Abdominal trauma

Done by : Areej Al-Hadidi & Bayan Abu Alia

introduction • Abdominal injuries are present in 7–10% of trauma patients. These injuries, if unrecognized, can cause preventable deaths.

• Death usually result from hemorrhage and sepsis

• The abdomen extends from the diaphragm to the pelvic floor, corresponding to the space between the nipples and the inguinal creases on the anterior aspect of the torso.

Can be divided into :-

• Anterior abdomen

• Thoracoabdomen

• Flank

• Back

• intraperitoneal contents

• Retroperitoneal space contents

• Pelvic cavity contents

M.C : RTA / Fall

gunshot

What is the difference between blunt trauma and penetrating trauma ?

Mechanisms 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 non fixed 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%)

Retroperitoneal hematoma(15% )

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

• gunshot wounds may cause additional intra-abdominal injuries based upon the trajectory, cavitation ,effect, and possible bullet fragmentation

• Patients who have suffered abdominal trauma can generally be classified into the following categories based on their physiological condition after initial resuscitation:

●hemodynamically ‘normal’ – investigation can be completed before treatment is planned;

● hemodynamically ‘stable’ – investigation is more limited. It is aimed at establishing whether the patient can be managed non-operatively, whether angioembolization can be used or whether surgery is required;

● hemodynamically ‘unstable’ – investigations need to be suspended as immediate surgical correction of the bleeding is required.

• A trauma laparotomy is the final step in the pathway to delineate intra-abdominal injury. Occasionally it is difficult to determine the source of bleeding in the shocked, multiple injured patient. If doubt still exists, especially in the presence of other injuries, a laparotomy may still be the safest option

Cont,,

• The patient’s physiology must be assessed at regular intervals and, if there is an indication that the patient is still actively bleeding, then the source must be identified, unless the patient is unstable, requiring immediate surgery.

• Blood loss into the abdomen can be subtle and there may be no clear clinical signs. Blood is not an irritant and does not initially cause any abdominal pain. Distension is subjective, and a drop in the blood pressure may be a very late sign in a young fit patient. Examination in unstable patients should take place either in the ED or in the operating theatre if the patient is deteriorating rapidly.

Presentations

- Depend on a few factors; size, site, organ involve, blunt or penetrating

- Visible truncal injury including chest or abdomen

- Abdominal pain

- Bleeding

- Piercing object

- Evisceration

- Shock

Penetrating trauma is usually diagnosed by clinical findings while blunt is more likely to be missed due to less obvious findings

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

Presentation of penetrating 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

Presentation of Blunt trauma

Assessment

History

1. AMPLE:

A: Allergy/Airway

M: Medications

P: Past medical history

L: Last meal

E: Event - What happened?

2. Mechanism a. MVA - Speed - Type of collision (frontal, lateral, sideswipe, rear, rollover) - Types of restraints - Vehicle intrusion into passenger compartment - Deployment of air bag - Patient's position in vehicle - Fatality at the scene b. Gun Shots - # number of shots heard - Type of gun used - Position of pt when shot - Distance

Cont,,

• So that’s why understanding the mechanism of injury is crucial specially in blunt trauma since it’s easier to miss.

• Blunt abdominal trauma is very common in RTAs where:

• There have been fatalities.

• Any casualty has been ejected from the vehicle.

• The closing speed is >50mph(>80km/h).

• Patients who have been involved in a RTA should be asked: speed of the vehicle// type of collision (e.g., frontal impact, lateral impact, sideswipe, rollover)

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

Cont,,

• When assessing a patient who has sustained penetrating trauma:

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

– number of stab wounds or shots sustained.

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

– distance from weapon and bullets caliber.

• For patients injured by falling:

the height of the fall is important to determine due to the potential for deceleration injury from greater heights.

Examination

- Inspect the abdomen and flanks for Lacerations, contusions (eg, seat belt sign), and ecchymosis, abdominal Distension, piercing objects, entry and exits for gunshots

- Palpate for tenderness and rigidity,rebound tenderness

- Auscultate for presence/absence bowel sounds

- Percuss to elicit subtle rebound tenderness

- Assess pelvic stability

- Examine gluteal regions and perinum,rectum,penile,vaginal

Diagnostic studies

• Focused assessment with sonography for trauma (FAST)

• CT scan –abdomen

• CXR and pelvic X-ray

• Diagnostic peritoneal lavage (DPL)”not commonly used anymore”

• Local wound exploration

FAST(Focused assessment with sonography for trauma)

• It is used to identify free fluid inside the peritoneal cavity as a source of significant hemorrhage.

