is MC cause

  • Driver > Passenger

• RLQ pain is common

Bucket Handle Injury

What does this refer to

Seatbelt Trauma

What does this refer to

• High speed vertical or horizontal deceleration trauma

  • Duodenal injuries

• Injuries range in severity

  • Intramural hematoma

  • Extensive crush or laceration

• Presentation includes

  • Abdominal pain

  • Fever

  • Nausea

  • Vomiting

Retroperitoneal Injuries

What does this refer to

• Perforation of the diaphragm is insidious

• Bowel sounds in the thorax is diagnostic

• Herniation of abdominal contents into thorax

• Findings on CXR

  • NG tube on CXR coiled in the thorax (rare)

  • MC blurring of the diaphragm or an effusion

Diaphragmatic injury

What does this refer to

Diaphragmatic Rupture

What does this refer to

Pneumoperitoneum

What does this refer to

• Inspection THEN Auscultation THEN Percussion THEN Palpation

  • Percussion – where do you expect dullness v tympany?

• Palpate the abdomen

  • Tenderness

  • Distention

  • Rigidity

  • Guarding

    • Voluntary?

    • Involuntary?

Assessment of abdominal and GU trauma

What does this refer to

• Purplish discoloration

  • Flanks (Grey Turner’s sign)

  • Umbilicus (Cullen’s sign)

• Obvious wounds or ecchymosis of the lumbar or flank areas

  • Damage to retroperitoneal or abdominal organs.

AssessmentInspection

What does this refer to

• Presence of bowel sounds in unlikely locations

  • Chest cavity

  • Diminished or absent bowel sounds may indicate an ileus or peritonitis.

AssessmentAuscultation

What does this refer to

• ________ identifies the presence of air, fluid, or tissue.

Assessment Auscultation

What does this refer to

• Tenderness is the most frequent and reliable sign of intraabdominal injury

• Rebound tenderness present

  • Don’t seek additional evidence of irritation

  • May cause the patient further & often unnecessary pain

• Voluntary guarding – unreliable exam

• Involuntary guarding

  • Reliable sign of peritoneal irritation

AssessmentPalpation

What does this refer to

• Admit

• Transfer

• Discharge

Penetrating Disposition

What does this refer to

• Stab wounds/low energy GSW

  • Lacerating and tearing

• High energy GSW

  • Transfers greater kinetic injury

  • Increased damage around the track of the missile

Penetrating Trauma

What does this refer to

• Dependent Factors

  • Mechanism and location of injury

  • Hemodynamic and neurologic status of the patient

  • Associated injuries

  • Institutional resources

• Stop the bleeding / plug the holes

• After the physical exam – cover the patient with warm blankets

• Definitive Tx

  • Ex-lap in the OR

  • Observation

Penetrating TraumaTreatment

What does this refer to

What does this refer to

• Saddle injury

• Penile fx

Blunt trauma

What does this refer to

• GSW or stabbing

Penetrating trauma

What does this refer to

• Foley

Iatrogenic

What does this refer to

• Injuries to the iliac vessels, bladder, sigmoid colon, renal pelvis and the transverse processes of the lumbar spine should raise suspicion of ureteral trauma

• Any patient who presents with hemodynamic instability due to abdominal, flank or back trauma

Urethral Injury

What does this refer to

• Male urethra divided by the urogenital diaphragm

  • Anterior

  • Posterior

Male Urethral Anatomy

What does this refer to

• Disruption of the posterior urethra accompanies 10% to 25% of pelvic ring fx

• 80% to 90% of posterior urethral injuries occur in combination with pelvic fx

GU Trauma

What does this refer to

• Urethral rupture —> Blood present at the urethral meatus

  • Contraindication for foley catheter

• Indication for foley

  • Inability or difficulty with voiding

  • Palpable, distended bladder

• Hematoma in sleeve distribution (along shaft of penis) – distal urethral injury

  • Buck’s fascia intact

• Butterfly hematoma (with extravasation into scrotum) – distal urethral injury

  • Buck’s fascia is not intact

Clinical Features of GU and Pelvic trauma

What does this refer to

• Urethral injury

  • Palpable rectal mass in association with urine or blood extravasation in the perineal region OR

