Chest and abdomen injury

lecture
TRAUMA OF THE CHEST
 The trauma of the chest is usually
accompanied by dysfunction of the vital
organs. Therefrom it is necessary
constantly to improve diagnostics and
treatment of the patients who suffer from
trauma.
Classification
 І. According to the injury of other organs:
 1. Isolated trauma.
 2. Combined trauma (craniocerebral, with damage of abdominal
organs, with damage of bones).

 ІІ. According to the mechanism of trauma:

 1. Contusion.
 2. Compression.
 3. Commotion.
 4. Fracture.

 ІII. According to the character of the chest viscerae damage:

 1. Without damage of viscerae.
 2. With damage of viscerae (lungs, trachea, bronchi, esophagus,
heart, vessels, diaphragm etc.).
Classification
 IV. According to the character of complications:
 1. Uncomplicated.
 2. Complicated:
 1) Early (pneumothorax, hemothorax, subcutaneous, mediastinal
emphysema floative rib fracture, traumatic shock, asphyxia);
 2) Late (posttraumatic pneumonia, posttraumatic pleurisy, suppurative
diseases of lungs and pleura).

 V. According to the state of cardiopulmonary system:

 1. Without respiratory failure.
 2. Acute respiratory failure (of І, ІІ, ІІІ degree).
 3. Without cardiovascular failure.
 4. Acute cardiovascular failure (of І, ІІ, ІІІ degree).

 VІ. According to the gravity of a trauma:

