Abdominal Trauma

ABDOMINAL TRAUMA
DR. INDRA MAULANA SULAEKA

 Mechanisms of Injury
Evaluation of  Assessment of Unstable Patients
Abdominal  Assessment of Stable Patients

 Case Discussions
Trauma  Diagnostic tests
 Decision making
 Thoracoabdominal area
 Transverse nipple line to costal margin
 Anterior abdomen
 Costal margin to groin crease to anterior axillary lines bilaterally
 Flank area
 Anterior axillary line to posterior axillary line, costal margin to iliac crests
 Back
 Medial to posterior axillary lines, tip of scapula to iliac crests
Abdomen
Abdominal  Blunt abdominal trauma
Trauma  Penetrating abdominal trauma

Blunt  More frequently encountered in the emergency department (ED)
than penetrating abdominal trauma
Abdominal  Usually results from a motor vehicle collision (MVC)
Trauma  Account for up to 75% of cases seen
 Compression, crush, or sheer injury to abdominal viscera:
deformation of solid or hollow organs, rupture (e.g. small bowel,
Mechanism of gravid uterus)
Injury: Blunt  Deceleration injuries: differential movements of fixed and non-

fixed structures (e.g. liver and spleen laceration at sites of
supporting ligaments)
 Bleeding:
 Liver
 Spleen
 Kidneys
 Mesentery
Problems  Bowel:
 Contamination
 Bladder:
 Intraperitoneal rupture
Spleen 40.6% Colorectal 3.5%
Liver 18.9% Diaphragm 3.1%

Pattern of Retroperitoneum 9.3% Pancreas 1.6%
Injury in Blunt
Small Bowel 7.2% Duodenum 1.4%
Abdominal
Trauma Kidneys 6.3% Stomach 1.3%
Bladder 5.7% Biliary Tract 1.1%

 AMPLE
 Mechanism
 MVC:
Initial  Speed
Assessment: 

Type of collision (frontal, lateral, sideswipe, rear, rollover)
Vehicle intrusion into passenger compartment
History  Types of restraints
 Deployment of air bag
 Patient's position in vehicle
 Physical exam
 Ultrasound (FAST)
Diagnostic  Computerized Tomography (CT)
Tools  Diagnostic Laparoscopy
 Exploratory laparotomy
 Neither sensitive nor specific to rule out intra-peritoneal
hemorrhage (bleeding)
 Excellent to watch for the development of peritonitis
(contamination)
Physical Exam  Less than 24 hours, usually by 13 hours
 A modality usually employed in penetrating trauma
 Very poor to detect bladder or diaphragmatic injury
 Inspection: abrasions, contusions, lacerations, deformity
 Auscultation: careful exam
 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
Physical Exam
 Looks for free intra-abdominal fluid (assumed to be blood or
gastrointestinal content, may be other)
Focused  Also pericardial fluid
 Non-invasive, no radiation, repeatable
Assessment  Highly Sensitive (79-100%) and Specific (96-100%)
With  Moreso in hemodynamic pts. after BAT
 Repeating FAST also increases Sn
Sonography in  May still need other imaging modalities with a negative FAST
Trauma (FAST)  Can be performed with equal accuracy by surgeons
Focused
Assessment
With
Sonography in
Trauma (FAST)
 Described in 1965, standard of care
 Open or closed (Seldinger) approach
 Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)
 Lead to a non-therapeutic laparotomy rate of 36%
Diagnostic  Laparotomy when:

 10 cc gross blood
Peritoneal  Enteric contents
 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3
Lavage (DPL)  High false positives with pelvic fractures
 High Sensitive for hollow viscus injuries
 Risk of visceral injury = 0.6%
 Retroperitoneum can’t be assessed
 The open technique
 utilizes a vertical infraumbilical incision and direct visualization of
peritoneal entry with a scalpel.
Diagnostic  The closed technique
Peritoneal  relies on percutaneous needle access to the peritoneal cavity,
followed by the insertion of a catheter using Seldinger technique.
Lavage  The semi-open technique
 follows the same principles of the open technique except that the
midline fascia is penetrated with a needle and the catheter is
advanced using the Seldinger technique
Diagnostic
Peritoneal
Lavage
 Imaging modality of choice only in HD normal patients
 Sn = 92-97%, Sp = 99% for bleeding
Computerized  Only modality to directly detect retroperitoneal injury
Tomography  Less accurate for HVI
 Poor test to diagnose diaphragmatic injury
 Applicable to patients with hemodynamically stable trauma (blunt
or penetrating)
Diagnostic  Indicated only in hemodynamically stable patients and in patients

without a clear indication for a laparotomy, such as evisceration,
Laparoscopy aspiration, or leakage of bile or bowel contents
 Useful to rule out diaphragmatic injuries in patients with
penetrating trauma to the thoracoabdominal region
Absolute Indications:
Indications for 1. Shock
Laparotomy – 2. Peritonitis
Blunt 3. Blood out of NG tube or on rectal exam
Abdominal 4. Intraperitoneal bladder rupture

5. Diaphragmatic rupture
Trauma
 Increasing because of the growth of violence in our society
Penetrating  Stab wounds are encountered three times more often than
gunshot wounds, but have a lower mortality because of their
Abdominal lower velocity and less invasive tract
Trauma  Injury to the bowel (small, then large) is most often found,
followed by hepatic injury
 Stab
Mechanism of  Low energy, lacerations
Injury:  Gunshot
 Kinetic energy transfer
Penetrating
 Physical exam
 Ultrasound (FAST)
Diagnostic  Computerized Tomography (CT)
Tools  Diagnostic Laparoscopy
 Exploratory laparotomy
 Inspection: abrasions, contusions, lacerations, deformity
 Auscultation: careful exam
 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
Physical Exam
1. Local Wound Exploration (LWE)
Stab Wounds –  Sterile procedure with local anesthetic
2. Serial Physical Examinations (SPE)
 Done by same clinician to assess for the development of
Anterior peritonitis
3. Focused Assessment with Sonography for Trauma (FAST)
Abdominal  ‘Not indicated’ in penetrating trauma
Wall 4. Diagnostic Peritoneal Lavage (DPL)
 Not done in many centers
Stab Wounds – 5.