  • Presence of a cephalad or "high riding" prostate during digital rectal exam

Male Physical Exam

What does this refer to

• Most females with an injury to the urethra present with incontinence

• Vaginal exam with hematoma on the urethra or urine leak into the vagina

  • High suspicion for urethral injury

• With females dx is confirmed in the OR during repair of pelvic fx

Female Urethral Injury

What does this refer to

• Diagnostic urethral catheterization inappropriate

  • Introduce infection

  • Lead to increased incidence of stricture formation

  • Convert a partial urethral rupture to complete

• Standard imaging study

  • Retrograde urethrogram

    • Extravasation of contrast along the urethra = disruption

Diagnostics of GU and pelvic trauma

What does this refer to

• Primary goal of treatment

  • Achieve urinary continence while minimizing stricture formation

  • Avoid sexual impotence

• Initial placement of a suprapubic catheter with delayed repair

• Endoscopic primary alignment

• Initial surgical exploration with bladder drainage

  • Urethral realignment occurring at a later time

    • Some consider this to be the gold standard

      • NOT UNIVERSAL

Treatment for GU and pelvic trauma

What does this refer to

• Empty adult bladder lies almost entirely in the minor pelvis

  • Almost completely protected by the pelvic bones

• As the bladder fills with urine – bladder more susceptible to injury

  • Fundus distends

  • Dome of the bladder rises out of the true pelvis into the abdominal

    • May reach level of the umbilicus

• Bladder rupture

  • Above peritoneal reflection extravasation of urine into the intraperitoneal space

  • Below the peritoneal reflection result in extraperitoneal extravasation

Bladder Anatomy

What does this refer to

Bladder trauma

What does this refer to

• Bladder anatomy

  • Reflects posteriorly to the abdominal wall

    • Creates the rectovesical recess

Male Bladder Anatomy

What does this refer to

• Travels over the uterus

  • Forms vesicouterine & rectouterine pouches before meeting the posterior wall of the abdomen

Female Bladder Anatomy

What does this refer to

• Gross hematuria is the hallmark finding in ________

• May also present with minimal urinalysis findings

  • Lower abdominal or suprapubic pain

  • +/- ability to urinate

Bladder injury

What does this refer to

• Plain film cystography – involves use of urinary catheter

  • Most accurate radiologic study to diagnose bladder rupture

  • Pelvic xray done 1st

  • If suspicion for urethral trauma – retrograde urethrogram before cystography

• CT imaging for trauma patients

  • Many trauma centers use either plain film cystography or CT imaging to evaluate injury to the bladder

Diagnostics for bladder injury

What does this refer to

• Approximately 100 mL of contrast material is placed into the bladder via the urinary catheter

• Plain film is taken to check for gross bladder extravasation

• If negative

  • Add 200-250ml contrast until bladder is filled

• Drain bladder

• Post drain xray to assess for contrast behind distended bladder

DiagnosticsNormal CT Cystogram

What does this refer to

• First priority in the treatment

  • Stabilize patient

  • Treat associated life-threatening injuries

• Blunt trauma bladder injury

  • Contusion (type 1) – usually do not require tx

  • Rupture

• Blunt trauma bladder location

  • Intraperitoneal

  • Extraperitoneal

Treatment for Bladder trauma

What does this refer to

• Blunt trauma bladder injury

  • Contusion (type 1) – usually do not require operative tx

    • Tx with large bore urinary catheter

    • Leave in place until urine clears

  • Rupture

Treatment for Bladder Contusions

What does this refer to

• Blunt trauma bladder location

  • Intraperitoneal (type 2) rupture

    • Operative management for multi-level closure

      • Laparotomy OR

      • Laparoscopic repair of intraperitoneal rupture

        • Urine diverted

• Extraperitoneal (type 3)

  • Often managed by urinary catheter drainage alone

  • If operative intervention for other injuries, bladder should be repaired too

TreatmentIntra-extra Peritoneal

What does this refer to

• Approximately 80% of renal injuries are the result of blunt trauma

• MC in MVC, falls, assaults, or sports events

Renal Injuries

What does this refer to

• Seldom immediately life-threatening

• May not be obvious in the setting of multiple trauma

• Deceleration mechanisms of injury or penetrating trauma in close proximity to the kidneys increase suspicion

• Tenderness or ecchymosis of the abdomen or flank should increase suspicion

• Hematuria is the best indicator of urinary tract injury

  • > 5 RBC/HPF

  • Degree of hematuria is not related to the severity or extent of injury

Clinical FeaturesRenal Injuries

What does this refer to

• CT Abd/Pelvis

  • With IV contrast

• Benefits of CT

  • Precise delineation of renal lacerations

  • Determine the presence and location of renal hematomas with or without extravasation

  • Indicate the presence of urinary extravasation or devascularized parenchymal segments

• Limitations of CT

  • Renal venous injuries not well defined

• Injuries of the UPJ

  • CT abd/pelvis with IV contrast

  • Delayed imaging studies that allows contrast to be excreted into collecting system and ureter

Diagnostics for renal injuries

What does this refer to

• Grading system

  • Based on the depth of injury + involvement of vessels OR the collecting system

• Stable patient – blunt force trauma

  • Non-operative observation until no hematuria

• Angiographic embolization

  • Access to renal vasculature through the groin to control bleeding

Treatment for renal injuries

What does this refer to

• Major pelvic hemorrhage can occur rapidly

• Unexplained hypotension may be the only initial indication of major pelvic disruption

Pelvic trauma

What does this refer to

• Hemodynamically stable patient (NO PLAIN FILM IMAGE OF PELVIS)