 1. Mild.
 2. Moderate.
 3. Severe.
Tracheobronchial injury
 Tracheobronchial injury is damage to the
tracheobronchial tree.
 It can result from blunt or penetrating
trauma to the neck or chest, inhalation of
harmful fumes or smoke, or aspiration of
liquids or objects.
Classification
 І. According to degree of disruption:
 Partial:
 without damage of cartilaginous rings (I degree);
 with fracture of cartilaginous rings (II degree).
 Partial disruption of all layers (ІІІ degree).
 Complete transverse disruption of all walls without disjunction of the of trachea,
(bronchus) (ІV degree).
 Abruption with disjunction of the edges of trachea (bronchus) (V degree).
 ІІ. According to direction of rupture:
 Longitudinal.
 Oblique.
 Transversal.
 Mixed.
 ІІІ. According to localization of the damage:
 Tracheo-laryngeal.
 Cervico-tracheal.
 Mediastino-bronchial.
 Bifurcational.
 Bronchial.
 ІV. According to the size of injury:
 Combined damages of trachea (bronchi) and adjacent organs.
 Damage of trachea (bronchi) and other segments of the body.
 Damage of a trachea (bronchi). adjacent organs and other segments of the body.
Mechanism
 The structures in the tracheobronchial tree
are well protected, so it normally takes a large
amount of force to injure them.
 In blunt trauma, tracheobronchial injury is
usually the result of violent compression of
the chest.
 Rapid hyperextension of the neck, usually
resulting from vehicle crashes, can also injure
the trachea, and trauma to the neck can
crush the trachea against the vertebrae.
Mechanism
 When airways are damaged, air can escape from
them and be trapped in the surrounding tissues in
the neck (subcutaneous emphysema) and
mediastinum (pneumomediastinum); if it builds up
to high enough pressures there, it can compress
the airways.
 Massive air leaks from a ruptured airway can also
compromise the circulation by preventing blood
from returning to the heart from the head and lower
body; this causes a potentially deadly reduction in
the amount of blood the heart is able to pump out.
 Blood and other fluids can build up in the airways,
and the injury can interfere with the patency of the
airway and interfere with its continuity.
Signs and symptoms
 Signs and symptoms vary depending on what part
of the tracheobronchial tree is injured and how
severely it is damaged.
 The patient may exhibit dysphonia or have
diminished breath sounds, and rapid breathing is
common.
 Coughing may be present, and stridor, an
abnormal, high-pitched breath sound indicating
obstruction of the upper airway can also occur.
 Damage to the airways can cause subcutaneous
emphysema (air trapped in the subcutaneous
tissue of the skin) in the abdomen, chest, neck,
and head.
Signs and symptoms
 Major and circular disruptions of trachea cause
a grave state of the patients.
 They manifest except difficult breathing by such
signs:
 mediastinal emphysema or pneumothorax;
 compression syndrome – compression and
inflection of major vessels due to tension
pneumothorax or mediastinal emphysema with
transmission into acute cardiopulmonary failure;
 hemorrhage syndrome;
 aspiration syndrome, which is the outcome of
bleeding into airways or aspirations of the gastric
content;
 traumatic shock.
Signs and symptoms
 The predominant clinical signs of a bronchial
disruption are the respiratory disturbance, gas
syndrome, hemoptysis and hemothorax.
 However these signs may be observed only in
isolated injuries of lungs.
 The patients state is grave.
 Rest dyspnea and acute pain behind a breastbone
are the most troubling manifestations.
 The difficult swallowing, hoarseness, swelling face
and subcutaneous crepitation are observed.
 Auscultatory on the side of trauma the breathing
sounds are weak or absent at all.
Diagnosis
 Bronchoscopy is the most effective method
to diagnose, locate, and determine the
severity of tracheobronchial injury, and it is
usually the only method that allows a
definitive diagnosis.
Chest x-ray
 Chest x-ray is the initial imaging technique used to
diagnose tracheobronchial injury.
 The film may not have any signs in an otherwise
asymptomatic patient.
 Indications of tracheobronchial injury seen on
radiographs include deformity in the trachea or a defect
in the tracheal wall.
 Radiography may also show cervical emphysema, air in
the tissues of the neck.
 X-rays may also show accompanying injuries and signs
such as fractures and subcutaneous emphysema.
 Tracheobronchial injury is also suspected if an
endotracheal tube appears in an X-ray to be out of
place, or if its cuff appears to be more full than normal or
to protrude through a tear in the airway.
CT scanning
 CT scanning
detects over
90% of
tracheobronchia
l injury resulting
from blunt
trauma, but
neither X-ray
nor CT are a
replacement for
bronchoscopy.
Treatment
 Treatment of tracheobronchial injury varies based on
the location and severity of injury and whether the
patient is stable or having trouble breathing, but
ensuring that the airway is patent so that the patient
can breathe is always of paramount importance.
 Intubation, one method to secure the airway, may be
used to bypass a disruption in the airway in order to
send air to the lungs.
 If the upper trachea is injured, an incision can be made
in the trachea (tracheotomy) or the cricothyroid
membrane (cricothyrotomy, or cricothyroidotomy) in
order to ensure an open airway.
 If a pneumothorax occurs, a chest tube may be
inserted into the pleural cavity to remove the air.
Treatment
While tracheobronchial injury may be managed
without surgery, surgical repair of the tear is
considered standard in the treatment of most
tracheobronchial injury. It is required
 if a tear interferes with ventilation;
 if mediastinitis (inflammation of the tissues in
the mid-chest) occurs; or
 if subcutaneous or mediastinal emphysema
progresses rapidly; or
 if air leak or large pneumothorax is persistent
despite chest tube placement.
Treatment
 Repair of extensive tears can include
sewing a flap of tissue taken from the
membranes surrounding the heart or lungs
(the pericardium and pleura, respectively)
over the sutures to protect them.
 When lung tissue is destroyed as a result
of tracheobronchial injury complications,
pneumonectomy or lobectomy (removal of
a lung or of one lobe, respectively) may be
required.
Treatment
 Surgery to repair a tear in the
tracheobronchial tree can be successful
even when it is performed months after the
trauma, as can occur if the diagnosis of
tracheobronchial injury is delayed.
 When airway stenosis results after delayed
diagnosis, surgery is similar to that
performed after early diagnosis: the
stenotic section is removed and the cut
airway is repaired.
Pneumothorax
 Pneumothorax is defined as the presence
of air in the pleural space.
 Normally, the pressure in the lungs is
greater than the pressure in the pleural
space surrounding the lungs.