• Used bedside so it can be used in relatively unstable patients.

• 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

• There should be no attempt to determine the nature or extent of the specific injury

Cont,,

• can be performed at the same time as resuscitation.

• It is accurate at detecting >100 mL of free blood; however, it is very operator dependent and, especially if the patient is very obese or the bowel is full of gas, it may be unreliable.

• Hollow viscus injury and solid organ injury are difficult to diagnose, even in experienced hands, as small amounts of gas or fluid are difficult to assess, and FAST a low sensitivity (29–35%) for organ injury without haemoperitoneum.

• FAST is also unreliable for excluding injury in penetrating trauma.(high false negative)

• If there is doubt, the FAST examination can be repeated.

• In case of previous surgery , there may be a lot of adhesion that affect the sensitivity of FAST

Perisplenic (LUQ)

pericardium

Morrison’s pouch

Pouch of Douglas

4P s

Diagnostic peritoneal lavage (DPL)

• Diagnostic peritoneal lavage (DPL) is a test used to assess the presence of blood or contaminants in the abdomen. A gastric tube is placed to empty the stomach and a urinary catheter is inserted to drain the bladder.

• If the FAST exam is unavailable/ limited (eg, poor image quality) , DPL should be performed as alternative in hemodynamically unstable patient.

• A cannula is inserted below the umbilicus, directed caudally and posteriorly. The cannula is aspirated for blood (>10 mL is deemed as positive) and, following this, 1000 mL of warmed Ringer’s lactate solution is allowed to run into the abdomen and is then drained out via the same route.

Cont,,

• The presence of >100 000 red cells/μL or >500 white cells/μL is deemed positive (this is equivalent to 20 mL of free blood in the abdominal cavity), as is the presence of vegetable fiber or a raised amylase level.

• In penetrating trauma, a minimum of one-tenth of the above would be regarded as evidence of peritoneal penetration or intraperitoneal injury. In the absence of laboratory facilities, a urine dipstick may be useful.

• Drainage of lavage fluid via a chest drain indicates penetration of the diaphragm.

https://www.youtube.com/watch?v=aRw3qQGjTzI

CT scan

• CT has become the ‘gold standard’ for the intra-abdominal diagnosis of injury in the stable patient.

• The scan can be performed using intravenous contrast.

• CT is sensitive for blood and individual organ injury, as well as for retroperitoneal injury.

• An entirely normal abdominal CT is usually sufficient to exclude intraperitoneal injury.

• The following points are important when performing CT: ● if duodenal injury is suspected from the mechanism of injury,

oral contrast may be helpful; ● if rectal and distal colonic injury is suspected in the absence of

blood on rectal examination, rectal contrast may be helpful.

laparoscopy

• Laparoscopy or thoracoscopy may be a valuable screening investigation in stable patients with penetrating trauma, to detect or exclude peritoneal penetration and/or diaphragmatic injury.

• Laparoscopy may be divided into:

● Screening: used to exclude a penetrating injury with breach of the peritoneum.

● Diagnostic: finding evidence of injury to viscera.

● Therapeutic: used to repair the injury.

• In most institutions, evidence of penetration requires a laparotomy to evaluate organ injury, as it is difficult to exclude all intra-abdominal injuries laparoscopically.

• When used in this role laparoscopy reduces the non-therapeutic laparotomy

Indications of Laparotomy

- Signs of peritonitis.

- Uncontrolled shock / hemorrhage.

- Clinical deterioration during observation.

-Evisceration

- Hemoperitoneum findings after DPL / FAST.

- Any knife injury –with visible viscera, clinical peritonitis, hemodynamic unstable, or developing fever/signs of sepsis.

- Any gunshot wounds

•MRI can be used for a stable pregnant patient in need of intrabdominal imaging following penetrating injury

X-Ray

• Plain radiographs typically add little to the management of abdominal trauma .

• If free peritoneal air is seen on upright chest or lateral decubiuts , then the peritoneal cavity has been violated , but this does not confirm hollow viscus injury.

• In diaphragmatic rupture when can see part of the intestine inside the peritoneal cavity

• if peritonitis signs but no peritontitis think of diaphragm rupture

It doesn’t use that much in trauma

Local wound exploration

• With the use of local anesthesia , this procedure could be performed at the bedside in stable patients with stab wound to the abdomen to evaluate the depth and the tract of the injury.

