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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
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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
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Epidemiology of Sudden Death in Young , Competitive Athletes Due to Blunt Trauma • US National Registry 1980‐2009 • 1,827 Deaths 1 cm
• not involving collecting system
*Kidney Injury Scale‐ American assoc. for Surgery of Trauma
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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
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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 o Falls o Other sports o MVAs o Work o Others
91 61 35 35 3 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%)
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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
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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 • Grade II • Grade III • Grade IV
• Grade V
Laceration 1 cm diameter Splenic tissue maceration or devascularization
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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 15 ‐19 o Splenomegaly 50 ‐60%; usually begins to recede by week 3 o Risk of rupture – greatest days 4 – 21 o Rupture (0.1 ‐0.4 %) • Spontaneously ~ 50 % • Athletic rupture may have no correlation with trauma • Rare after 4th week
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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 50‐60 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
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