Intra-abdominal injuries carry high morbidity and mortality because they often not detected or their severity is underestimate.

BLUNT TRAUMA

Occur when object strikes the abdomen or vice versa due to motor vehicles collision. Crushing injury Spleen and liver are most injured organ.

PENETRATING TRAUMA

occurs when an object physically enters through the skin and wall of the abdominal cavity Gunshot, stab wounds and animal bites > in urban than rural morbidity rate due to wound infection and intraabdominal abscess

Primary survey ABCDE + high flow O2 supplementation + secure airway Secondary survey complete a thorough history complete abdominal examination inspection,palpation,percussion,auscultation complete other examinations- toe to head

Inspection
Abrasion, bleeding and spillage bowel content Identify any patterns indicate internal injury
shoulder belt demarcation, or a steering wheel impression

bruising patterns
Cullen's sign and Grey-Turner's sign

Expose the genitalia

look for swelling, bruising and blood accumulation

evisceration
protruding or exposed abdominal organ -need for surgery.

Identify any impaled objects or entrance wounds from a penetrating object

Palpation
Palpate the abdomen
Rib pain or tenderness
for masses, tenderness and deformity suggests fracture and indicates spleen injury(left) and liver injury (right)

A full or doughy sensation indicates free blood Rigidity and guarding

(+) an injury with intestinal leakage and suggest developing peritonitis.

Percussion
light percussion (+)tenderness =peritonitis

Auscultation

Hear lung area (+)bowel sounds in the thoracic cavity suggests a diaphragmatic rupture

Indicators Suggestive of Abdominal Trauma

Mechanism of injury consistent with abdominal compression Bent steering wheel Safety belt impressions Shock without an obvious cause Soft tissue injury to the lower thorax, back, flank or abdomen Significant tenderness on palpation or coughing Involuntary guarding

The primary goal of trauma care remains ABC cardiovascular hemodynamic support

airway stabilization, breathing protection, circulation support and cervical spine stabilization.

place a nasogastric or an oral-gastric (NG/OG) tube

establishing IV access and administering crystalloid fluids to prevent hypotension

protects the intestines by emptying the stomach and permits stomach content evaluation for blood. with a sterile dressing moistened with sterile saline and place an occlusive dressing over the top. control it with well-aimed pressure directly on the bleeding source. Once bleeding is controlled, cover the wound with a sterile dressing.

Cover any protruding abdominal

severe bleeding at the wound site Pain and anxiety management

Abdomen

Blood Radiology Focused Abdominal Sonography for Trauma (FAST) CT Scan Diagnostic Peritoneal Lavage (DPL)

FBC GXM LFT RP

Non-specific Erect CXR > preferable to supine AXR- exclude free intra peritoneal air AXR may show : - lower ribs #, transverse processes # - foreign bodies eg: bullets - acute gastric dilatation

Examination using portable ultrasound machine to detect fluid: - right upper quadrant - left upper quadrant - pelvis - pericardial window (pericardial effussion) Screening tool blunt abdominal injury

Negative scan- absence abdominal fluid Positive scan- presence of abdominal fluid

Advantages
Fast Non-invasive Portable Inexpensive Technically simple, easy to train Can be performed serially Useful for guiding triage decisions in trauma patients

Limitations
Operator dependent Limited sonography window due to dressings, chest tube and subcutaneous emphysema Misses retroperitoneal/hollow viscus injury May not detect free fluid <50-80 cc

accurate for the diagnosis of intra-abdominal and retroperitoneal injuries reliably detect: - free blood/ fluid in peritoneal cavity - solid visceral injury, eg: liver, spleen, pancreas & kidney - free gas use of contrast- exclude hollow visceral injury

Advanatages
Good sensitivity Non-invasive information on the magnitude of injury allows for non-operative management of patients with solid organ injuries Detect bleeding pelvic #

Limitations
need transport pt to scanner risk pt becoming haemodynamically unstable Expensive involves the use of intravenous contrast administration exposes the patient to radiation

gold standard for blunt abdominal injury Accuracy >97% False +ve 1.4% and false ve 1.3% involves passing a small catheter into the peritoneal cavity, usually at infraumbilical. If pelvic # ,incision supraumbilical.

criteria for positive DPL are:

-10ml gross blood -RBC>100,000/mm3 -WBC>500/mm3 -Amylase>175 IU/dL -Bile, bacteria, or food fiber

+ve DPL: exploratory laparotomy indicated.

