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ER14 Emergency Medicine
Traumatology Toronto Notes 2019
• imagingmustbedoneif:
■ equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma,
spinal cord injury resulting in abdominal anesthesia)
■ unexplained shock/hypotension
■ patients have multiple traumas and must undergo general anesthesia for orthopedic, neurosurgical,
or other injuries
■ fractures of lower ribs, pelvis, spine
■ positive FAST
Management
• general:ABCs,fluidresuscitation,andstabilization
• surgical:watchfulwaitingvs.laparotomy
• solidorganinjuries:decisionbasedonhemodynamicstability,notthespecificinjuries • hemodynamicallyunstableorpersistentlyhightransfusionrequirements:laparotomy • holloworganinjuries:laparotomy
• eveniflowsuspicionofinjury:admitandobservefor24h
PENETRATING TRAUMA
• highriskofgastrointestinalperforationandsepsis
• history:sizeofblade,calibre/distancefromgun,routeofentry
• localwoundexplorationunderdirectvisionmaydeterminelackofperitonealpenetration(notreliable
in inexperienced hands) with the following exceptions:
■ thoracoabdominal region (may cause pneumothorax) ■ back or flanks (muscles too thick)
Management
• general:ABCs,fluidresuscitation,andstabilization • gunshotwoundsalwaysrequirelaparotomy
Genitourinary Tract Injuries
• seeUrology,U33
Etiology
• blunttrauma:oftenassociatedwithpelvicfractures ■ upper tract
◆ renal
– contusions (minor injury – parenchymal ecchymoses with intact renal capsule)
– parenchymal tears/laceration: non-communicating (hematoma) vs. communicating (urine
extravasation, hematuria)
◆ ureter: rare, at uretero-pelvic junction
■ lower tract ◆ bladder
– extraperitoneal rupture of bladder from pelvic fracture fragments
– intraperitoneal rupture of bladder from trauma and full bladder ◆ urethra
– posterior urethral injuries: MVCs, falls, pelvic fractures
– anterior urethral injuries: blunt trauma to perineum, straddle injuries/direct strikes ■ external genitalia
• penetratingtrauma
■ damage to: kidney, bladder, ureter (rare), external genitalia
• acceleration/decelerationinjury
■ renal pedicle injury: high mortality rate (laceration and thrombosis of renal artery, renal vein, and
their branches) • iatrogenic
■ ureter and urethra (from instrumentation)
History
• mechanismofinjury
• hematuria(microscopicorgross),bloodonunderwear • dysuria,urinaryretention
• historyofhypotension
Physical Exam
• abdominalpain,flankpain,CVAtenderness,upperquadrantmass,perineallacerations • DRE:sphinctertone,positionofprostate,presenceofblood
• scrotum:ecchymoses,lacerations,testiculardisruption,hematomas
• bimanualexam,speculumexam
• extraperitonealbladderrupture:pelvicinstability,suprapubictendernessfrommassofurineor extravasated blood
• intraperitonealbladderrupture:acuteabdomen
• urethralinjury:perinealecchymosis,scrotalhematoma,bloodatpenilemeatus,highridingprostate,
Laparotomy is Mandatory if Penetrating Trauma and:
• Shock
• Peritonitis
• Evisceration
• Free air in abdomen
• Blood in NG tube, Foley catheter, or on DRE
“Rule of Thirds” for Stab Wounds
• 1/3 do not penetrate peritoneal cavity • 1/3 penetrate but are harmless
• 1/3 cause injury requiring surgery
Gross hematuria suggests bladder injury
pelvic fractures