ABDOMINAL TRAUMA Done by : dina jebril

Outlines :

■ Brief information about Anatomy of the abdomen

■ Know the difference between penetrating and blunt trauma

■ Mechanism of injury

■ Mangment

■ Specific diagnosis

Anatomy of the abdomen

What is the difference between blunt trauma and penetrating trauma ?

Mechanism of injury

■ Blunt abdominal trauma can be explained by :

■ direct blow

- compression and crushing injuries to abdominal viscera

- such force deform solid and hollow organs and can cause rupture with secondary hemorrhage

- contamination by visceral contents and associated peritonitis

rapid deceleration ( shearing injuries)

differential movement of fixed and nonfixed parts of the body

example: laceration injury to liver and spleen both are movable organs at the sites of their fixed supporting ligaments

■ In patients who sustain blunt trauma the organs most frequently injured

spleen (40%-55%) ( this is from the book)

but recently the most common organ injured in both blunt and penetrating trauma is

the liver )

liver ( 35%-45%)

small bowel (5%-10%)

Penetrating trauma ■ stab wounds and low velocity gunshot wounds cause tissue damage by lacerating

and cutting

■ High velocity gunshot wounds transfer more kinetic energy to abdominal viscera

■ Stab wounds traverse adjacent abdominal structures and most commonly involve

the live (40%) small bowel(30%) diaphragm(20%) and colon (15%)

■ gunshot wounds may cause additional intraabdominal injuries based upon the

trajectory, cavitation ,effect, and possible bullet fragmentation

So mechanism of injury is very important, you can suspect it through history and physical examination ■ Through hx:-

■ motor vehicle crash

■ ,pertinent historical information includes

speed of the vehicle,

type of collision (e.g., frontal impact, lateral impact, sideswipe, rollover),

types of restraints,

deployment of air bags, patient’s position in the vehicle, and status of passengers,

if any.

■ For patients injured by falling,

the height of the fall is important to determine due to the potential for deceleration injury

from greater heights.

■ When assessing a patient who has sustained penetrating trauma,

pertinent historical information includes:-

** the time of injury

**type of weapon (e.g., knife, handgun, rifle, or shotgun),

** distance from the assailant (particularly important with shotgun wounds, as the likelihood of major visceral injuries decreases beyond the 10-foot or 3-meter range), number of stab wounds or shots sustained,

** the amount of external bleeding from the patient noted at the scene.

If possible, important additional information to obtain from the patient includes the magnitude and location of any abdominal pain.

Left

Penetrating traumaclassification

One third do not penetrate the

abdominal cavity

One third penetrate the

abdominal cavity but don’t cause

any significant intra abdominal

injury

One third do cause significant

abdominal damage

Blunt trauma

In awake unimpaired patient

without abdominal complaints

Hospital admission+ seril

abdominal examination

(Rare)

Unstable patient with abdominal

injury

Immediate celiotomy

Unstable patient with multiple

injury

FAST exam may be useful

Stable patient with multiple injuries

Abdomen may harbor occult organ

involvement >>

Ct scan is necessary

Options to assess abdominal injury :-

■ CXR ( free air under diaphragm)

■ Ultrasound (FAST)

■ DPL (diagnostic peritoneal lavage)

■ CT abdomen with contrast ( if the patient is hemodynamically stable ct scan is the

best assessment tool ) note: ct scan is contraindicated in hemodynamically

unstable patient )

FAST( focused assessment sonography in trauma)

FAST is one of two rapid studies utilized to identify hemorrhage.

■ In FAST, ultrasound technology is used by properly trained individuals to detect the

presence of hemoperitoneum

■ With specific equipment and in experienced hands, ultrasound has a sensitivity,

specificity, and accuracy in detecting intraabdominal fluid comparable to DPL.

■ Thus, ultrasound provides a rapid, noninvasive, accurate, and inexpensive means of

diagnosing hemoperitoneum that can be repeated frequently

■ four regions

FAST image of

the right upper quadrant

showing the liver, kidney,

and

free fluid.

