Trauma Abdominal O Comitê de Trauma Apresenta © ACS Title slide

Apresentação em tema: "Trauma Abdominal O Comitê de Trauma Apresenta © ACS Title slide"— Transcrição da apresentação:

1 Trauma Abdominal O Comitê de Trauma Apresenta © ACS Title slide
The instructor introduces the topic and relates to the students that based on their preparation for the course, a series of questions are asked and student participation and responses are expected. When presenting this lecture, please keep in mind that there are 40 slides and 35 minutes are allotted for this presentation. The first mouse click causes the photo and title to strip down from the left. Photograph of seatbelt injury courtesy of John Fildes, MD, FACS © ACS

2 Objetivos Identificar as principais referências anatômicas do abdome.
Descrever os padrões de lesão no trauma fechado e nos ferimentos penetrantes. Descrever a avaliação do paciente com suspeita de lesão abdominal. Lecture objectives-1 Three (3) of the five objectives are listed on this first objectives slide. The instructor reviews the objectives as provided on the slide, while emphasizing the clinical and other important aspects in the approach to the injured patient with abdominal trauma. © ACS

3 Objetivos Identificar e utilizar os procedimentos diagnósticos e terapêuticos mais apropriados. Discutir o tratamento de urgência das fraturas de bacia. Lecture objectives-2 (Ibid. slide 2) © ACS

4 Questões-Chave Qual é a prioridade do trauma abdominal no tratamento do paciente com trauma múltiplo? Por que é que o mecanismo de trauma é importante? Como descobrir se o choque pode ser devido a lesão intra-abdominal? Key Questions-1 Two slides with key questions are presented next. The intent of these slides is to set the stage for the presentation and then proceed with the interactive lecture. The instructor reviews these questions with the students. No student responses are required at this time. Periodically throughout this presentation, the instructor asks additional questions (secondary questions) related to key questions. © ACS

5 Questões-Chave Como saber se existe lesão abdominal?
Quem deve ser operado (laparotomia)? Como tratar os pacientes com fratura de bacia? Key Questions-2 (Ibid slide 4)  ACS

6 Anatomia Externa Flanco Abdome Dorso anterior © ACS External Anatomy
This slide illustrates the 3 main areas of external abdominal anatomy. The instructor briefly reviews each component while relating the potential structures for injury that exist within each. The anterior abdomen extends from the 4th intercostal space superiorly (often the transnipple line in men) to the inguinal ligament and symphysis pubis inferiorly, and between the anterior axillary lines. The flank area extends from the 6th intercostal space superior to the iliac wing inferiorly, and between the anterior and posterior axillary lines. The back area extends from the tip of the scapula superiorly to the iliac crest (or maybe to the inferior gluteal fold) inferiorly, and between the posterior axillary lines. Each figure is grouped together as one illustration which progress from left to right with each mouse click. The anterior abdomen figure strips down from the top, the flank figure strips up from the bottom, and the back figure wipes from left to right. Illustrations used or modified with permission from LifeART, Super Anatomy 1, External Views 1. © ACS

7 Regiões Internas do Abdome
Abdome superior Abdome inferior Internal Abdominal Regions This slide illustrates the anatomy of the 3 abdominal cavities, while emphasizing the potential for risk for injury to specific structures. The figure is permanent on the screen, as is the white, dividing dotted line at the figure’s waist line. The first mouse click reveals the “upper peritoneal cavity” with its directional arrow. The second mouse click causes the rib cage to wipe down over the thorax and upper abdomen. The instructor emphasizes that the upper part of the peritoneal cavity (anterior and inferior) is covered by the lower aspect of the rib cage. Additionally, the instructor emphasizes the position of the diaphragm during inspiration and expiration and the impact its position may have on the potential for injury to underlying structures. The third mouse click reveals the “lower peritoneal cavity” with its directional arrow. The fourth mouse click reveals “pelvic cavity” with its directional arrow. The instructor should note that the pelvic cavity is not a true anatomic space. It contains contents that are found in both the peritoneal cavity and the retroperitoneal space (rectum, bladder, iliac vessels, and the internal reproductive organs in women. Illustrations used or modified with permission from LifeART, Super Anatomy 1, Skeletal 1; Super Anatomy 3, By Popular Demand 3-1. Cavidade pélvica  ACS