 However, if air enters the pleural space,
the pressure in the pleura then becomes
greater than the pressure in the lungs,
causing the lung to collapse partially or
completely.
Pneumothorax
If air is present in the pleural space, one of
three events must have occurred:
 communication between alveolar spaces
and pleura
 direct or indirect communication between
the atmosphere and the pleural space
 presence of gas-producing organisms in
the pleural space.
Classification
 І. According to the mechanism of occurrence:
 Spontaneous
 Primary (no apparent underlying lung disease)
 Secondary (clinically underlying lung disease: COPD, cystic fibrosis et al.)
 Traumatic
 ІІ.According to extension of process:
 Unilateral
 Bilateral
 ІІІ. According to degree of a lung collapse:
 Partial (collapse of lung to 1/3 of its volume)
 Subtotal (collapse of lung to 2/3 of its volume)
 Total (collapse of lung exceeding 2/3 of its volume)
 ІV. According to type:
 Closed
 Open
 Valvular (Tension)
Closed pneumothorax
 Closed pneumothorax is when air or gas gets
in the pleural space without any outside
wound.
 This sometimes happens when the lung is
already injured somehow, like from diseases
such as cancer or cystic fibrosis.
 The most common cause of closed
pneumothorax is called spontaneous
pneumothorax.
 In chest trauma the cause of occurrence of
the closed pneumothorax is the perforation of
a visceral pleura and pulmonary tissue by the
fragment of fractured rib.
Open pneumothorax
 The open pneumothorax results from
formation of hole in a chest wall at massive
trauma and free entry of air during
inspiration inward a pleural space, and
during expiration – outward.
Valvular (tension) pneumothorax
 The valvular (tension) pneumothorax occurs
at damage of a pulmonary tissue or chest wall
with formation of the valve, when the air
during inspiration enters a pleural space, and
during expiration, due to valve closure, does
not exits outside.
 Tension pneumothorax is a serious and
potentially life-threatening condition.
 This greatly increased pressure in the pleural
space causes the lung to collapse completely,
compresses the heart, and pushes the heart
and associated blood vessels toward the
unaffected side.
Signs and symptoms
 The symptoms of pneumothrax depend on
how much air enters the chest, how much
the lung collapses, and the extent of lung
disease.
 The chief clinical manifestation of
pneumothorax is the rest dyspnea, which
amplifies at a minor exertion.
 This sign arises due to atelectasis of lung
and its exclusion from breathing.
Signs and symptoms
 The chest pain is more characteristic
manifestation for trauma. Nevertheless the
patients promptly adapt for paint and the
dyspnea finally remains the basic clinical
manifestation.
Signs and symptoms
 Progressing of air entry in a pleural space and
pulmonary collapse cause the respiratory lag on
affected side.
 Upon physical examination, breath sounds may
be diminished on the affected side.
 Measures of the conduction of vocal vibrations
to the surface of the chest may be altered.
 Percussion of the chest may be perceived as
hyperresonant, and vocal resonance and tactile
fremitus can both be noticeably decreased.
 The expressiveness of clinical pattern depends on
degree of a pulmonary collapse.
Signs and symptoms
Tension pneumothorax
 The most common findings in people with tension
pneumothorax are chest pain and respiratory
distress, often with a tachycardia and tachypnea in
the initial stages.
 Other findings may include quieter breath sounds
on one side of the chest, low oxygen levels and
blood pressure, and displacement of the windpipe
away from the affected side.
 Rarely, there may be cyanosis, altered level of
consciousness, a hyperresonant percussion note
on examination of the affected side with
hyperexpansion and decreased movement, pain in
the epigastrium, displacement of the apex beat,
and resonant sound when tapping the sternum.
Diagnosis
 Traditionally a plain radiograph of the
chest has been the most appropriate first
investigation.
Chest X-ray
Chest X-ray
 The size of the pneumothorax (i.e. the volume of
air in the pleural space) can be determined with a
reasonable degree of accuracy by measuring the
distance between the chest wall and the lung.
 An air rim of 2 cm means that the pneumothorax
occupies about 50% of the hemithorax.
 British professional guidelines have traditionally
stated that the measurement should be performed
at the level of the hilum with 2 cm as the cutoff.
 American guidelines state that the measurement
should be done at the apex of the lung with 3 cm
differentiating between a "small" and a "large"
pneumothorax.
Chest X-ray
 Not all pneumothoraces are uniform; some
only form a pocket of air in a particular
place in the chest.
 Small amounts of fluid may be noted on
the chest X-ray (hydropneumothorax); this
may be blood (hemopneumothorax).
 Computed tomography
 Computed tomography
can be useful in
particular situations. In
trauma, where it may
not be possible to
perform an upright film,
chest radiography may
miss up to a third of
pneumothoraces, while
CT remains very
sensitive.
Ultrasound
 Ultrasound is commonly used in the
evaluation of people who have sustained
physical trauma.
 Ultrasound may be more sensitive than chest
X-rays in the identification of pneumothorax
after blunt trauma to the chest.
 Ultrasound may also provide a rapid
diagnosis in other emergency situations, and
allow the quantification of the size of the
pneumothorax.
Ultrasound
Treatment
Closed pneumothorax
 Small spontaneous pneumothoraces do
not always require treatment, as they are
unlikely to proceed to respiratory failure or
tension pneumothorax, and generally
resolve spontaneously.
 This approach is most appropriate if the
estimated size of the pneumothorax is
small, there is no breathlessness, and
there is no underlying lung disease.
Aspiration
 In a large pneumothorax (>50%) recommend that
reducing the size by aspiration is equally effective
as the insertion of a chest tube.
 This involves the administration of local anesthetic
and inserting a needle connected to a three-way
tap.
 If there has been significant reduction in the size of
the pneumothorax on subsequent X-ray, the
remainder of the treatment can be conservative.
 Aspiration may also be considered in secondary
pneumothorax of moderate size (air rim 1–2 cm)
without breathlessness, with the difference that
ongoing observation in hospital is required even
after a successful procedure.
 Chest tube
 A chest tube (or
intercostal drain) is
the most definitive
initial treatment of a
pneumothorax.
 Chest tubes are
required in
pneumothorax that
have not responded
to needle
aspiration, in large
pneumothorax
(>50%), and in
cases of tension
pneumothorax.
 Chest tube
 These are typically
inserted in an area under
2
the axilla called the "safe
triangle", where damage
to internal organs can be 1
avoided. 3

