Trauma Notes PDF 2020

YEAR 5 2020 TRAUMA NOTES CONTENT TAKEN FROM ONLINE LEARNING MATERIAL PROVIDED VIA VULA SPECIAL THANKS TO NASTASJIA-LEIGH PILLAY FOR HER ADDITIONS/ASSISTANCE JESSICA ANDRAS (ANDJES003) CONTENTS INITIAL MANAGEMENT & ASSESSMENT............................................................................

YEAR 5 2020 TRAUMA NOTES CONTENT TAKEN FROM ONLINE LEARNING MATERIAL PROVIDED VIA VULA SPECIAL THANKS TO NASTASJIA-LEIGH PILLAY FOR HER ADDITIONS/ASSISTANCE JESSICA ANDRAS (ANDJES003) CONTENTS INITIAL MANAGEMENT & ASSESSMENT........................................................................................3 EVALUATION OF THE C-SPINE.......................................................................................................9 PENETRATING NECK INJURY (PNI)............................................................................................... 19 PENETRATING THORACIC TRAUMA............................................................................................ 34 BLUNT THORACIC TRAUMA........................................................................................................ 37 PENETRATING ABDOMINAL TRAUMA......................................................................................... 52 BLUNT ABDOMINAL TRAUMA.................................................................................................... 57 VASCULAR TRAUMA................................................................................................................... 63 HEAD INJURIES........................................................................................................................... 67 BURNS....................................................................................................................................... 78 SHOCK....................................................................................................................................... 95 (MOST) ADDITIONAL IMAGE SOURCES..................................................................................... 101 2 INITIAL MANAGEMENT & ASSESSMENT Concepts of the initial assessment PRIMARY RESUSCITATION RE-EVALUATION SURVEY DETAILED DEFINITIVE SECONDARY RE-EVALUATION CARE SURVEY Even though ATLS teaches a stepwise approach of ABCDE, all these procedures are done almost simultaneously, by various members of the team Advanced Trauma Life Support (ATLS) principles and application Standard precautions: Gown, gloves, shoe covers, goggle and face shield Triage is done according to the ABCDEs and available resources: Green: Walking wounded Yellow & Orange: Stretcher cases Red: Resuscitation Quick simple way to assess patient in 10s 1. Identify yourself 2. Ask patient his/her name 3. Ask patient what happened If patient is able to answer these 2 questions, it means the patient has a patent airway, sufficient respiratory reserve to speak and a clear sensorium If unable to answer → Move to initial primary survey Rapid primary survey A: Airway with C-spine protection B: Assist patient with breathing C: Circulation with haemorrhage control and fluid resuscitation D: Disability (gross neurological picture of the patient) E: Exposure/environment 3 Airway Objective: Maintain patent airway while protecting the C-spine Airways can be divided into temporary and definitive: Initial manoeuvres (chin lift, jaw thrust) and oropharyngeal airway (i.e. Guedelle) are employed to pre-oxygenate the patient = Temporary airways Gold standard for definitive airway in trauma is oral endotracheal intubation, if that fails then – surgical cricothyroidotomy or laryngeal mask to temporise Tracheostomy is the other definitive airway, usually employed for long-term ventilation ALWAYS PROTECT THE C-SPINE until it is cleared either by collar or head blocks o It can only be cleared clinically in an awake patient with no distracting injuries OR by CT scan (x-rays are only a screening modality) Breathing There are non-invasive and invasive ways of assisting the patient with breathing Anticipate pitfalls such as equipment failure, inability to intubate, occult airway injury and progressive loss of airway Non-invasive: Supplemental oxygen (via nasal prongs or face mask), CPAP, Optiflow Invasive: Mechanical ventilation ABG: The arterial blood gas is the most important adjunct to gauge adequacy of ventilation Circulation Objective: Control bleeding and restore volume Assess organ perfusion using: Level of consciousness, skin temperature and colour, pulse rate and character, blood pressure, urine output