Contraindication: -Clear indication for exploratory laparatomy

-Prior abdominal surgeries -Pregnancy -Obesity

Limitations: - not indicate source/volume hrhage - no information on retroperitoneal injury

Eastern Association for the Surgery of Trauma, 2001

highly vascular organ -filters an estimated 10-15% of total blood volume every minute. under the rib cage -left upper quadrantdeep to 9th, 10th and 11th ribs Most common injured

Blunt abdominal trauma-most common -from compression or deceleration (motor vehicle accidents, falls ,direct blow to abdomen,with haematological abnormalities) 2. Penetrating trauma-RARE (Assaultknife, gun shot) 3. Combined (Explosive type injuries-warfare, bombing) 4. Iatrogenic-Colonoscopy
1.

Risk factors for severe splenic injury:

Preesitin illness e.g. malariasplenomegalythinning of capsulespleen > fragile

Clinical symptoms vary Left upper abdominal or flank pain Reffered pain to left shoulder (kehr sign) Some may be asymptomatic

PE insensitive & non-specific. signs of left upper quadrant tenderness or signs of generalized peritoneal irritation. May present with tachycardia ,Tachypnea, anxiety , Hypotension (shock)

Operative Vs Non-operative
Factors for decision:
Haemodynamic stability on presentation Age of patient Other associated injuries Grade of splenic injury

10% of all abdominal injuries Mechanism of injury:

Blunt (90%)
Direct blow to back, flank, upper abdomen
Suspect wif of 10th to 12th ribs or T12, L1, L2 Rapid deceleration

Penetrating

Shearing of renal artery/ vein

Assault-Gun shot, knife

 Gross Hematuria
80% of cases Absence does NOT exclude renal injury

Localized flank/abdominal pain Abrasion or bruising to the flank Palpable mass Tenderness: Lower ribs, upper L-spine, flank

Classification for Kidney Injury

Grade I

Type Contusion Hematoma

Description Microscopic or gross hematuria, urologic studies normal Subcapsular, nonexpanding without parenchymal laceration Nonexpanding perirenal hematoma confined to renal retroperitoneum <1-cm parenchymal depth of renal cortex without urinary extravasation >1-cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation Parenchymal laceration extending through renal cortex, medulla, and collecting system

II

Hematoma Laceration

III

Laceration

IV

Laceration
Vascular

Main renal artery or vein injury with contained hemorrhage

Laceration Completely shattered kidney Vascular Avulsion of renal hilum, devascularizing the kidney

Conservative (minor trauma) Vs Surgery (major trauma)

(**80% of injuryminor trauma (Class 1 or 11) Aim: -To preserve renal fxn -Minimize blood loss

Uncommon-lie

under diaphragm & protected by chest wall. If injury happen, it associated with high morbidity & mortality. 2 type injuries :
Blunt : result of direct compression. Causes laceration, contusion, and avulsion. Sharp/penetrating : stab/gunshot , a/c with chest or pericardial involvement.

Severe blood loss

Shock : tachycardia, hypotension. tachypnoea Fail to achieve haemodynamically stable after considerable amount of volume expander is given.

Tenderness
Lower right chest Right hypochondriac region.

Coagulopathy a/c injuries

Lower chest or upper abdomen stab wound Ribs # or haemathorax.

To confirm :

Peritoneal lavage will confirm present of haemoperitoneum Contrast enhanced CT scan will demonstrate evidence of liver parenchyma damage and a/c injury to the feeding vessels.