8 Divisão Interna do Abdome
Abdome superior Espaço retroperitoneal Abdome inferior Internal Abdominal Regions This slide also illustrates the anatomy of the 3 abdominal cavities, while illustrating and emphasizing the retroperitoneal space. The figure, dotted lines that divide the upper and lower peritoneal cavities, and related text are not animated. The first mouse click causes the “Pelvic cavity” with “intraperitoneal” and “retroperitoneal” insets appear. The second mouse click reveals the text “retroperitoneal space” and its related green directional arrows. The instructor emphasizes that assessing this potential space for possible injury requires a high index of suspicion and further diagnostic adjuncts. Additionally, this space is not sampled by DPL. Illustration used with permission from LifeART, Super Anatomy 4, Gastrointestinal 2. Cavidade pélvica Intraperitoneal Retroperitoneal  ACS

9 Lesão intra-abdominal não diagnosticada
Trauma Abdominal Qual é uma das principais causas de morte evitável? Lesão intra-abdominal não diagnosticada Abdominal Trauma: What is one of the leading causes of preventable mortality? Following the slides on anatomy and after discussing the potential abdominal components at risk for injury, the instructor asks this question. The instructor reveals the bracketed item after eliciting responses from the students. The students should state the answer as “unrecognized intraabdominal injury.” Missed internal injuries remain the leading cause of preventable mortality in the nonbrain-injured patient. The first mouse click causes the response to zoom out from the center of the screen.  ACS

10 Prioridade no trauma abdominal?
Trauma de crânio e abdome? Trauma de crânio, tórax e abdome? Trauma de crânio, tórax, abdome e extremidades? Trauma de crânio, tórax, abdome, extremidades e pelve? What priority is abdominal trauma in the management of the multiply injured patient? A series of items are provided on this slide. As the instructor reveals each bulleted item, the students are asked to identify which priority abdominal trauma has. The first priority in each group is highlighted in bold-face type. Need Dr. Jurkovich’s narrative.  ACS

11 Ele determina que órgãos mais provavelmente estarão lesados.
Mecanismo de Trauma Por que é importante conhecê-lo? Ele determina que órgãos mais provavelmente estarão lesados. Why is knowledge of the mechanism of injury important in assessing the patient? The instructor reveals the bracketed response on the slide after eliciting responses from the students. The students should respond with, “It determines what organs are probably injured.” This slide sets the stage for the discussion on mechanisms of injury. The first mouse click causes the rectangular shape and text to vertically blind across the screen from the left. © ACS

12 Trauma Fechado Qual o mecanismo de lesão? Compressão Esmagamento
Cisalhamento Desaceleração (órgãos fixos) How does blunt force injure intraabdominal organs? Pursuing the topic of mechanism of injury and types of blunt injury to the abdomen, the instructor asks this question. The students should arrive at the responses listed on the slide. The discussion of the types of injuries that may be sustained with the above-referenced blunt forces is reserved for the next slide.  ACS

13 Trauma Fechado Órgãos mais freqüentemente lesados? Baço Fígado
Intestino delgado What organs are most commonly injured in blunt trauma? After the instructor asks this question, the students should arrive at these 3 responses, which are listed in order of most common injury. The instructor facilitates the discussion so the injured organs can be revealed in the order of most common to least common. The most commonly injured intraabdominal organs in blunt trauma are: (1) Spleen (40% to 55%), (2) Liver (35% to 45%), and bowel (5% to 10%). As the students list the organs in order, the instructor can further query the students as to the type of blunt force that causes the injury: (1) Compression: Direct blow to liver or blowout of the bowel; (2) Crushing: Direct blow to the epigastrium with crushing of the pancreas over the spine; and (3) Shearing: Inappropriate location of the lap belt contributing to bowel injury. Airbag deployment does not preclude injury. Three-point restraints are better than the use of the lap belt only and the lab belt is better than no restraint. The instructor also may relate to the students that solid organs bleed, but the patient may be nonoperatively managed (observed) if the bleeding is slow and spontaneously stops.  ACS