This is delineated by
 a horizontal line at the level of the nipple (1)
 pectoralis major muscle (2)
 latissimus dorsi muscle(3).
Chest tube
 They are connected to a
one-way valve system that
allows air to escape, but
not to re-enter, the chest.
 This may include a bottle
with water that functions
like a water seal, or a
Heimlich valve.
 The tube is left in place
until no air is seen to
escape from it for a period
of time, and X-rays
confirm re-expansion of
the lung.
Treatment
Open pneumothorax
 In traumatic pneumothorax, chest tubes
are usually inserted.
 Any open chest wound should be covered
with an airtight seal, as it carries a high risk
of leading to tension pneumothorax.
 Ideally, a dressing called the "Asherman
seal" should be utilized.
 Asherman seal
 The Asherman
seal is a specially
designed device
that adheres to
the chest wall
and, through a
valve-like
mechanism,
allows air to
escape but not to
enter the chest.
Treatment
Tension pneumothorax
 Tension pneumothorax is usually treated with
urgent needle decompression.
 This may be required before transport to the
hospital, and can be performed by an
emergency medical technician or other trained
professional.
 The needle or cannula is left in place until a
chest tube can be inserted.
 If tension pneumothorax leads to cardiac
arrest, needle decompression is performed as
part of resuscitation as it may restore cardiac
output.
Technique of needle decompression