For investigate the extent and nature of the injury and to access the severity of any concomitant injuries. 6 Gradegrades Injury

Subcapsular hematoma <1 cm in maximal thickness capsular avulsion superficial parenchymal laceration <1 cm deep isolated periportal blood tracking Parenchymal laceration 1-3 cm deep parenchymal/subcapsular hematomas 1-3 cm thick

II

III
IV V VI

Parenchymal laceration >3 cm deep parenchymal or subcapsular hematoma >3 cm in diameter

Parenchymal/subcapsular hematoma >10 cm in diameter lobar destruction or devascularization Global destruction or devascularization of the liver Hepatic avulsion

Penetrating

Resuscitation GXM Volume replacement Chest tube: if pneumo/haemothorac present Once pt haemodynamically stable, transfer to OT for further management Control the bleeding point: 4 Ps ( push, pringle, plug & pack) FFP or cryoprecipitate admistration should be discussed as pt might develops irreversible coagulopathies due to lack of fribrinogen and clotting factors. Coagulation profile or thromboelastography (TEG)should be done to evaluate the loss of clotting factors.

Blunt
Resuscitation, same as penetrating, main purpose is to achieve stable haemodynamic. CT scan should be done to further evaluate the nature of the injury. Conservative management. Admit pt to ICU/HDU Surgical treatment is needed when: On-going blood loss despite correction of any underlying coagulopathy Development of signs of generalized peritonitis.

Intrahepatic haematoma (resolve spontaneouly) Liver abscess (common in penetrating injury) Bile collection Biliary fistula Hepatic artery aneurysm AVF Arteriobiliary fistula Liver failure (rare)

Uncommon. ~ 2% Commonly due to blunt trauma. Result from severe anterior posterior compression trauma against the spinal column. Mostly in connection with seat belt injury and deceleration trauma.

Hard to diagnose. Retroperitoneal organ, examination like DAP and FAST are insignificant. CT scan is the best way to examine for pncreatic injury.

Clinical signs are non-specific. Clinical triads:

Leucocytosis Raised amylase level (might be normal in 248hours) Upper abdominal pain.

Determine the management plan. 5 grades (CT scan)

Grade
I II III IV V

Injury
Haematoma Laceration Haematoma Laceration Laceration Laceration Disruption

Description
Minor contusion without duct injury Superficial laceration w/0 duct injury Major contusion w/0 duct injury Major laceration w/o duct injury or tissue loss Distal transection or parenchymal injury with duct injury Proximal transection or parenchymal injury involving the ampulla or bile duct Massive disruption of the pancreatic head

Conservative tx . Efforts in controlling haemorrhage and closed suction drainage. Injuries to the tail are treated by closed suction drainage, with distal pancreatectomy if the duct is involved Prox injures (to R of the sup. Mesenteric art.) are treated as conservatively as possible. Partial pancreatectomy maybe necessary. Whipples procedure rarely needed, and should not be performed in emergency situation due to high mortality rate.

Pancreatic pseudocyst Pancreatic fistula Pancreatic abscess.

The intestine can be ruptured with or without an external wound The most common cause is a blow on the abdomen which crushes the bowel against the vertebral column or sacrum In small perforations, the mucosa may prolapse through the hole and partly seal it, making the early signs misleading. In addition, there may be a laceration in the mesentery The patient will then have a combination of intraabdominal bleeding and release of intestinal contents into the abdominal cavity peritonitis

Traumatic rupture of the large intestine is much less common. Rupture of the upper rectum can occur during sigmoidoscopy and occasionally during the placement of rectal catheters for barium radiology. Traumatic rupture of the colon can occur during colonoscopy. The most common site is the sigmoid colon, where the formation of a sigmoid loop pushes against the antimesenteric border of the sigmoid colon, stretching it out and eventually perforating it.

Gunshot wounds of the bowel have more serious consequences because of the introduction of debris from the patients clothing which can mix with the bacteria in the patients gut. It can cause extensive damage of the bowel over a much wider area than just the entry and exit wounds.

Where rupture is suspected, a plain radiograph in the erect or lateral position will demonstrate the presence of free air in the peritoneal cavity. In almost all cases, an abdominal exploration must be performed and simple closure of the perforation is required. In others, for example where the mesentery is lacerated and the bowel is not viable, resection may be necessary.

In the case of retroperitoneal portions of the intestine, for example the duodenum, perforations can involve the front and back walls, and the duodenum in particular has to be carefully mobilised to check that a concealed tear is not overlooked. In all cases, the abdomen is washed out with saline and broad-spectrum intravenous antibiotics are given.

Thank you..