1. Ruptured diaphragm – penetrating injury below the 4th ICS. S/S: peristaltic gurgling sounds in left chest, progressively scaphoid abdomen, Kehr’s sign (left shoulder pain) worse when supine. TX: Emergent exploratory laparotomy, not thoracotomy.
2. Splenic injury (#1 injured in blunt trauma) – S/S: LUQ pain radiating to left shoulder (Kehr’s sign).
a. Grading – Grade IV - > 25% of spleen injured, Grade V – completely shattered.
b. Splenectomy – it is normal to have increased WBC post-op. Give pneumococcal, meningococcal, influenza vaccines if splenectomy; and seek medical attention if animal bites, risk of malaria.
3. Liver injury – (MVC with restraints – cavitation injury) – S/S: RUQ pain and signs of shock, Cullen’s sign (ecchymosis around umbilicus).
a. DX: Coagulation, H&H, LFT’s. Grading I (hematoma) to VI (vascular avulsion).
b. TX: Damage-control surgery (under 90 minutes) to control bleeding. Lower grade injury – monitor H&H closely.
4. Bowel rupture – Lap restraint injury, associated with Chance fracture (T12-L2); transverse colon most often injured. Stomach and bowel injury seen in GSW.
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