and ABG Stop/control bleeding! Use Damage Control surgery/resuscitation principles: Restore volume o MTP – Massive Transfusion Protocol → Giving patient packed cells (RBC’s), FFP and platelets after 1-1.5l of crystalloid o Coagulopathic patients may benefit from tranexamic acid (PEG/MTP) within 3 hours from trauma Permissive hypotension → Aim for SBP of 90mmHg EXCEPT when there are head injuries Disability Gross neurological assessment – GCS Pupillary response to light o Size o Are they equally reactive? Environment/Exposure Undress patient fully Log-roll to examine back (also PR and PVs) 4  Be mindful of hypothermia (environment) because it leads to coagulopathy o Inhibits clotting factors Warm IV fluids and active warming of patient if necessary Special considerations Trauma in the elderly, paediatric trauma and pregnant women → Physiology is different Athletes → Obvious signs of hypovolaemic shock are not there initially Medications → Some drugs, such as β-blockers can mask the signs of hypovolaemic shock Adjuncts of primary survey 1. Vital signs 2. ABG 3. Pulse oximeter and capnography 4. Urinary/gastric catheter unless contraindicated 5. Urinary output 6. ECG 7. Diagnostic tools a. DPL – Diagnostic peritoneal lavage (mostly historical) b. FAST – Focused abdominal sonogram in trauma + e(extended) FAST ABG NORMAL pH 7.35-7.45 pCO2 4.5-6kPa or 32-48 mmHg pO2 12-14kPa or 83-108 mmHg BE -1-1 Lactate 96% of injuries heal spontaneously) o If a persistent leak is present, conservative treatment is continued for a further 5 – 7 days as above (majority heal by this time) o Indications for delayed surgery are sepsis/abscess formation or persistence 30  Active bleeding patients in shock in whom bleeding cannot be controlled in the emergency room require immediate surgical management Chest radiograph showing an abnormal ‘wide’ mediastinum with a retained missile → In a stable patient this is an indication for CTA 31  All retained blades must be assessed (ABCDE) and thoroughly investigated for exclusion of a vascular injury and other visceral injury Removal is performed in the OR under controlled conditions with or without general anaesthesia 32 33 PENETRATING THORACIC TRAUMA Introduction/Overview Significant cause of mortality 15-30% require operation Most life-threatening injuries identified in primary survey Most penetrating thoracic injury will require only suturing – those requiring “operation”, majority will only nee thoracostomy tube (ICD) insertion Life threatening injuries Should be identified during the primary survey and managed immediately Airway injury/obstruction Tension pneumothorax o Pathology: Air from ruptured lung enters the pleural cavity without a means of escape. As air pressure builds up, the affected lung is compressed, and all of the mediastinal tissues are displaced to the opposite side of the chest o Tension pneumothorax is a clinical diagnosis and is managed by needle decompression followed by ICD insertion o Clinical signs: Decreased/absent breath sound on the affected side, dyspnoea, tracheal deviation to the other side; hyper-resonance, cyanosis and hypotension are late signs Open pneumothorax o All pneumothoraxes following penetrating trauma are ‘open’ o Treatment is suturing followed by ICD insertion. If facilities are not available for suturing and ICD insertion → A semi-occlusive dressing can be used as a temporising measure ▪ The piece of gauze is taped on 3 sides to act as a one-way valve and prevent a tension pneumothorax Massive haemothorax o Defined at more than 1.5L of blood drained at the time of ICD insertion o On CXR: Extensive opacification over the affected lung field Cardiac tamponade o Raised JVP, muffled heart sounds, hypotension, and pulsus paradoxus ▪ Beck’s triad = Low arterial BP, distended neck veins and muffled heart sounds o On CXR: Straightened heart border o Cardiac ultrasound can also be used and is a very important too to assess for the presence of blood in the pericardium o On ECG: J wave ▪ Positive deflection on the downward slope of the R wave ▪ Also seen in hypothermia and hypocalcaemia 34 Thoracostomy Tube insertion is done in the 5th ICS between the mid and anterior axillary line → NEVER OUTSIDE THE SAFE TRIANGLE ICD (TT) insertion Most common procedure done for penetrating thoracic trauma Adhere to technique (blunt dissection) Landmarks = Safe triangle o Between pectoralis major, nipple line and latissimus dorsi muscle Specific indications Never use a trocar Most common mistakes = Wrong site, wrong technique, and not properly