Computerized Tomography (CT)
Historically not used for anterior abdominal stab wounds
▪ More useful in penetrating injury to the flank and back
6. Diagnostic Laparoscopy
Anterior 
▪
Used to rule out:
Peritoneal penetration
Abdominal ▪ Diaphragmatic injury on left side
7. Exploratory Laparotomy
Wall  Still the gold standard in ruling out intra-abdominal injury
Absolute Indications:
Indications for 1. Shock
Laparotomy – 2. Peritonitis
Penetrating 3. Evisceration
Abdominal 4. Weapon still in situ

5. Blood out of NG tube or on rectal exam
Trauma 6. Gross hematuria
1. Hemodynamically stable
Non-Operative 2. No peritonitis or diffuse abdominal pain
Management 3. In a center with surgical expertise

4. Patient is evaluable*
of Stab
Wounds *Evaluable: absence of brain or spinal cord injury,
intoxication or need for sedation or anesthesia
 Patients with penetrating abdominal injuries selected for NOM
How long to should be observed for 24 hours
observe?  They may be discharged after 24 hours in the presence of a

reliable physical exam and minimal to no tenderness
Algorithm for
Penetrating
Abdominal
Trauma
Classification
of
Hemorrhage
 40 yo male, MVC – driver
 Airway clear
 RR=32
 BP=80/50, HR=140
Case 1  GCS=9
 Diagnosis?
 Management?
 40 yo male, MVC Driver
 Airway clear
 RR= 24
 BP = 130/70, HR=100
Case 2  GCS=14
 Diagnosis?
 Management?
 40 yo male, stab wound
 Airway clear
 RR= 40
 BP = 100/70, HR=120
Case 3  GCS=15
 Diagnosis?
 Management?
 Airway
 Breathing
 Circulation
Decision SHOCK
Making
Rapid Responder
Transient Non Responder
Responder
 Scalp
 Chest – clinically vs. chest x-ray
 Abdomen
 FAST
Shock  DPL
 Pelvic X-ray
 Extremities – Femur
 Other causes of shock – cardiogenic, obstructive, anaphylactic,
septic
FAST
DPL
 ABC
 Chest x-ray, Pelvis x-ray
 IV access
On Route to  Resuscitation
OR  Notify OR, Surgeon, Anaesthesia
 Request OR equipment
 Consent
 Antibiotics
Case 1:  Recognize Shock
Learning  Hemodynamically unstable = OR
Points  Role of FAST, DPL

 Hemodynamically stable:
Decision 

ABCDE, secondary survey
FAST
Making  CT Scan
 Lab work
FAST
CT
 CT scan is helpful for decision making in a stable patient
Case 2:  Poor detection of hollow viscus, pancreatic and diaphragmatic

injury
Learning  Be worried of free fluid in abdomen
Points  Repeat CT Scan and close clinical observation
Diffuse Abdominal Tenderness
Yes No
Options for Laparotomy Hemodynamic Stability?
Management Indications for Laparotomy – Penetrating Trauma
● Hemodynamically abnormal
● Peritonitis
● Evisceration
● Positive DPL, FAST, or CT
● Violation of peritoneum
 Hemodynamically stable penetrating injury
Serial Observation
Wound Exploration
DPL
CT scan +/- Contrast
Options for Laparoscopy
Management Laparotomy
Ultrasound/echo – cardiac box
Pericardial window – cardiac box
Case 3:  Indications for early surgery
Learning  Consider diagnostic options
Points

Abdominal Trauma

Uploaded by

Copyright:

Available Formats

Abdominal Trauma

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Abdominal Trauma

Uploaded by

Copyright:

Available Formats

ABDOMINAL TRAUMA

DR. INDRA MAULANA SULAEKA

Abdominal  Assessment of Stable Patients

Trauma  Penetrating abdominal trauma

Injury: Blunt  Deceleration injuries: differential movements of fixed and non-

Liver 18.9% Diaphragm 3.1%

Bladder 5.7% Biliary Tract 1.1%

Diagnostic  Laparotomy when:

Diagnostic  Indicated only in hemodynamically stable patients and in patients

Abdominal 4. Intraperitoneal bladder rupture

Abdominal 4. Weapon still in situ

Non-Operative 2. No peritonitis or diffuse abdominal pain

Management 3. In a center with surgical expertise

observe?  They may be discharged after 24 hours in the presence of a

Learning  Hemodynamically unstable = OR

Points  Role of FAST, DPL

Case 2:  Poor detection of hollow viscus, pancreatic and diaphragmatic

Options for Laparotomy Hemodynamic Stability?

Management Indications for Laparotomy – Penetrating Trauma

You might also like