• if the anterior rectus fascia is not violated << no further investigation is needed << considered a deep laceration

• If the fascia is violated <<needs further investigation << CT scan if stable to evaluate the degree of bowl or vascular injury .

Management

Primary survey (ABCDE )

• Evaluation of vitals and resuscitation should be done concurrently

• Any patient persistently hypotensive despite resuscitation ,no obvious cause of blood loss -intrabdominal bleeding

• In abdominal penetration and there is no signs of perforation ,, admit the patient , keep him NPO for 8-12 hours .. If no peritonitis , send him home

Liver

• Blunt liver trauma occurs as a result of direct injury.

• The liver is a solid organ and is usually compressed between the impacting object and the rib cage or vertebral column.

• Most injuries are relatively minor and can be managed non-operatively.

• Penetrating trauma to the liver is relatively common. Bullets have a shock wave and when they pass through a solid structure such as the liver they cause significant damage some distance from the actual track of the bullet.

• Not all penetrating wounds require operative management and may stop bleeding spontaneously.

• In the stable patient, CT is the investigation of choice. (liver , biliary tree and vascular structures)

• Injury in which there is a suggestion of a vascular component should be reimaged, as there is a significant risk of the development of subsequent ischemia, false aneurysms, arteriovenous fistulae or hemobiliary fistula. It is advised that all patients should be rescanned prior to discharge.

• Liver injury can be graded and managed using the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS)

Management

• The operative management of liver injuries can be summarized as ‘the four Ps’:

● push

● Pringle;

● plug;

● pack.

• At laparotomy the liver is reconstituted and bleeding is controlled by direct bimanual compression to achieve its normal architecture as best as possible (push).

• The inflow from the portal triad is controlled by a Pringle’s manoeuvre, with direct compression of the portal triad, either digitally or using a soft clamp .This has the effect of reducing arterial and portal venous inflow into the liver, although it does not control the backflow from the inferior vena cava and hepatic veins.

• Any holes due to penetrating injury can be plugged directly using silicone tubing or a Sengstaken– Blakemore tube, and, after controlling any arterial bleeding, the liver can then be packed

• Bleeding points should be controlled locally when possible, and such patients if required, subsequently undergo subsequent angioembolization.

• It is not usually necessary to suture penetrating injuries of the liver, unless hemostasis cannot be controlled by other means.

• If there has been direct damage to the hepatic artery, it can be tied off.

• Damage to the portal vein must be repaired, as tying off the portal vein carries a greater than 50% mortality rate. If it is not technically feasible to repair the vein at the time of surgery, it should be shunted and the patient referred to a specialist center. A closed suction drainage system must be left in situ following hepatic surgery.

• Finally, the liver can be definitively packed, restoring the anatomy as closely as possible. Placing omentum into cracks in the liver is not recommended.

A large atraumatic hemostat is used to clamp the hepatoduodenal ligament (free border of the lesser omentum) interrupting the flow of blood through the hepatic artery and the portal vein and thus helping to control bleeding from the liver.

Biliary injuries

• Isolated traumatic biliary injuries are rare and occur mainly from penetrating trauma, often in association with injuries to other structures that lie in close proximity.

• The common bile duct can be repaired over a T-tube or drained and referred to appropriate care as part of damage control, or even ligated.

spleen

• isolated splenic injuries, especially in children, can be managed non-operatively. However, in adults, especially in the presence of other injury or physiological instability, laparotomy should be considered.

• The spleen can be packed, repaired or placed in a mesh bag.

• Splenectomy may be a safer option, especially in the unstable patient with multiple potential sites of bleeding.

• In certain situations, selective angioembolisation of the spleen can play a role.

• Following splenectomy there are significant, though transient, changes to blood physiology. The platelet and white count rise and may mimic sepsis.

• Innoculation against Pneumococcus is advisable within 2–3 weeks, by which time the patient’s immune system has recover

• hemodynamically stable / no indications for laparotomy preferred management >> splenic embolization

• hemodynamically unstable >> surgical exploration and splenectomy or splenorraphy

➢ Indications for splenectomy:

• Adults, especially >55 years

• Presence of other injury

• Physiological instability

pancreas

• Most pancreatic injury occurs as a result of blunt trauma.

• The major problem is that of diagnosis, because the pancreas is a retroperitoneal organ.

• CT remains the mainstay of accurate diagnosis.

• Amylase or lipase estimation is insensitive.

• In penetrating trauma, injury may only be detected during laparotomy.