 The first choice of site is the 2nd

intercostal space in the mid‐clavicular line.
 The cannula may also fail to decompress
the tension pneumothorax due to
obstruction by blood, tissue or kinking.
 Therefore, the cannula should be inserted
into the chest attached to a syringe and
flushed with 2 ml of air, if there is no
obvious air release on insertion.
Treatment
 The absence of effect (incomplete
expansion of lung) of active aspiration, and
also valvular closed pneumothorax is the
indications to operative management –
suturing of the pulmonary wound.
 In some cases a segmental resection of
lung, or lobectomy is carried out.
Treatment
 Pleurodesis is a procedure that permanently
obliterates the pleural space and attaches the
lung to the chest wall.
 The best results are achieved with a
thoracotomy with identification of any source
of air leakage and stapling of blebs followed
by pleurectomy of the outer pleural layer and
pleural abrasion (scraping of the pleura) of
the inner layer.
 During the healing process, the lung adheres
to the chest wall, effectively obliterating the
pleural space.
VATS
 A less invasive approach is thoracoscopy,
usually in the form of a procedure called
video-assisted thoracoscopic surgery
(VATS).
 VATS may also be used to achieve
chemical pleurodesis; this involves
insufflation of talc, which activates an
inflammatory reaction that causes the lung
to adhere to the chest wall.
Haemothorax