14 Ferimentos Penetrantes
Qual o mecanismo de lesão? Arma branca Transferência de energia cinética Cavitação Tombo (Cambalhota) Fragmentação Baixa energia Lacerações How does penetrating force injure? The instructor proceeds to the discussion of penetrating force injuries and asks the afore-referenced question. The instructor leads this discussion by revealing responses sequentially to each type of penetrating force, emphasizing the differences between the two. Each time the instructor presses the down arrow key, another response appears and then dims with each successive press of the down arrow key. The two subheadings of “stab wound” and “gunshot wound” do not dim with successive clicks of the mouse. Arma de fogo Alta energia  ACS

15 Ferimentos Penetrantes
Lesões mais comuns? Baixa Energia Alta Energia Fígado Delgado Diafragma Cólon Delgado Cólon Fígado Estruturas vasculares What organs are most commonly injured in penetrating trauma? After the instructor asks this question, the students should arrive at these 3 responses, which are listed in order of most common injury on the slide. The instructor facilitates the discussion so the injured organs can be revealed in the order of most common to least common. The most commonly injured intraabdominal organs in low-velocity injuries are: (1) Liver (40%), (2) Small bowel (30%), (3) Diaphragm (20%), and (4) Colon (15%). The most commonly injured intraabdominal organs in high-velocity injuries are: (1) Small bowel (50%), (2) Colon (40%), (3) Liver (30%), and (4) Abdominal vascular structures (25%). The instructor also may relate that large organs are injured more often and that bowel injuries often require surgical repair. The terms low energy and high energy are not animated.  ACS

16 Avaliação: História Trauma fechado Ferimentos penetrantes Velocidade
Ponto de impacto Intrusão Equipamentos de segurança Posição Ejeção Tipo de arma Distância Número de ferimentos Assessment: History: What do I need to know from the prehospital sector that may help me in my assessment of the patient’s abdomen or cause me to suspect an abdominal injury? The instructor emphasizes the importance of obtaining the prehospital history and particularly, the mechanism of injury. These clues help lead the doctor to accurate assessment and management processes. The instructor then asks the aforereferenced question and reveals the bulleted items after eliciting responses from the students. The items listed for blunt trauma and penetrating trauma appear sequentially in the order as seen here. The instructor should add these areas of emphasis when discussing the history associated with penetrating injuries: (1) distinguish the type of knife (eg, sword, butcher knife, or ice pick), including the length of the blade and type of blade (eg, serrated, smooth, or smooth and jagged ); (2) distinguish the type of gun, eg, handgun, shotgun, rifle; (3) caliber of the missile; (4) distance of victim from shooter; (5) number of wounds sustained; (6) identification of entrance and exit wounds and their locations (taking photographs of the wounds may be helpful in determining which one is which.); and (7) forensic evidence: generally, do not debride the skin sites, but preserve them for the medical examiner or police.  ACS

17 Avaliação: Exame Físico
Inspeção Ausculta Percussão Palpação Assessment: Physical Exam: How do I assess the abdomen? The instructor reveals the bulleted items after eliciting responses from the student. The instructor facilitates this discussion by encouraging the students to identify the various components of a physical examination in the order listed on the slide. After the students identify “inspection” as a means of evaluating the patient’s abdomen, the instructor further queries the student about what to look at and for, eg, the anterior and posterior abdomen as well as the lower chest and perineum for abrasions, contusions from restraint devices, lacerations, penetrating wounds, impaled foreign bodies, evisceration of omentum or small bowel, and the pregnant state. Additionally, the patient’s lower back should be examined (carefully logrolling) for the same types of injuries. After identifying, “auscultation,” the instructor queries the students about where to auscultate and for what to listen. The students should respond, all four quadrants for the presence or absence of bowel sounds. The instructor relates that free intraperitoneal blood or gastrointestinal contents may produce an ileus. The instructor cautions the students in that injuries to adjacent structures also may produce an ileus when an intraabdominal injury does not exist. After identifying “percussion,” the instructor further queries the students about subtle signs of peritonitis, tympanitic sounds or diffuse dullness. After the students identify “palpation,” the instructor queries the students the significance of involuntary muscle guarding, rebound tenderness, and the presence of a pregnant uterus.  ACS