  • Glasgow coma scale >13

  • No pelvic, abdominal, or back complaints

  • No tenderness in the lower abdomen, lower back, groin, or bony pelvis

• Hemodynamically unstable patient

  • FAST

  • Plain film x-ray of pelvis

• Physical examination findings indicating retrograde urethrogram BEFORE FOLEY

  • Blood at the urethral meatus

  • High riding prostate

  • Gross hematuria

Pelvic Assessment

What does this refer to

• Ball and socket joint

  • Fracture AND/OR

  • Dislocate

• Types of hip fractures

  • Intracapsular fractures

  • Extracapsular fractures

Anatomy Of The Hip & Pelvis

What does this refer to

Pelvic fracture

What does this refer to

Open book pelvic fracture

What does this refer to

Pelvic Fractures

What does this refer to

• Physical exam findings suggestive of ______

  • Ruptured urethra

  • Scrotal hematoma

  • Blood at urethral meatus

  • Discrepancy in limb length

  • Rotation of the leg without obvious (long bone) fx

Pelvic fracture

What does this refer to

Hip fracture

What does this refer to

Hip dislocation

What does this refer to

Treatment (Pelvic Binder)Pelvic Fracture(s)

What does this refer to

• Attempted sexual touching of another person without their consent

  • Sexual intercourse (rape)

  • Sodomy (oral-genital or anal-genital contact)

  • Fondling

Sexual Assault/Rape

What does this refer to

• Child engages in sexual activity for which he/she cannot give consent, is unprepared for developmentally, cannot comprehend; and/or an activity that violates the law or social taboos of society

• Includes fondling and all forms of oral-genital, genital, or anal contact with the child (whether the victim is clothed or unclothed)

• Includes non-touching abuses such as exhibitionism, voyeurism, or involving the child in pornography

Sexual Assault In Pediatrics

What does this refer to

• Occurs when there is asymmetry in age or development among the participants

• Coercive quality to the event

Sexual abuse

What does this refer to

• Occurs in the absence of coercion and involves children of the similar age

  • Separated by no more than four years or developmental level

  • Engage in viewing or touching each other's genitalia because of mutual interest or curiosity

Sexual play

What does this refer to

The Pediatric Interview

What does this refer to

• To identify injuries or other conditions that require treatment

• To screen for or diagnose sexually transmitted infections (STIs)

• To evaluate for and, if possible, reduce the risk of pregnancy

• To document findings of potential forensic value

Abuse

What does this refer to

Male examination for rape/sexual assault (pediatric)

What does this refer to

• Place child in supine position in a frog leg position

• Inspect the labia majora, labia minora, introitus, and hymen

• Assess for

  • Lacerations/tears

  • Contusions/ecchymosis

  • Bleeding

  • Bite marks/lesions

  • Abrasions/erythema

• Speculum exam if appropriate for age

• Vaginal discharge – collect specimens for STIs

Female examination in rape/sexual assault (pediatric)

What does this refer to

• Sexual act performed by one person on another without consent

• May result from the use of force or threat of force

• May also result from the victim's inability or refusal to give consent

• Sexual assault victims do not "entice" their assailants

• Sexual assault is an act of conquest and control

Rape And Sexual Assault In Adults

What does this refer to

• The victim's clothing

• Swabs and smears from the buccal mucosa, vagina, and rectum and from other areas highlighted by ultraviolet light

• Combed specimens from the scalp and pubic hair

• Fingernail scrapings and clippings

• Control samples of the victim's scalp and pubic hair (ideally, at least 20 to 25 pulled hairs per site)

• Whole blood sample

• Saliva sample

SANE nurse

What does this refer to

• Tears

• Ecchymoses

• Abrasions

• Redness

• Swelling

Terminology For Describing Exam Findings – TEARS Categorization

What does this refer to

• STIs

  • Gonorrhea

  • Chlamydia

  • Trichomoniasis

• DNA swabs

• PCR (syphilis)

• hCG

• Standard Rape Kit for forensic evidence

• Some facilities have a “Rape Panel” which may also include HIV, Hepatitis pane

• EtOH

• Urine drug screen

• CBC w/ diff

• CMP

• Urinalysis

• Imaging as required based on injuries

Diagnostics for rape/sexual assault

What does this refer to

• Treat STIs prophylactically

• Drug cocktail for prophylactic tx

  • Ceftriaxone (Rocephin) 500mg IM

  • Azithromycin 1 g PO

  • Metronidazole (Flagyl) 2g PO

• Hep B vaccine series initiated if not immunized

• Post-coital contraception (Plan B)

• Acute crisis counseling

Treatment for rape/sexual assault

What does this refer to

• Rape can occur

  • Male – Female

  • Female – Male

  • Male – Male

  • Female – Female

• Patient may be very difficult to engage in conversation

• Withdrawn and almost non-cooperative

Things To Remember when accessing for rape/sexual assault