Abdominal Trauma pdf - D. Muhanned

Abdominal Trauma

D. Mohanad Al-Alsherefi / Professor assistant

Abdominal Trauma

• Penetrating Abdominal Trauma

o  Stabbing 3x more common than firearm wounds
o  GSW cause 90% of the deaths
o  Most commonly injured organs: small intestine > colon > liver

• Blunt Abdominal Trauma

o Greater mortality than PAT (more difficult to diagnose, commonly associated

with trauma to multiple organs/systems)

o Most commonly injured organs: spleen > liver, intestine is the most likely

hollow viscus.

o Most common causes: MVA (50 - 75% of cases) > blows to abdomen (15%) >

falls (6 - 9%)

Pathophysiology of injury

Penetrating Abdominal Trauma

• Stab Wounds

o Knives, ice picks, pens, coat hangers, broken bottles
o Liver, small bowel, spleen

• Gunshot wounds

o Small bowel, colon and liver
o Often multiple organ injuries, bowel perforations

Blunt Abdominal Trauma

  Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures
  Crushing effect
  Acceleration and deceleration forces → shear injury
  Seat belt injuries

“seat belt sign” = highly correlated with intraperitoneal injury

Physical Exam

 Generally unreliable due to distracting injury, AMS, spinal cord injury
 Look for signs of intraperitoneal injury

o abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage,

hypovolemia, hypotension

o  Entrance and exit wounds to determine path of injury.
o  Distention -  pneumoperitoneum, gastric dilation, or ileus
o  Ecchymosis  of  flanks  (Gray-Turner  sign)  or  umbilicus  (Cullen's  sign)  -

retroperitoneal hemorrhage

o Abdominal contusions – eg lap belts
o

↓bowel sounds suggests intraperitoneal injuries

o DRE: blood or subcutaneous emphysema

Diagnostic studies

 Lab tests: not very helpful
 May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase.

Imaging

• Plain films:

o  fractures – nearby visceral damage
o  free intraperitoneal air
o  Foreign bodies and missiles

• CT

o  Accurate for solid visceral lesions and intraperitoneal hemorrhage
o  guide nonoperative management of solid organ damage
o  IV not oral contrast
o  Disadvantages : insensitive for injury of the pancreas, diaphragm, small bowel,

and mesentery

• Angiography

o To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma

in an unstable pt

o Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after

penetrating abdominal trauma

FAST

Focused assessment with sonography for trauma (FAST)

o To diagnose free intraperitoneal blood after blunt trauma
o 4 areas:

  Perihepatic & hepato-renal space (Morrison’s pouch)
  Perisplenic
  Pelvis (Pouch of Douglas/rectovesical pouch)
  Pericardium (subxiphoid)

o Sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid

Extended FAST (E-FAST):

o Add thoracic windows to look for pneumothorax.
o Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

Morrison’s pouch (hepato-renal space)

Perisplenic view

Advantages:

  Portable, fast (<5 min),
  No radiation or contrast
  Less expensive

Disadvantages

 Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic

defects.

 Limited by obesity, substantial bowel gas, and subcut air.

 Can’t distinguish blood from ascites.
 high (31%) false-negative rate in detecting hemoperitoneum in the presence of

pelvic fracture

Diagnostic Peritoneal Lavage

• Largely replaced by FAST and CT
• In blunt trauma, used to triage pt who is HD unstable and has multiple injuries with

an equivocal FAST examination

• In stab wounds, for immediate dx of hemoperitoneum, determination of

intraperitoneal organ injury, and detection of isolated diaphragm injury

• In GSW, not used much

1. attempt to aspirate free peritoneal blood

a. >10 mL positive for intraperitoneal injury

2. insert lavage catheter by semiopen, or open
3. lavage peritoneal cavity with saline

• Positive test:

o In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm

o In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm

Local Wound Exploration

 To determine the depth of penetration in stab wounds

 If peritoneum is violated, must do more diagnostics

 Prep, extend wound, carefully examine (No blind probing)
 Indicated for anterior abdominal stab wounds, less clear for other areas

Laparoscopy

 Most useful to eval penetrating wounds to thoracoabdominal region in stable pt

o esp for diaphragm injury: Sens 87.5%, specificity 100%

 Can repair organs via the laparoscope

o Diaphragm, solid viscera, stomach, small bowel.