18 Trauma Abdominal O que é que pode comprometer o exame?
Álcool ou outras drogas Lesão cerebral ou de medula Fratura de costelas, coluna ou bacia Abdominal Trauma: What can compromise the abdominal exam? During the discussion on assessment, the instructor queries the students about what may compromise the abdominal examination. The students should respond with the bulleted items on the slide. The instructor also may query the students by asking, “How do associated orthopaedic injuries compromise, limit, or ‘distract’ from the abdominal examination?”  ACS

19 Avaliação: Arma Branca
Como avaliar e o que fazer com um doente que apresenta um ferimento por arma branca na parede anterior do abdome, na parte inferior do tórax, no flanco ou no dorso? Assessment: Stab Wound The instructor must take the time to prepare for the discussions related to penetrating abdominal trauma. (See slides 19 through 21.) Slides 19 through 21 only ask the questions, whereas with some of the other slides include anticipated responses from the students. However with slides 19-21, the instructor must be able to lead and facilitate the discussion without the benefit of responses on the slides. Information to use in preparing for and facilitating this discussion is in the ATLS® Student Manual, V. Assessment, B. Physical Exam, 5. Evaluation of penetrating wounds, through 9. Gluteal examination, and G. Diagnostic Studies in Penetrating Trauma. The instructor needs to discuss the different management strategies of anterior stab wounds as compared to the back and flank, and lower chest. Brief information is provided herein with more as noted previously. Positive wound exploration: The anterior fascia is penetrated and the surgeon is not able to convincingly follow the tract to the end of the stab wound (ie, lost in muscle), or the peritoneum is penetrated. Lower chest wounds should not be explored. A chest x-ray should be obtained. There may the likelihood of an intraabdominal injury as well. If the back or flank fascia is penetrated, any one of these four management strategies may be needed: (1) admit and observe, (2) perform a DPL or FAST, (3) perform double or triple contrast CT (IV, oral, colonic), or (4) perform a celiotomy. O que quer dizer exploração “positiva”, quando um cirurgião examina um ferimento abdominal?  ACS

20 Avaliação: Ferimentos Penetrantes
Como avaliar e o que fazer com os ferimentos penetrantes de períneo, reto, vagina ou região glútea? How do I evaluate and manage perineal, rectal, vaginal, or gluteal penetrating injuries? The instructor must take time to prepare for the discussions related to penetrating abdominal trauma. (See slides 19 through 21.) Slides 19 through 21 only ask the questions, whereas with some of the other slides, anticipated responses from the students are provided. Subsequent, with slides 19-21, the instructor must be able to lead and facilitate the discussion without the benefit of responses on the slides. Information to use in preparing for and facilitating this discussion is in the ATLS® Student Manual, V. Assessment, B. Physical Exam, 5. Evaluation of penetrating wounds, through 9. Gluteal examination, and G. Diagnostic Studies in Penetrating Trauma.  ACS

21 Avaliação: Arma de Fogo
Como avaliar e o que fazer com um doente que apresenta um possível ferimento por arma de fogo no abdome? Tangencial? Orifício de saída? Lesões prováveis? Radiografias? Exames de laboratório? How do I evaluate and manage the abdomen of a patient with a possible abdominal GSW? The instructor must take the time to prepare for the discussions related to penetrating abdominal trauma. (See slides 19 through 21.) Slides 19 through 21 only ask the questions, whereas with some of the other slides, anticipated responses from the students are provided. Subsequently, with slides 19-21, the instructor must be able to lead and facilitate the discussion without the benefit of responses on the slides. Information to use in preparing for and facilitating this discussion is in the ATLS® Student Manual, V. Assessment, B. Physical Exam, 5. Evaluation of penetrating wounds, through 9. Gluteal examination, and G. Diagnostic Studies in Penetrating Trauma. The instructor also should review the salient points of evaluating a GSW to the abdomen. The primary question is present on the slide when it is projected. The bulleted items appear sequentially and aid the instructor in leading the discussion.  ACS