 Haemothorax is a collection of blood in the

pleural space and may be caused by blunt
or penetrating trauma.
 The cause of occurrence of this
complication is the damage of vessels of
the chest wall, pleura, lungs and
mediastinum.
Classification
 І. According to extent:
 Unilateral.
 Bilateral.
 ІІ. According to degree of hemorrhage:
 Small (the loss less 10 % of volume of circulating blood).
 Moderate (loss of 10-20 % of volume of circulating blood).
 Great (loss of 20-40 % of volume of circulating blood).
 Total (exceeds 40 % of volume of circulating blood).
 ІІІ. According to duration of bleeding:
 With persistent hemorrhage.
 With the stopped bleeding.
 ІV. According to the presence of clots in a pleural space:
 Coagulated.
 No- coagulated.
 V. According to the presence of infection:
 Not infected.
 Infected (suppurative).
Signs and symptoms
 If hemothorax is the complication of blunt
chest trauma, the clinical manifestations
depend on the gravity of trauma and
degree of hemorrhage.
 Also hemothorax by itself results in
pulmonary compression and shift of
mediastinum.
Signs and symptoms
 Tachypnea
 Dyspnea
 Cyanosis
 Decreased or absent breath sounds on affected side
 Tracheal deviation to unaffected side
 Dull resonance on percussion
 Unequal chest rise
 Tachycardia
 Hypotension
 Pale, cool, clammy skin
 Possibly subcutaneous emphysema
 Narrowing pulse pressure
Signs and symptoms
 In case of small hemothorax clinical
manifestations of hemorrhage are slightly
expressed or absent at all.
 Dyspnea, cough, general malaise and
dizziness are obvious in moderate
hemothorax.
 The skin is pale.
 The hemodynamic disturbances –
tachycardia and decreased arterial
pressure are observed.
Signs and symptoms
 The great and total hemothorax are
associated with extremely grave condition.
 The patients are troubled with expressed
general malaise, dizziness, dyspnea and
difficult breathing.
 In some cases they enter medical hospitals in
a terminal state.
 The skin is sharply pale.
 The peripheral pulse impaired or absent.
 Tachycardia, weak cardiac tones, low arterial
pressure are obvious.
 Chest X-ray
 In the erect patient
the classical picture
of a fluid level with a
meniscus is seen.
 The intensive
homogeneous
shadow on the side
of the lesion with
oblique upper
contour (Damuaso'
line) is observed.
 The costal sinus
does not visualized.
Chest X-ray
 Although the erect film is more sensitive, it
takes approximately 400-500mls of blood
to obliterate the costo-phrenic angle on a
chest radiograph.
Chest X-ray
 In small hemothorax, depending on the
degree of intrapleural bleeding, the shadow
observed only in the region of sinus.
 In moderate hemothorax it achieves a
scapular angle (on the back surface) or V rib
on anterior surface of the chest wall.
 In great hemothorax this shadow achieves ІІІ
rib, and total hemothorax characterized by
complete shadow of a pleural space, and in
some cases – mediastinal shift to the healthy
side.
Ultrasound
 It may be difficult to
detect small amounts
of blood (< 200mls)
on the plain chest
radiograph.
 Ultrasound
examination can
detect smaller
haemothoraces.
Computed tomography
 Most cases of thoracic trauma do not
require computed tomography (CT).
 However, CT can be invaluable in
determining the presence and significance
of a haemothorax, especially in the blunt,
supine trauma patient who may have
multiple thoracic injuries.
 Small amounts of blood are detectable and
can be localised to specific areas of the
thoracic cavity.
Computed tomography
Treatment
Chest drain
 Chest tube placement is the first step in the
management of traumatic haemothorax.
 The majority of haemothoraces have already
stopped bleeding and simple drainage is all
that is required.
 All chest tubes placed for trauma should be of
sufficient calibre to drain haemothoraces
without clotting.
 The manipulation is carried out in VІ-VІІ
intercostal spaces in the postaxillary or
scapular lines.
Treatment
 In some cases bleeding continues and
surgery is necessary to stop the source of
bleeding.
 Thoracotomy
 The indications for thoracotomy are usually quoted as the
immediate drainage of 1000-1500mls of blood from a
hemithorax.
 However the initial volume of blood drained is not as
important as the amount of on-going bleeding.
 If the patient remains haemodynamically stable they may
be admitted and observed.
 The colour of the blood is also important - dark, venous
blood being more likely to cease spontaneously than
bright red arterial blood.
 Patients admitted for observation who have continuing
drainage with no signs of reduction in chest tube output
over 4-5 hours should also undergo thoracotomy.
 The threshold for this is usually stated at around 200-
250mls of blood per hour.
Thoracotomy
 The bleeding wounds of lungs are sewed
up by twist suture.
 If the pleural space contains liquid blood,
the surgeon carries out its reinfusion.
 The clots are removed from pleural space.
Abdominal trauma
 Abdominal trauma can be life threatening because
abdominal organs, especially those in the
retroperitoneal space, can bleed profusely, and the
space can hold a great deal of blood.
 Solid abdominal organs, such as the liver and
kidneys, bleed profusely when cut or torn, as do
major blood vessels such as the aorta and vena
cava.
 Hollow organs such as the stomach, while not as
likely to result in shock from profuse bleeding,
present a serious risk of infection.
 Gastrointestinal organs such as the bowel can spill
their contents into the abdominal cavity.
 Hemorrhage and systemic infection are the main
causes of deaths that result from abdominal trauma.
Classification
 Abdominal trauma is divided into blunt and
penetrating types.
 While penetrating abdominal trauma is
usually diagnosed based on clinical signs,
diagnosis of blunt abdominal trauma is more
likely to be delayed or altogether missed
because clinical signs are less obvious.
 Penetrating trauma is further subdivided into
stab wounds and gunshot wounds, which
require different methods of treatment.
Signs and symptoms
 Early indications of abdominal trauma include