 Disadvantages:

o  poor sensitivity for hollow visceral injury, retroperitoneum
o  Complications from trocar misplacement.
o  If diaphragm injury, PTX during insufflation

Management

 General trauma principles:

o Airway management, 2 large bore IVs, cover penetrating wounds and

eviscerations with sterile dressings

 Prophylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal

perf/spillage

 In general, leave foreign bodies in and remove in the OR

Management of penetrating abdominal trauma

Mandatory laparotomy

Selective non-operative management

Mandatory laparotomy

• Standard of care for abdominal stab wounds until 1960s, for GSWs until

recently

•  Now thought unnecessary in 70% of abdominal stab wounds
•  Increased complication rates, length of stay, costs
•  Immediate laparotomy indicated for shock, evisceration, and peritonitis

Selective management used to reduce unnecessary laparotomies

• Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair
• Strategy depends on abdominal region:

o Thoracoabdomen

 Nipple line to costal margin

o Anterior abdomen

 Xiphoid to pubis

o Flank and back

 Posterior to anterior axillary line

Thoracoabdomen

• Big concern is diaphragmatic injury

o 7% of thoracoabdominal wounds

• Diagnostic evaluation:

o  CXR (hemothorax or pneumothorax)
o  Diagnostic peritoneal lavage
o  FAST
o  Thoracoscopy

• Anterior abdomen

o  Only 50-70% of anterior stab wounds enter the abdomen
o  of these, only 50-70% cause injury requiring OR
o  Is immediate lap indicated?
o  Has peritoneal cavity been violated?
o  Is laparotomy required?

• Back/Flank

o  Risk of retroperitoneal injury
o  Intraperitoneal organ injury 15-40%
o  Difficulty evaluating retroperitoneal organs with exam and FAST
o  In stable pts, CT scan is reliable for excluding significant injury:

• Gunshot wounds

o  Much higher mortality than stab wounds
o  Over 90% of pts with peritoneal penetration have injury requiring operative management
o  Most centers proceed to lap if peritoneal entry is suspected
o  Expectant management rarely done
o  assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited)

Management of Blunt abdominal trauma

 Exam less reliable
 Diagnostic studies to determine if there is hemoperitoneum or organ injury requiring

surgical repair

o FAST, CT, DPL
o In HD stable pts, CT is preferred

Clinical Indications for Laparotomy after Blunt Trauma

Manifestation

Pitfall

Unstable vital signs with strongly
indicated abdominal injury

Alternative sources, shock

Unequivocal peritoneal irritation

Unreliable

Pneumoperitoneum

Insensitive;

may

due

cardiopulmonary source or invasive
procedures

(diagnostic

peritoneal

lavage, laparoscopy)

Evidence of diaphragmatic injury

Nonspecific

Significant gastrointestinal bleeding

Uncommon, unknown accuracy

Damage Control

 Patients with major exsanguinating injuries may not survive complex procedures
 Control hemorrhage and contamination with abbreviated laparotomy followed by

resuscitation prior to definitive repair

0. initial resuscitation
1. Control of hemorrhage and contamination

a. Control injured vasculature, bleeding solid organs
b. Abdominal packing

2. Back to the ICU for resuscitation

a. Correction of hypothermia, acidosis, coagulopathy

3. Definitive repair of injuries
4. Definitive closure of the abdomen

Resuscitation in the ICU

 IVF (crystalloid, not colloid)
 Transfusion

o ?1:1:1 PRBC/plt/FFP

 Recombinant activated factor VII

o Increased thromboembolic complications

  Rewarming if hypothermic
  Correction of metabolic abnormalities
  Low tidal volume ventilation recommended (4-6 ml/kg)

Open abdominal wounds and definitive closure

 40-70% can’t have primary closure after definitive repair.
 Temporary closure methods

Abdominal Compartment Syndrome

 Common problem with abdominal trauma
 Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple

organ system failure

o ± APP below 50 mm Hg

 Primary ACS: associated with injury/disease in abdomen
 Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary

leak)

Effects of elevated IAP

  Renal dysfunction
  Decreased cardiac output
  Increased airway pressures and decreased compliance
  Visceral hypoperfusion

Management

  Surgical abdominal decompression
  Nonsurgical: paracentesis, NGT, sedation
  Staged approach to abdominal repair
  Temporary abdominal closure

Conclusions

  Watch out for implements and missiles violating the abdomen
  Laparotomy is mandatory if shock, evisceration, or peritonitis
  Diagnostic studies used to determine need for laparotomy in PAT and BAT
  FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood
  Damage  Control  is  a  principle  of  staged  operative  management  with  control  and

resuscitation prior to definitive repair

 Abdominal compartment syndrome is a common problem in abdominal trauma

References

 Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin

Crit Care 2010;16:609-617

 Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med.

2010 Sep;38(9 Suppl):S421-30.

 Marx: Rosen’s Emergency Medicine, 7

ed. 2009 Mosby

 Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
 Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

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