secured Treatment of life-threatening injuries During primary survey Always ABCDE Tension pneumothorax = Clinical diagnosis → Needle decompression → TT Thoracostomy tube insertion for pneumo/haemothoraces 35 Indications for emergency thoracotomy Massive haemothorax (>1.5L or >200ml/hr) Cardiac tamponade Internal cardiac massage – in patient with PEA (pulseless electrical activity) Any haemodynamically unstable patient with penetrating chest trauma (exclude tension pneumothorax first) Note the antero-lateral incision Transmediastinal GSW Significant morbidity and mortality Mediastinal structures: Heart, great vessels, oesophagus, trachea, bronchi CXR is part of primary survey If patient stable → CT/CTA to exclude vascular injuries Contrast swallow to exclude oesophageal injury (or scope) Summary Life threatening injuries discovered and resolved in primary survey Tension pneumothorax is a clinical diagnosis In penetrating neck injuries, look for chest involvement TT insertion = Most common procedure Emergency thoracotomy = Life-saving procedure Stable transmediastinal GSW require CT/CTA with or without a contrast swallow/scope 36 BLUNT THORACIC TRAUMA Background Majority of significant injuries occur during MVA o Speed is a critical factor – 10 % increase in impact speed translates to 40 % rise in case fatality risk for restrained and unrestrained occupants MOI related to rapid deceleration at the moment of impact & interaction of occupant (pedestrian) with mass of the vehicle Initial priorities are: o Ensure patent airway o Adequate ventilation o Restoration of effective circulation Classification of chest injuries Skeletal injury o Clavicle fractures o Rib fractures o Sternal fractures Pulmonary injury o Contusions Heart and great vessel injury Diaphragmatic injury Clavicular fractures Mechanism of injury Children: Fall on shoulders or outstretched arms Adults: Contact sports Signs and symptoms Pain Point tenderness Evident deformity Treatment Immobilize the affected shoulder and arm o Collar and cuff o Clavicular strap Analgesia Heals within 4-6 weeks 37  Fracture of the lateral third of the clavicle Rib fractures Pathophysiology Infrequent until adult life Significant force required Associated underlying pulmonary or cardiovascular injury Ribs 3 - 8 fractured most often (thin & poorly protected) Respiratory restriction as a result of pain & splinting Associated complications include: o Rupture of the aorta o Tracheobronchial tree injury o Vascular injury (intercostal vessels) o Atelectasis o Hypoventilation o Inadequate cough o Pneumonia Associated injuries Fractured ribs 1-3 Subclavian artery Brachial plexus Rupture of thoracic aorta Fractured ribs 3-7 Haemo/pneumothorax Pulmonary contusion Fractured ribs 8-12 Diaphragm 38  Intra-abdominal trauma (liver/spleen) Clinical findings and management Assessment Localized pain, crepitus, audible crunch, point tenderness Pain worsened with movement, deep breathing, coughing Splinting on respiration Apply ATLS principles Non-pharmacological measures High-concentration oxygen Positive-pressure ventilation (if intubated) Chest physiotherapy (adequate cough & breathing) Pharmacological measures Analgesics (Multimodal) o NSAIDS o Opioids o Paracetamol Red circle indicates multiple rib fractures of the posterior ribs 39  Black arrows: Multiple posterior and anterior rib fractures on right Red arrow: Pulmonary contusion White arrow: Surgical emphysema (air in the subcutaneous tissue) Flail chest Mechanism of injury MVA Falls from heights Industrial accidents Assault Indicates significant chest trauma: 20% - 40% of patients with a flail chest have associated injuries Mortality increased with: Advanced age > 7 rib fractures > 3 associated injuries Shock Head injuries Definition Two or more adjacent ribs Fractured in two or more places Produce a free-floating segment of chest wall 40 Pathophysiology Respiratory failure due to: Underlying pulmonary contusion Associated intrathoracic injury Inadequate bellows action of the chest Symptoms and signs Chest wall contusion Respiratory distress Paradoxical chest wall movement → Pathognomonic of flail chest Pleuritic chest pain Crepitus Pain and splinting of affected side Tachypnoea Tachycardia Possible bundle branch block on ECG 41 Management Airway and ventilation High-concentration oxygen initially CPAP – via face mask – effective in the cooperative patient (without facial fractures ) , may avoid intubation , ventilation Evaluate the need for endotracheal intubation Positive-pressure ventilation may be needed o