22 Tratamento: Arma de Fogo
Geralmente a melhor estratégia é a cirurgia precoce. Management: Gunshot Wound This slide is a continuation of the previous slide. The instructor emphasizes that if the patient is hemodynamically abnormal (eg, hypotensive and unstable), then little additional information is needed prior to a celiotomy and an early operation usually is the best strategy. The first mouse click causes the rectangle and related text to blind vertically onto the screen.  ACS

23 O trauma abdominal pode levar a choque?
Evidência de lesão abdominal pelo mecanismo de trauma, pela história ou pela avaliação Hipotensão Ultra-som (FAST) positivo ou lavagem peritoneal diagnóstica (LPD) francamente positiva Ausência de hemotórax maciço pela radiografia de tórax How do I know if shock is the result of an intraabdominal injury? Dr. Jurkovich needs to provide narration.  ACS

24 Medida Auxiliar: Sonda Gástrica
Alívio da distensão Descompressão do estômago antes da LPD Cuidado Adjunct: Gastric Tube—Why is a gastric tube inserted for the patient with abdominal trauma? When and why do I need to be cautious when inserting a gastric tube? The instructor reveals the bulleted items after eliciting responses from the students to the first question. The instructor then asks the second question. The third mouse click causes the caution sign to split vertically outward. The bulleted items associated with the caution sign are revealed after eliciting responses from the students. Fraturas de base de crânio / face Pode induzir vômito / aspiração  ACS

25 Medida Auxiliar: Sonda Vesical
Monitoração do débito urinário Descompressão da bexiga antes da LPD Diagnóstico Cuidado Adjunct: Urinary Catheter—Why is a urinary catheter inserted in the patient with an abdominal injury? When and why do I need to exercise caution when inserting a urinary catheter? The instructor reveals the first 3 bulleted items after eliciting responses from the students to the first question. The instructor then proceeds to the second question. After eliciting responses from the students, the instructor clicks the mouse again. The caution sign and photograph wipe onto the screen from the left. The illustration serves as a graphic reminder to assess for signs of a possible urethral injury before inserting a urinary catheter, eg, perineal and scrotal hematomas, bleeding from the urethra, rectal blood on the examiner’s gloved finger. Photograph courtesy of John A. Weigelt, MD, FACS, USA ©ACS

26 Medidas Auxiliares: Exames de Sangue / Urina
Não existem exames de sangue obrigatórios Gravidade do trauma e lesões prováveis Hemodinamicamente anormal: Tipagem e prova cruzada Teste de gravidez Pesquisa de álcool ou outras drogas Hematúria macroscópica vs microscópica Adjuncts: Blood / Urine Tests—What laboratory tests do I need to obtain in the patient with an abdominal injury and when do I obtain them? The instructor reveals the bulleted items after eliciting responses from the students. The instructor emphasizes key points related to these items from the text.  ACS

27 Medidas Auxiliares: Exames Radiológicos
Rotina Trauma fechado: Tórax e bacia em AP Ferimentos penetrantes: Tórax em AP e abdome com marcas radiopacas (se hemodinamicamente normal) Adjuncts: X-ray Studies—What x-ray studies do I need to obtain on the patient sustaining blunt and penetrating abdominal trauma? The instructor reveals the bulleted items after eliciting responses from the students. The instructor emphasizes salient points from the text during the discussion, including differentiating tests done for the hemodynamically normal and abnormal patient with abdominal trauma.  ACS

28 Medidas Auxiliares: Exames Contrastados
Uretrografia Cistografia Urografia excretora Tubo digestivo Tomografia Adjuncts: Contrast Studies—What contrast studies should be obtained and what circumstances dictate whether to obtain them in the patient with abdominal injury? The instructor reveals the bulleted items after eliciting responses from the students. The instructor emphasizes salient points from the text during the discussion. The last bulleted item and abdominal CT film wipe across the screen to the right with the final mouse click. CT scan of renal retroperitoneal hematoma courtesy of Trauma.org, renal 0005,  ACS