nausea, vomiting, and fever.
 Blood in the urine is another sign.
 The injury may present with abdominal pain,
tenderness, distension, or rigidity to the touch, and
bowel sounds may be diminished or absent.
 Abdominal guarding is a tensing of the abdominal
wall muscles to guard inflamed organs within the
abdomen.
 Pneumoperitoneum, air or gas in the abdominal
cavity, may be an indication of rupture of a hollow
organ.
 In penetrating injuries, an evisceration (protrusion
of internal organs out of a wound) may be present.
 Physical examination
 Inspection: abrasions, contusions, llacerations, deformity
 Grey-Turner sign: Bluish discoloration of lower flanks, lower
back; associated with retroperitoneal bleeding of pancreas,
kidney, or pelvic fracture.
 Cullen sign: Bluish discoloration around umbilicus, indicates
peritoneal bleeding, often pancreatic hemorrhage.
 Kehr sign: L shoulder pain while supine; caused by
diaphragmatic irritation (splenic injury, free air, intra-abd
bleeding)
 Balance sign: Dull percussion in LUQ. Sign of splenic injury;
blood accumulating in subcapsular or extracapsular spleen.
 Percussion: subtle signs of peritonitis; tympany in gastric
dilatation or free air; dullness with hemoperitoneum
 Palpation: elicit superficial, deep, or rebound tenderness;
involuntary muscle guarding
Liver
 Liver injuries present a serious risk for
shock because the liver tissue is delicate
and has a large blood supply and capacity.
 The liver may be lacerated or contused,
and a hematoma may develop. It may leak
bile, usually without serious
consequences.
 If severely injured, the liver may cause
exsanguination, requiring emergency
surgery to stop the bleeding.
Spleen
 Spleen is the most common damaged
organ in blunt abdominal trauma.
 A laceration of the spleen may be
associated with hematoma.
 Because of the spleen's ability to bleed
profusely, a ruptured spleen can be life
threatening, resulting in shock.
Pancreas
 The pancreas may be injured in abdominal
trauma, for example by laceration or
contusion.
 Indications that the pancreas is injured
include enlargement and the presence of
fluid around the pancreas.
Kidneys
 The kidneys may also be injured; they are
somewhat but not completely protected by
the ribs.
 Kidney lacerations and contusions may also
occur.
 Kidney injury ,may be associated with bloody
urine.
 Kidney lacerations may be associated with
urinoma, leakage of urine into the abdomen.
 A shattered kidney is one with multiple
lacerations and an associated fragmentation
of the kidney tissue.
Bowel
 The bowel may be perforated.
 Gas within the abdominal cavity seen on CT is
understood to be a diagnostic sign of bowel
perforation; however intra-abdominal air can
also be caused by pneumothorax or
pneumomediastinum.
 The injury may not be detected on CT.
 Bowel injury may be associated with
complications such as infection, abscess,
bowel obstruction, and the formation of a
fistula.
 Bowel perforation requires surgery.
Diagnosis
Diagnostic techniques used include
 CT scanning
 Ultrasound
 X-ray
 Diagnostic peritoneal lavage
 Diagnostic laparoscopy or exploratory
laparotomy
X-ray
 X-ray can help determine the path of a
penetrating object and locate any foreign
matter left in the wound, but may not be
helpful in blunt trauma.
 Plain abdominal radiography has no role in
the assessment of blunt abdominal trauma.
 Abdominal radiography may provide indirect
evidence of hollow viscus injury by showing
air or gas in the peritoneum, but it lacks
sensitivity and specificity.
Ultrasound
 Abdominal ultrasound can be used to look
for organ injury and free intra-abdominal
fluid, which after trauma is assumed to be
blood or gastrointestinal content, and
provides indirect evidence of injury.
 It is a noninvasive procedure and relatively
safe for the patient.
 A negative ultrasound does not rule out injury,
and if ultrasound is used as the sole imaging
modality, patients should be admitted for
observation and possibly repeat examination.
Diagnostic peritoneal
lavage
 Diagnostic peritoneal lavage is a
controversial technique but can be used to
detect injury to abdominal organs: a
catheter is placed in the peritoneal cavity,
and if fluid is present, it is aspirated and
examined for blood or evidence of organ
rupture.
 If this does not reveal evidence of injury,
sterile saline is infused into the cavity and
evacuated and examined for blood or other
material.
Diagnostic peritoneal lavage
 While peritoneal lavage is an accurate way
to test for bleeding, it carries a risk of
injuring the abdominal organs, may be
difficult to perform, and may lead to
unnecessary surgery.
 Diagnostic peritoneal lavage is more
sensitive than computed tomography or
ultrasound for the detection of hollow
viscus injuries, but does not exclude
retroperitoneal injury.
 Computed tomography
 CT is only able to detect 76% of hollow viscous injuries.
 However, CT has been demonstrated to be useful in
screening patients with certain forms of abdominal
trauma.
 CT is the imaging modality of choice for evaluating
haemodynamically stable patients.
 Its main advantage is the ability to detect arterial
contrast extravasation.
 CT also accurately evaluates the retroperitoneum, but it
is less sensitive for detecting hollow viscus injuries.
 Computed tomography is also the modality of choice for
diagnosing injuries to the diaphragm.
 This technique is not appropriate in haemodynamically
compromised patients.
Diagnosis
 Diagnostic laparoscopy or exploratory
laparotomy may also be performed if other
diagnostic methods do not yield conclusive
results.
Diagnosis
 Treatment
 Initial treatment involves stabilizing the patient
enough to ensure adequate airway, breathing,
and circulation, and identifying other injuries.
 Surgery may be needed to repair injured organs.
 Surgical exploration is necessary for people with
penetrating injuries and signs of peritonitis or
shock.
 Laparotomy is often performed in blunt
abdominal trauma, and is urgently required if an
abdominal injury causes a large, potentially
deadly bleed.
Thanks for attention