Reverses the mechanism of paradoxical chest wall movement o Restores the tidal volume o Reduces the pain of chest wall movement o Internally splint the chest until fibrous union of the chest occurs Assess for a pneumothorax – Delayed exhalation and increased intrapulmonary pressures Stabilize flail segment → Only current standardized indication for rib plating Sternal fractures Incidence: 5% - 8% Causes Deceleration compression injury Steering wheel Dashboard A blow to the chest; massive crush injury Severe hyperflexion of the thoracic cage 42 Morbidity/mortality 25% - 45% mortality rate High association with myocardial or lung injury o Myocardial contusion o Myocardial rupture o Cardiac tamponade o Pulmonary contusion o Flail chest o Vascular disruption of thoracic vessels Management ATLS principles Circulation → Restrict fluids if pulmonary contusion suspected Pharmacological measures → Multimodal analgesia Fixation – Sternal plating and/or wiring Pulmonary contusion Most common potentially lethal chest injury Incidence: 30% - 75% Associated with: Rib fractures High-energy shock waves from explosion High-velocity missile wounds Rapid deceleration Extrathoracic injuries Low velocity → Ice pick Pathophysiology Result of bleeding into the pulmonary parenchyma Usually occurs beneath fractured ribs or flail segment in adults May be present in children in absence of rib fractures (due to elasticity of their rib cage) Significant contusions often not diagnosed until 24 hours after admission → CXR signs typically delayed & underestimate the degree of pulmonary injury Respiratory dysfunction in those with pulmonary contusion(s) Due to combination of: Lack of pulmonary function in the contused segment Remote lung injury mediated by cytokines released by the trauma to the lung parenchyma 43  Contusion in right lower lobe Larger contusion in right middle and lower lobes Assessment findings Tachypnoea Tachycardia Cough Haemoptysis Apprehension Respiratory distress Evidence of blunt chest trauma Management Airway and ventilation 44  o High-concentration oxygen initially o Positive-pressure ventilation if indicated Circulation → Avoid fluid overload o Restriction of fluid in the hypovolemic patient not advised Adequate analgesia Chest physiotherapy Heart and great vessel injury Myocardial contusion (blunt myocardial injury) Incidence o Most common cardiac injury o 16% - 76% Mechanism o Chest wall strikes the dashboard / steering column (MVA) o Crush injury Associations o Sternal fractures o Multiple rib fractures Assessment findings o Retrosternal chest pain o ECG changes ▪ Persistent tachycardia ▪ ST elevation, T-wave insertion ▪ Right BBB ▪ Atrial flutter; fibrillation ▪ Premature ventricular contractions ▪ Premature atrial contractions o New cardiac murmur o Hypotension o Chest well contusion and ecchymosis o Pericardial friction rub (late) Management o ATLS principles o Circulation: Continuous cardiac monitoring for 48 hours o Pharmacological measures: ▪ Antiarrhythmics ▪ Vasopressors and inotropes if indicated o Cardiac troponins and CKMB not useful Traumatic aortic rupture Incidence o 15 % of fatalities Mechanism of injury o Major deceleration injury ▪ Rapid deceleration in high-speed motor vehicle crashes 45  ▪ Falls from great heights ▪ Crushing injuries to torso Pathophysiology o 3 mechanisms: o Shearing stress ▪ Generated by differential movement between fixed portion of the aorta &relatively more mobile one o High peak of intraluminal pressure occurring during the moment of the accident o Crushing of the aorta between chest wall & spinal column (Osseous pinch) o Majority occur at aortic isthmus → Proximal descending aorta within 1cm of origin of left subclavian artery – where aorta is fixed by ligamentum arteriosum Assessment findings o Upper-extremity hypertension with absent or decreased amplitude of femoral pulses ▪ Compression of the aorta by the expanding haematoma o Generalized hypertension ▪ Increased sympathetic discharge o Systolic murmur over the pericardium or interscapular region (25%) o Paraplegia with a normal cervical &thoracic spine (rare) o Retrosternal or interscapular pain o Dyspnoea o Dysphagia o Ischemic pain of the extremities o Chest wall contusion Diagnostic modalities o CXR ▪ Widening of the mediastinum ▪ Most sensitive finding > 8 cm at arch in supine film > 6 cm erect film o Multi-slice CT scan with IVI contrast (CTA chest) = Gold standard o Aortography ▪ If CT scan does not give accurate information o Transesophageal echocardiography ▪ Highly operator dependent ▪ Certain anatomic regions difficult to visualize Management o Airway and ventilation: ▪ High-concentration oxygen ▪ Ventilatory support with spinal precautions o Circulation ▪ Avoid fluid overload ▪ Maintain systolic BP < 120 mmhg ▪ Maintain HR < 90 bpm o B Blocker (Labetalol) o Vasodilator (Nitroprusside) 46 o Cardiothoracics (Ascending aorta affected) → Bypass required for repair o Vascular surgery → Conservative versus endovascular management (Descending arch affected) Widened mediastinum Widened mediastinum with globular-shaped heart 47  Angiogram of aorta: Pseudo-aneurysm of descending aorta, distal to the left subclavian CTA Chest: Aorta filled with contrast; dissection of aorta with bilateral haemothoraces 48 Diaphragmatic rupture Blunt trauma o 0.8-1.6 % o 90% of injuries associated with high-speed MVA Areas of injury: o L sided injuries predominate o Underdiagnosis of R sided injuries o Hepatic protection of R hemidiaphraghm & weakness of L side at points of embryological fusion have been proposed to explain L sided injuries Rupture allows intra-abdominal organs to enter the thoracic cavity causing: o Compression of the lung with reduced ventilation o Decreased venous return o Decreased cardiac output o Shock Assessment findings o Tachypnoea o Tachycardia o Respiratory distress o Dullness to percussion o Scaphoid abdomen (hollow or empty appearance) ▪ If a large quantity of the abdominal contents are displaced into the chest o Bowel sounds in the affected hemithorax o Decreased breath sounds on the affected side o Possible chest or abdominal pain Diagnostic modalities o Diagnosis frequently missed in acute phase o CXR: 33-70% diagnosed on initial CXR ▪ Elevation of hemidiaphragm (diaphragmatic rupture; visceral herniation; phrenic nerve paralysis) ▪ If herniated stomach or bowel is constricted (“Collar sign”) as it transits torn diaphragm ▪ If tip of NGT resides above diaphragm o CT scan: Sensitivity low – 14-61% ▪ Improved if there is herniation of intra-abdominal contents into chest 49  Elevation of left hemidiaphragm and gastric bubble → Alludes to possible diaphragmatic injury Multiple air-fluid levels with compression of left lung → Possible diaphragmatic injury 50  Stomach contents next to heart with multiple rib fractures on left Management o Airway and ventilation ▪ High-concentration oxygen ▪ Positive-pressure ventilation if necessary Caution: Positive pressure may worsen the injury o Circulation: IV access o Non-pharmacological measures: Do not place patient in Trendelenburg position o Surgical repair: Acutely approached through the abdomen → 90% have associated intra-abdominal injury ▪ Non-absorbable suture (Ethibond, Nylon) ▪ Mesh if too large to approximate 51 PENETRATING ABDOMINAL TRAUMA Negative laparotomy: The abdomen is opened and there is NO injury or NO breach in the peritoneal cavity or retroperitoneum Non-therapeutic laparotomy: There is peritoneal violation BUT no surgical intervention is required; e.g.: an injury to the liver that is NOT bleeding 52 Physical examination of the abdomen has a high accuracy (97% sensitive and 100% specific) for determining the need for a laparotomy There is no place for local wound exploration and diagnostic peritoneal lavage CT and laparoscopy have specific indications Indications for laparotomy Haemodynamic instability o Patients with obvious penetrating abdominal trauma who present unstable and with progressive abdominal distention and do not respond to simple fluid resuscitation, require immediate emergency laparotomy without any investigations Acute abdomen/clinical signs of peritonitis o Diffuse abdominal tenderness o Rebound/percussion tenderness o Guarding/rigidity o Diminished or absent bowel sounds Unreliable clinical examination o Severe head injury o Spinal cord injury o Intoxication o Need for sedation/intubation Evisceration of intra-abdominal contents (organ or omentum) o Eviscerated bowel is at risk of ischaemia due to congestion and swelling. The wound in the abdominal wall must be extended down to the sheath and muscle to release the entrapped bowel. Any obvious perforation must be over sewn temporarily to prevent massive fluid losses and contamination Radiologically proven ureter/bladder injuries o Would follow investigation of haematuria Fresh blood per rectum o The lower third and entire posterior wall of the rectum is extra-peritoneal and patients may not present with signs of peritonism in the presence of blood per rectum o In this scenario, diagnostic laparoscopy is used to exclude any intra-abdominal