• Classically the pancreas should be treated with conservative surgery and closed suction drainage.

Cont,, • Injuries to the pancreatic body to the left of the superior mesenteric vessels and

to the tail are treated by closed suction drainage alone, with distal pancreatectomy if the duct is involved.

• Proximal injuries (to the right of the superior mesenteric artery) are treated as conservatively as possible, although partial pancreatectomy may be necessary.

• The pylorus can be temporarily closed (pyloric exclusion) in association with a gastric drainage procedure, to minimize pancreatic enzyme stimulation by gastric juice or distension.

• A Whipple’s procedure (pancreaticoduodenectomy) is rarely needed and should not be performed in the emergency situation because of the very high associated mortality rate.

• A damage control procedure with packing and drainage should be performed and the patient referred for definitive surgery once stabilized.

Cont,,

Non-operative:

• May follow with serial labs and exam if patient can be reliably examined.

Operative:

• No ductal injury: hemostasis and external drainage.

• Distal transection, parenchymal injury with ductal injury: Distal pancreatectomy with ductal ligation.

• When duodenum or pancreatic head is devitalized, consider Whipple or total pancreatectomy.

• Proximal transection/injury with probable ductal disruption: If duct is spared, external drainage

• If duct is damaged, external drainage and pancreatic duct stenting may be considered.

stomach

• Most stomach injuries are caused by penetrating trauma.

• Blood presence is diagnostic if found in the nasogastric tube, in the absence of bleeding from other sources.

• Surgical repair is required but great care must be taken to examine the stomach fully, as an injury to the front of the stomach can be expected to have an ‘exit’ wound elsewhere on the organ.

Duodenum

• Duodenal injury is frequently associated with injuries to the adjoining pancreas. Like the pancreas, the duodenum lies retroperitoneally and so injuries are hidden, discovered late or at laparotomy performed for other reasons.

• CT is the diagnostic modality of choice. The only sign may be gas or a fluid collection in the periduodenal tissue, and leakage of oral contrast (improve accuracy of diagnosis).

• Smaller injuries can be repaired primarily. The first, third and fourth parts of the duodenum behave like small bowel, and can be repaired in the same fashion.

• The second part of the duodenum is fixed to the head of the pancreas with a common blood supply, and may have a poorer blood supply compared to the remainder.

• Major trauma, especially if the head of the pancreas is simultaneously injured, should be treated as part of a damage control procedure and be referred for definitive care.

Small bowel

• The small bowel is frequently injured as a result of blunt trauma.

• The individual loops may be trapped, causing high-pressure rupture of a loop or tearing of the mesentery.

• Penetrating trauma is also a common cause of injury.

• Small bowel injuries need urgent repair.

• Hemorrhage control takes priority and these wounds can be temporarily controlled with simple sutures.

• In blunt trauma with mesenteric vessel damage, the bowel ischaemia that results will dictate the extent of a resection. Resections should be carefully planned to limit the loss of viable small bowel, but should be weighed against an excessive number of repairs or anastomosis.

• Hematomas in the small bowel mesenteric border need to be explored to rule out perforation.

• With low energy wounds, primary repair can be performed, whereas more destructive wounds associated with military type weapons require resection and anastomosis.

• Damage control ‘clip and drop’ of damaged or resected bowel may be necessary.

Diagnosis for Bowel Injury:

• If the patient is awake and reliable, the exam is important to look for peritoneal irritation.

• If the exam is not reliable, DPL or laparoscopy may be required.

• CT-scan has a high false-negative rate for small bowel injuries.

• Look for free air on CXR.

• Laparotomy for gastric or small bowel injury with primary repair and peritoneal lavage except in cases that have heavy soiling of the peritoneal cavity and present late, where intestinal diversion must be considered (e.g.; ileostomy)

colon

• Injuries to the colon from blunt injury are relatively infrequent, and are more frequently a penetrating injury.

• If relatively little contamination is present and the viability is satisfactory, such wounds can be repaired primarily.

• Primary repair used for small or medium-sized perforations, repair the perforation or if needed, resect the affected segment and close with primary anastomosis. (Anastomosis is contraindicated in the setting of massive soiling).

• If, however, there is extensive contamination, the patient is physiologically unstable or the bowel is of doubtful viability, then the bowel can be closed off (‘clip and drop’).

• A defunctioning colostomy can be formed later or the bowel re-anastomosed once the patient is stable.