29 Exames Especiais no Trauma Fechado
LPD FAST* Tomografia Tempo Rápido Rápido Demorado Transporte Não Não Necessário Alta Alta? Alta Sensibilidade Special Studies in Blunt Trauma—Which test should I perform? This table allows the instructor to lead an interactive discussion with the students about using these adjuncts (DPL versus FAST versus CT) to confirm an abdominal injury. The instructor emphasizes that these tests should not be performed if there is early or obvious evidence that the patient requires transfer to another facility or an operation. When the slide is projected, the table is present on the screen. However, the content in the labeled columns is absent. Each mouse click reveals a response to transport, sensitivity, specificity, and eligibility for DPL, FAST, and CT. The responses are revealed horizontally from left to right so the instructor and students can readily compare the benefits of each adjunct and determine which is best for a given patient. The instructor may wish to incorporate brief scenarios to enhance the use of this slide. Baixa Intermediária Alta Especificidade Todos os pacientes Todos os pacientes Hemodinamica- mente normal Indicação * Depende de quem faz  ACS

30 Exames Diagnósticos: Ferimentos Penetrantes
Transição tóraco-abdominal: Exame físico repetido, toracoscopia, laparoscopia ou tomografia Ferimentos por arma branca na parede anterior do abdome: Exploração do ferimento, LPD ou exame físico repetido Ferimentos por arma branca no dorso ou no flanco: LPD, exame físico repetido ou tomografia com duplo ou triplo contraste Diagnostic Studies: Penetrating—What diagnostic studies and should be performed in patients with penetrating injuries to the lower chest, anterior abdomen, back, and flank. Which type of injury warrants an operation? The instructor reveals the each bulleted item after eliciting responses from the students for that specific item until the students have identified the studies to perform for all three types listed. Celiotomy is either the safest policy or reasonable option for each type of injury. The instructor emphasizes salient points from the text for each bulleted item.  ACS

31 Indicações de laparotomia?
Trauma Fechado  PA, suspeita de lesão de víscera Pneumoperitônio Ruptura de diafragma Peritonite Positividade no LPD, FAST ou tomografia com contraste What are the indications for a celiotomy in the patient sustaining blunt abdominal trauma? The instructor reveals the bulleted items after eliciting responses from the students to this question. The instructor emphasizes that in individual patients, surgical judgment is required to determine the timing and need for an operation. The indications listed herein are commonly used to facilitate the surgeon’s decision-making process in this regard.  ACS

32 Indicações de laparotomia?
Ferimentos Penetrantes Hipotensão Lesão peritoneal / retroperitoneal Peritonite Evisceração Positividade no LPD, FAST ou tomografia com contraste What are the indications for a celiotomy in the patient sustaining penetrating abdominal trauma? The instructor reveals the bulleted items after eliciting responses from the students to this question. The instructor emphasizes that in individual patients, surgical judgment is required to determine the timing and need for an operation. The indications listed herein are commonly used to facilitate the surgeon’s decision-making process in this regard.  ACS

33 Lembre-se … …. as lesões abdominais não percebidas são uma causa comum de morte potencialmente evitável. Remember: A missed abdominal injury is a common cause of a potentially preventable death. Early in this presentation, the instructor asked the students, “What is one of the leading causes of preventable mortality?” The students were to respond, “unrecognized intraabdominal injury.” It is important that the instructor emphasize this salient point again before proceeding with the discussion about pelvic fractures. .  ACS

34 Fraturas de Bacia Mecanismo Compressão ântero-posterior
Compressão lateral Cisalhamento vertical Pelvic Fractures: Why is the mechanism of injury important when assessing a patient with a suspected pelvic fracture? The instructor reveals the bulleted items after eliciting responses from the students. The instructor also may query the students about associated injuries with these types of mechanisms. The instructor also provides salient points from the text. The fourth mouse click causes the x-ray of a butterfly fracture of the pelvis to appear. The instructor may use this illustration to query the students about what the x-ray demonstrates. This particular patient was buried by a collapsed wall. The final mouse click reveals the classifications (open and closed) of pelvic fractures. X-ray courtesy of Ray McGlone, Lancaster Royal Infirmary, UK.  ACS