injury and treat the rectal injury by creating diverting sigmoid loop colostomy 53 54 RUQ and right thoracoabdominal (RTA) penetrating injury If no indication for immediate surgery, should have a CT scan to exclude liver injury Left thoracoabdominal stab wounds LEFT THORACOABDOMINAL STAB Incidence of occult diaphragm WOUND laceration: 3-67% Must prevent complications of diaphragmatic hernia PERITONITIC NON-PERITONITIC which is associated with high morbidity and mortality LAPAROTOMY ABDOMINAL OBSERVATION Non-operative management of gunshot wounds DIAGNOSTIC When managing patients with abdominal GSWs where there is not LAPAROSCOPY an indication for surgery, CT scanning is recommended The trajectory of the missile is determined on CT and can be categorised as: o Extraperitoneal o Peritoneal breach (no visceral injury) o Peritoneal breach (with solid organ injury) o Hollow viscous injury ▪ In line ▪ Gas locules/free air ▪ Free fluid ▪ Bowel wall oedema ▪ Mesentery stranding Investigation of haematuria All patients must be investigated Gold standard is CT with IV contrast If the trajectory involves the pelvis, a CT-cystogram must be done The observation period Patients not undergoing surgery, must be admitted for abdominal observation: o At least 24 hours o NPO o Serial abdominal examination o Baseline laboratory investigations o Vital signs o IV fluids 55  After 24 hours, if afebrile, haemodynamically stable, no abdominal signs, pain-free, hungry, and passing flatus → The patient is fed, and if tolerated, is discharged with an abdominal injury form 56 BLUNT ABDOMINAL TRAUMA Mechanisms of injury Blunt abdominal trauma occurs as a result of: Road traffic accidents Fall from heights Assault Sporting incidents Injuries in the abdomen occur from direct forces causing: External compression (increases the intra-abdominal pressure) Deceleration (causing shear forces) Crushing of the abdominal wall against spine, pelvis and chest Injured organs in order of frequency Spleen (40 – 55%) Liver (35 – 45%) Small bowel / mesentery (5 – 10%) Kidneys Bladder Colon / rectum Diaphragm Pancreas Major vessels Management challenge(s) with BAT The evaluation of the abdomen is very challenging and can often result in missed intra- abdominal injury or overuse of diagnostic imaging such as CT Physical examination can be difficult in the presence of neurologic injury, alcohol, drug or multisystem trauma Many trauma patients for various reasons are not examinable or certain physiological reasons make your exam less reliable Non-examinable patients should be evaluated through CT to aid in diagnosis Non-examinable patients: o GCS175IU Occult ongoing haemorrhage indicates chest, abdomen and/or pelvis involvement Continued intra-abdominal bleeding in the setting of compromised haemodynamic status, despite aggressive resuscitation efforts is an indication for surgery 58  HAEMODYNAMICALLY UNSTABLE FAST DPL ASPIRATION OF 10ML GROSS BLOOD ABUNDANT FREE FLUID? 500/MM3 WBC 100000/MM3 RBC PRESENCE OF ENTERIC CONTENT YES - LAPAROTOMY AMYLASE >1751U YES - NO - EVALUATE FOR LAPAROTOMY OTHER SOURCES OF SHOCK NO - EVALUATE FOR OTHER SOURCES OF SHOCK CT is generally not required for unstable patients who will ultimately require surgical intervention Approach to the stable patient Primary and secondary survey o Primary survey to address any life-threatening injuries o Secondary survey to evaluate the abdomen The secondary survey should include an inspection of the abdomen for symmetry, distention and the location of contusions o Lateral contusions across the abdomen (seatbelt sign) should alert you to the possibility of internal injury o Hypoactive or absent bowel sounds are associated with internal injury o Gentle palpation of the abdomen and pelvis should be performed → Any increase in pain or instability should raise the suspicion of internal injury or pelvic fracture o Abdominal pain, rigidity and guarding are considered classic signs of internal injury 59 Using abdominal prediction rules and risk factors can help differentiate the low-risk patients who would not require CT for diagnosis which would ultimately prevent the over-exposure to radiation Stable patients considered non-examinable or positive for predictors for blunt abdominal injury should receive an abdominal CT Predictors & risk factors of BAI Abdominal pain and tenderness during an exam Pelvic or femur fracture Abdominal contusions Lower rib fractures Pneumothorax Costal margin tenderness Lumbar spine fracture Haematuria Positive FAST Hypotension ALT>125 AST>200 HCT