DPL ( diagnostic peritoneal lavage)

■ The doctor said NO need to know about it // recently not used

■ FAST scan is not available or in the setting of equivocal FAST scan

■ how it is done?

small abdominal incision is made under local anesthesia and a catheter is inserted into peritoneal cavity

the test begins with peritoneal aspiration (>20 cc of gross blood is aspirated ,+) (DPA) >> transfer to OR

no blood detected >> perform a lavage of peritoneal cavity with one liter of normal saline

+ DPL > 100,000 RBCs / mm3 defined by biochemical analysis

DPA like FAST can not detect retroperitoneal bleeds

Penetrating abdominal injury

■ Initial management

■ ABCs ( primarily concerned with blood loss)

■ Focused physical examination

■ Assessment of injury { plain x ray , stabilize patient : ct scan , unstable: FAST not

useful in penetrating trauma // not used )

■ All GSWs to the abdomen will need exploratory laparotomy

■ Stab wounds may treated conservatively or require exploratory laparotomy

Blunt trauma ■ Initial management

■ ABCs ( primarily concerned with blood loss)

■ Focused physical examination

■ Assessment of injury { plain x ray , stabilize patient : ct scan , unstable: FAST)

Indications for emergent laparotomy in penetrating abdominal trauma :-

■ Any hemodynamically abnormal patient

■■ Gunshot wound with a transperitoneal trajectory

■■ Signs of peritoneal irritation

■■ Signs of fascia penetration

Emergent laparotomy ■ ■■ Blunt abdominal trauma with hypotension with a positive FAST or clinical evidence of

intraperitoneal bleeding

■ ■■ Blunt or penetrating abdominal trauma with a positive DPL

■ ■■ Hypotension with a penetrating abdominal wound

■ ■■ Gunshot wounds traversing the peritoneal cavity or visceral/vascular retroperitoneum

■ ■■ Evisceration

■ ■■ Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma

■ ■■ Peritonitis

■ ■■ Free air, retroperitoneal air, or rupture of the hemidiaphragm

■ ■■ Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal

bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or

penetrating trauma

Subsequent management :- after blunt trauma ■ what is the management of intra abdominal bleeding due to splenic injury?

hemodynamically stable / no indications for laparotomy

preferred management >> splenic embolization

hemodynamically unstable >> surgical exploration and splenectomy or splenorraphy

** what is the management of intra abdominal bleeding due to liver injury ?

Most patients with liver injury can be managed conservatively

patient stable but demonstrates ongoing bleeding

embolization ,

Unstable >> surgical exploration is necessary

Specific diagnosis ■ DIAPHRAGM INJURIES

■ Blunt tears can occur in any portion of either diaphragm;

The left hemidiaphragm is more commonly injured.

The most common injury is 5 to 10 cm in length and involves the posterolateral left

hemidiaphragm.

■ Abnormalities on the initial chest x-ray include elevation or “blurring” of the

hemidiaphragm, hemothorax, an abnormal gas shadow that obscures the

hemidiaphragm, or the gastric tube positioned in the chest. However, the initial chest x-

ray can be normal

In a small percentage of patients. The diagnosis should be suspected with any wound of

the thoracoabdomen and may be confirmed with laparotomy, thoracoscopy, or laparoscopy

■ DUODENAL INJURIES

■ Duodenal rupture is classically encountered in unrestrained drivers involved in

frontal-impact motor vehicle collisions and patients who sustain direct blows to the

abdomen.

■ bloody gastric aspirate or retroperitoneal air on a flat plate x-ray of the abdomen or

abdominal CT should raise suspicion for this injury.

■ .An upper gastrointestinal x-ray series or double-contrast CT is indicated for high-risk

patients

■ PANCREATIC INJURIES

■ Pancreatic injuries most often result from a direct epigastric blow that compresses

the organ against the vertebral column.

■ An early normal serum amylase level does not exclude major pancreatic trauma.

Conversely, the amylase level can be elevated from nonpancreatic sources.

■ However, persistently elevated or rising serum amylase levels should prompt further

evaluation of the pancreas and other abdominal viscera.

■ Double-contrast CT may not identify significant pancreatic trauma in the immediate

postinjury period (up to 8 hours); it should be repeated later if pancreatic injury is

suspected. Should there be concern after an equivocal CT, surgical exploration of

the pancreas is warranted

■ HOLLOW VISCUS INJURIES

■ Blunt injury to the intestines generally results from sudden deceleration with

subsequent tearing near a fixed point of attachment, especially if the patient’s seat

belt was applied incorrectly.

■ The appearance of transverse, linear ecchymoses on the abdominal wall (seat-belt

sign) or the presence of a lumbar distraction fracture (Chance fracture) on x-ray

should alert the clinician to the possibility of intestinal injury.

■ Although some patients have early abdominal pain and tenderness, diagnosis can

be difficult in others, especially because injured intestinal structures may only

produce minimal hemorrhage

References:-

■ ATLS Student course manual / 9th edition

■ The Washington Manual of surgery /8th edition

■ Surgery: A Case Based Clinical Review

■ Thank you