35 Fraturas de Bacia Mecanismo Classificação Abertas Fechadas
Compressão ântero-posterior Compressão lateral Cisalhamento vertical Abertas Fechadas Pelvic Fractures: Why is the mechanism of injury important when assessing a patient with a suspected pelvic fracture? The instructor reveals the bulleted items after eliciting responses from the students. The instructor also may query the students about associated injuries with these types of mechanisms. The instructor also provides salient points from the text. The fourth mouse click causes the x-ray of a butterfly fracture of the pelvis to appear. The instructor may use this illustration to query the students about what the x-ray demonstrates. This particular patient was buried by a collapsed wall. The final mouse click reveals the classifications (open and closed) of pelvic fractures. X-ray courtesy of Ray McGlone, Lancaster Royal Infirmary, UK.  ACS

36 Fraturas de Bacia Força significativa Lesões associadas
Sangramento pélvico Pelvic Fractures: Need Dr. Jurkovich’s narrative. X-ray courtesy of ACS ATLS archives Extremidades ósseas Musculatura  Veias / artérias  ACS

37 Fraturas de Bacia Avaliação Inspeção Palpação da próstata Anel pélvico
Pelvic Fractures: How do I assess the patient for a pelvic fracture? The instructor reveals the bulleted items after eliciting the students’ responses. The instructor emphasizes that manual manipulation of the pelvis to test for mechanical instability is performed only once because repeated testing for pelvic instability may dislodge clots from coagulated vessels and result in fatal hemorrhage. Assimetria no tamanho das pernas, rotação externa Dor à palpação da bacia  ACS

38 Fraturas de Bacia Conduta de Emergência Reposição de volume
Fratura aberta ou fechada? Lesões perineais / gênito-urinárias associadas? Necessidade de transferência? Imobilização da fratura de bacia Pelvic Fractures: How do I manage the patient with pelvic fractures? The instructor reveals the bulleted items after eliciting responses from the students. The salient points are self-explanatory and the instructor may enhance these items with information from the text.  ACS

39 Fraturas de Bacia: Tratamento
Sangramento intraperitoneal significativo? Sim Laparotomia Não Arteriografia Pelvic Fractures: Management—How do I manage the patient with pelvic fractures? This algorithm is a simplification of one component of Algorithm 1, Management of Pelvic Fractures, in the ATLS Student Manual. The instructor uses this slide as a summation of the management of pelvic fractures. This algorithm is animated and the sequence is described herein. The first mouse click reveals the top line and first arrow-bracket set. The algorithm then progresses down the right side of the screen. Each successive mouse click reveals: (1) No and angiography together and then the fixation device. The algorithm then proceeds to the left side of the screen and progresses down with each mouse click: (1) yes and celiotomy. The next mouse click causes the double horizontal arrow to appear between celiotomy and angiography. The final mouse click reveals control hemorrhage and the double horizontal arrow between control hemorrhage and fixation device. The instructor should emphasize the key point as being the need to determine if there is gross intraperitoneal blood. The instructor may ask the students how this may usually be determined. The students should respond by a grossly positive DPL (>10 mL). The use of the FAST exam has not been well studied in this regard. Computed tomography generally is not indicated in the hemodynamically abnormal patient. The instructor may query the students about transferring the patient. Their response should be affirmative if resources are not available. The students also should relate that orthopaedic consultation is required. If angiography and embolization capabilities are not readily available, the instructor may query the students as to what temporary stabilizing measures could be employed. The students should respond that consideration could be given to a pelvic belt, a draw sheet wrapped around the patient’s pelvis, application of the PASG, or a more definitive fixation device (external fixation). Fixação Controle da hemorragia  ACS

40 ? Questions The instructor asks for questions from the students and then pauses, allowing the students adequate time to form and ask their questions.  ACS

41 Resumo ABCDEs e consultar precocemente o cirurgião
A avaliação e o tratamento variam com o mecanismo de trauma e a resposta fisiológica Exame físico repetido e exames complementares Alto índice de suspeita Diagnóstico precoce / laparotomia imediata Summary The instructor uses these bulleted items to summarize the presentation. The instructor may wish to expand on these items, reiterating relevant salient points from the presentation.  ACS