Blunt Abdominal Trauma in Athletes

Transcription

1 Blunt Abdominal Trauma in Athletes Robert A. Heyer, M.D. Carolinas Medical Center Department of Internal Medicine Carolina Panthers February 9, 2013 Overview of Injuries Abdominal wall, lower chest Liver Kidney Genitourinary system Spleen Ribs (lower rib cage) Stomach and intestines Anatomy Muscular Layers 1

2 Anatomy Abdominal Contents Anatomy Abdominal Contents Abdominal Anatomy Children & Adolescents Special considerations o Compact torso with smaller anterior to posterior diameter o Smaller area over which force can be dissipated o Relatively larger viscera oless overlying fat oweaker abdominal musculature 2

3 Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma US National Registry ,827 Deaths < 21 years old 261 Trauma: o 235 male, 26 female o 231 Head and neck o 4 Chest o 12 Abdominal splenic rupture, laceration of liver or intestines Abdominal Wall, Lower Chest Wind knocked out o Blow to solar plexus o Momentary paralysis of the diaphragm Abdominal muscle o Various muscles (rectus abdominis, ext. and internal oblique) o Rectus sheath hematoma Sudden abdominal pain with rapid swelling Tender palpable mass Imaging U/S, CT, or MRI Treatment ice, relative rest, analgesics Liver Injury Relatively rare during athletics o Football o Rugby o Wrestling o Soccer 3

4 Liver Injury Contusion o Subcapsular hemorrhage o Intraperitoneal hemorrhage RUQ pain, nausea, increased HR, decreased BP, right shoulder pain (Kehr s sign referred pain from the diaphragm) Return to play o Pain free o Stable Renal Problems in Athletes Proteinuria Hematuria Renal Injuries Bladder, testicular and penile injuries Hematuria Normal urinalysis o Men 1 2 RBCs per high power field (hpf) o Women 4 5 RBC s / hpf Detection o Dipstick (screening test) Peroxidase reacts with Heme group Detects intact RBCs, free hemoglobin & myoglobin High false + o Microscopic UA Definitive test for intact RBCs in spun urine sediment 4

5 Exercise Induced Hematuria o Characteristics The more exertion, more hematuria o 55% football, rowing o 20% marathoners Source RBCs from kidney to urethra Exercise Induced Hematuria o Characteristics Lower tract most common source o Blalock s 10,000 meter hematuria 18 normal IVP 8 of 18 had bladder contusions at cystoscopy Exercise Induced Hematuria Evaluation Repeat urine 48 hrs. after NO exercise + EIH Further work up 5

6 Abdominal Anatomy Traumatic Renal Injuries Pediatric o 30% are sports related o Kidneys are large oincomplete ossification of the rib cage, thus exposed Traumatic renal injuries Adult o Higher energy mechanisms of injury NFL o Kidneys are protected by the rib cage, muscles and fat 6

7 Kidney Injury Scale *Grade I Contusion / Hematoma Blush, no fracture line Microscopic or gross hematuria Normal urological studies *Kidney Injury Scale American assoc. for Surgery of Trauma Kidney Injury Scale *Grade II Hematoma, laceration Non expanding subcapsular hematoma Laceration of the cortex of less than 1.0 cm *Kidney Injury Scale American assoc. for Surgery of Trauma Kidney Injury Scale *Grade III Laceration > 1 cm not involving collecting system *Kidney Injury Scale American assoc. for Surgery of Trauma 7

8 Kidney Injury Scale *Grade IV Laceration, vascular Through the cortex, medulla, collecting system & vascular structures *Kidney Injury Scale American assoc. for Surgery of Trauma Kidney Injury Scale *Grade V Laceration, vascular Completely shattered kidney Avulsion of the renal hilum *Kidney Injury Scale American assoc. for Surgery of Trauma Significance of Hematuria The presence of hematuria rather than the quantity of blood determines the need for diagnostic workup Hematuria does NOT correlate with the severity of the injury 8

9 Significance of Hematuria Vascular pedicle injuries o Renal artery and vein o Only 10 of 33 had gross hematuria Blunt Renal Trauma in Children C Radmayr, Innsbrook, Austria 256 cases over 26 years Causes o Skiing accidents 91 o Falls 61 o Other sports 35 o MVAs 35 o Work 3 o Others 29 Blunt Renal Trauma in Children C Radmayr, Innsbrook, Austria Type of hematuria o Gross hematuria 112 (44.1%) o Microscopic hematuria 102 (40.2%) o NO hematuria 40 (15.7%) 9

10 Blunt Renal Trauma in Children C Radmayr, Innsbrook, Austria Management o Conservative 81.1% o Required surgery 18.9% 11 cases partial nephrectomy 4 cases complete nephrectomy Blunt Renal Trauma in Children C Radmayr, Innsbrook, Austria Important observations o The grade of hematuria did not correlate with the grade of renal injury o Only 51% of the children requiring surgical exploration had GROSS hematuria Traumatic Kidney Injuries Diagnostic Workup CT scan with IV contrast o More sensitive and specific than IVP o Accurately assesses the injury Laceration, extravasation, perinephric hematoma, vascular damage o Spine, ribs and the lower chest Kidneys 10

11 Spleen Injury Trauma to o Left upper quadrant LUQ o Left rib cage o Left flank Lower rib fracture adults and children o Associated with splenic injury 31% Spleen Injury Symptoms o LUQ pain o Left chest wall pain o Left shoulder pain (referred diaphragmatic pain Phys. Exam o VS may be normal; increased HR, Decreased BP o Tender LUQ o Rib tenderness (9, 10, 11) o Contusion o Normal Splenic CT Injury Grading Scale Grade I Laceration < 1 cm deep, subcapsular hematoma < 1 cm in diameter Grade II Laceration(s) 1 3 cm deep, subcapsular or central hematoma 1 3 cm diameter Grade III Laceration(s) 3 10 cm deep, subcapsular or central hematoma 3 10 cm diameter Grade IV Laceration(s) > 10 cm diameter, subcapsular or central hematoma > 1 cm diameter Grade V Splenic tissue maceration or devascularization 11

12 Spleen Injury Treatment o Surgical trauma specialist o Admit o Observe for ~ 5 days; identifies 95% who would require intervention o Nonoperative management (observation plus possible early embolization) ~ 80% o 80% show radiographic healing at 2 months (Grade V excluded) Spleen Injury Nonoperative management o Children splenic capsule is thicker 75 93% are managed with observation + embolization Delayed rupture (0 7.5%) o Adults splenic capsule is thinner 35 65% are managed with observation + embolization Delayed rupture (1 8%) Splenomegaly Infectious Mononucleosis Special consideration o Ages o Splenomegaly 50 60%; usually begins to recede by week 3 o Risk of rupture greatest days 4 21 o Rupture ( %) Spontaneously ~ 50 % Athletic rupture may have no correlation with trauma Rare after 4 th week 12

13 Splenomegaly Infectious Mononucleosis Special considerations o Return to play Noncontact sports gradually resume activity Contact sports wait a minimum of 4 weeks after the onset of illness Blunt Abdominal Injury Final Thoughts Worry early If the player doesn t look right, there may be something wrong. Left or right shoulder pain (Kehr s sign) may be referred diaphragmatic pain not a shoulder injury Respect splenomegaly in infectious mononucleosis; be firm don t be swayed by the Division 1 scholarship. Don t be fooled by normal vital signs; baseline heart rate may be in athletes. Young athletes don t go into Shock until they have lost 40% of their blood volume It is OK to Bother the doctor Thank you 13