Signs & symptoms of large bowel injury:

Abdominal distention, tenderness, guaiac-positive stool(gFOBT)

Diagnosis:

• In an awake & reliable patient, exam findings are consistent with peritonitis.

• CXR may show free air.

• In a patient with a flank injury but without clear peritoneal signs, consider a contrast enema

Rectum

• Only 5% of colon injuries involve the rectum.

• These are generally from a penetrating injury, although occasionally the rectum may be damaged following fracture of the pelvis.

• Digital rectal examination will reveal the presence of blood, which is evidence of intestinal or rectal injury.

• These injuries are often associated with bladder and proximal urethral injury.

• With intraperitoneal injuries, the rectum is managed as for colonic injuries.

• Full-thickness extraperitoneal rectal injuries should be managed with either a diverting end-colostomy and closure of the distal end (Hartmann’s procedure) or a loop colostomy.

• Presacral drainage is no longer used.

Renal and urological tract injury

• In the stable patient, CT scanning with contrast is the investigation of choice.

• For assessment of bladder injury a cystogram should be performed. A minimum of 300 mL of contrast is instilled into the bladder via a urethral catheter.

• The large volume is enough to produce a leak from a small bladder injury once the cystic muscle is contracted.

• It is important to assess the films as follows:

● two views – AP and lateral (and sometimes oblique);

● two occasions – full and post micturition.

Cont,,

• Generally, renal injury is managed non-operatively unless the patient is unstable.

• The kidney can be angioembolised if required.

• Ureteric injury is rare and is generally due to penetrating trauma. Most ureters can be repaired or diverted if necessary, or may even be ligated as part of Damage control procedures.

• Intraperitoneal rupture of the bladder, usually from direct blunt injury, will require surgical repair.

• Extraperitoneal rupture is usually associated with a fracture of the pelvis and will heal with adequate urine drainage via the transurethral route. Suprapubic drainage is reserved for when this is not possible.

Damage Control Surgery • Rapid initial control of hemorrhage and contamination, temporary closure,

resuscitation to normal physiology in the intensive care unit, and subsequent re-exploration and definitive repair.

• Following major injury, protracted surgery in the physiologically unstable patient can in itself prove fatal. Patients with the ‘deadly triad’ of hypothermia, acidosis and coagulopathy are at highest risk. ‘Damage control’ or ‘damage limitation surgery’ is a concept that originated from naval strategy, whereby a ship which has been damaged may have minimal repairs needed to prevent it from sinking, while definitive repairs wait until it has reached port.

• The minimum surgery needed to stabilize the patient’s condition may be the safest course until the physiological derangement can be corrected. Damage control surgery is restricted to only two goals:

- Stopping any active surgical bleeding

- Controlling any contamination

Cont,,

• Once these goals have been achieved, then the operation is suspended and the abdomen temporarily closed. The patient’s resuscitation then continues in the ICU.

• Once the physiology has been corrected, the patient warmed and the coagulopathy corrected, the patient is returned to the operating theatre for any definitive surgery.

Non-operative management

• Non-operative management is universally preferred for the management of solid organ injury in hemodynamically stable children. Non-operative management of solid abdominal organ injury has rapidly gained acceptance in the management of adults as well. A stable patient and accurate CT imaging are prerequisites for this approach. Failure of non-operative management is uncommon and typically occurs within the first 12 hours after injury. Therefore, if we correctly selected, the vast majority of these patients will avoid surgery, require less blood transfusion, and sustain fewer complications than operated patients.

Antibiotics in torso trauma

• There is no level 1 evidence to recommend the use of antibiotics for the insertion of chest drains. However, they should be used in all causes of penetrating abdominal trauma.

Abdominal compartment syndrome • Sustained elevation above 35 mmHg.

• Organ dysfunction caused by intra-abdominal hypertension (e.g. falling renal perfusion, respiratory insufficiency)

• ACS is a major cause of morbidity and mortality in the critically ill patient and its early recognition is essential.

• Operative decompression is always indicated.

• In all cases of abdominal trauma in which the development of ACS in the immediate postoperative phase is considered a risk, the abdomen should be left open and managed as for damage control surgery.

Take home messages

• Abdominal trauma is often difficult to evaluate in the pre-hospital setting .

• Death from Abdominal injury usually from hemorrhage and delayed surgical repair .

• CT is gold standard to diagnose intra-abdominal injury in hemodynamically stable patient

• liver is the most affected organ in blunt or penetrating

• 85 % with hepatic blunt trauma are stable

• When there is a chance of abdominal trauma , don`t delay transport !!