4. Introduction
One of the leading cause of death and disability.
Identification of serious intra-abdominal injuries is
often challenging.
Many injuries may not manifest during the initial
assessment and treatment period.
5. Epidemiology
Peak incidence Abdominal Trauma 15 – 30 yr .
More than 15,000 people die every year as a result of
injuries by motor vehicle accident, fall.
Injury accounts for 10% of all deaths .
Estimates indicate that by 2020, 8.4 million people will
die yearly.
Prevalence: 13%.
8. Aetiology
M.V. Accidents involving high kinetic energy and
acceleration or deceleration forces - 60%.
Direct blow to abdomen - 15% .
Fall- 6-9%.
Child Abuse .
Domestic Violence .
Iatrogenic injury -Endoscopic /Laparoscopic
surgical procedures -Bag-mask ventilations -
Inadvertent esophageal intubation -External cardiac
compressions –Heimlich maneuver.
9. Prehospital Care
The goal of prehospital is to deliver the pt to hospital
for definitive care as rapidly as possible.
‘Scoop and Run’
ABC & Care of spinal cord
start IV line
Communicate to medical control
Rapid transport of patient to trauma centre
10. Primary survey
Identification & treatment of life threatening conditions
A irway , with cervical spine precautions
B reathing
C irculation
D isability
E xposure
11. Emergency Care
Control external bleeding
IV fluids
Dressing of wounds /Protect eviscerated organs
Stabilize an impaled object in place
Give high flow oxygen
Immobilize the patient with a fractured pelvis
Keep the patient warm
Analgesics
12. Secondary Survey
General & Systemic Examination to identify all occult
injuries.
Special attention to Back, Axilla , Perineum
PR - sphincter tone ,bleeding ,perforation , high riding
prostate
Foley’s catheter- monitor urine out-put
NG tube
13. Secondary Survey (Con’td)
AMPLE History
A llergy
M edications
P ast medical history
L ast meal
E vent - What Happened?
16. Examination (Con’td)
Cullen’s Sign : Bluish discoloration around umbilicus Diffusion of
blood along periumbilical tissues or falciform ligament
Hemoperitoneum
Grey-Turner’s Sign : Bluish discoloration of the flanks
Retroperitoneal
Hematoma hemorrhagic pancreatitis
. Kehr’s sign : Referred pain, Right shoulder irritation of the
diaphragm
Splenic injury, free air, intra-abdominal bleeding)
Balance’s Sign : Dullness on percussion of the left upper quadrant
Ruptured spleen
Labia and Scrotum: Pooling of blood from abdominal and pelvic
cavities.
17. Examination (Con’td)
Auscultation
1. Bowel sounds in the thoracic cavity (Diaphragmatic
rupture)
2. Haemothorax
Palpation
Mass -Tenderness - Signs of peritonitis - # Ribs -Chest
& Pelvic compression test
19. Focused Assessment with
Sonography in Trauma (FAST)
First used in 1996
Rapid
Accurate
Sensitivity 86- 99%
Can detect 100 mL of blood
Cost effective
Four different views :Pericardiac - Perihepatic -
Perisplenic - Peripelvic spaces
Eliminates unnecessary CT scans
Helps in management plan
20. Plain X-Ray Chest & Abdomen
Pneumotharax
Haemothorax
Free air under diaphragm
Nasogastric tube,Bowel loops in the chest
Elevation of the both /Single diaphragm
Lower Ribs #
Liver /Spleen Injury???
Ground Glass Appearance -Massive Hemoperitoneum
Obliteration of Psoas Shadow –Retroperitoneal
Bleeding - # vertebra
21. USG
Advantage :
Easy & Early to Diagnose
Noninvasive
No Radiation
Exposure
Resuscitation/Emergency room
Used in initial Evaluation Low cost
Disadvantage:
Examiner Dependent
Obesity
Gas interposition
Low Sensitivity for free fluid less 100 mL
False –Negative retroperitoneal & Hallow viscus injury
22. Paracentasis
Four quadrant aspiration of abdomen
Positive tap – blood, air, and bile stained fluid
Negative tap doesn’t rule out injury. False negatives are
as high as 22-60%--------NOT Recommended
23. Diagnostic Peritoneal Lavage
First described in 1965
Rapid & Accurate test used to identify intra-abdominal injuries
Predictive value of greater than 90%
The RBC count for lavage fluid is > 1,00,000/cu m.m .
WBC count > 500/cu m.m
Test is highly sensitive to presence of intraperitoneal blood
However specificity is low
Indications Unexplained Shock
Altered sensorium (Head injury , Drug)
General anesthesia for extra-abdominal procedures
Contraindications Clear indication for Exploratory Laparotomy
Relative - Previous Laparotomy
Pregnancy
Obesity
24. CT-scan
Gold Standard
Haemodynamically Stable
Provides excellent imaging of pancreas, duodenum and
genitourinary system
Standard for detection of solid organs injury.
Determines the source and amount of bleeding
Can reveal other associated injuries e.g.
High Specificity-95%
Contraindication
Clear indication for Laparotomy
Haemodynamically Unstable
Allergy to contrast media
33. Anatomic Injuries
The most commonly injured organs
are :
the spleen, liver, retroperitoneum,
small bowel,, bladder, colorectum,
diaphragm, and pancreas.
Men tend to be affected slightly
more often than women
34. SPLENIC INJURY
Most common intra- abdominal organ to injured (40-
55%)
20% of splenic injuries due to left lower rib fractures
Success rate of Splenic salvage procedure is 40-60%
35. Liver injury
Liver is the largest organ in abdomen 2nd most
common organ injured (35-45%)
50% liver injury has stop bleeding spontaneously by
the time of surgery
Mortality of liver injury is 10%
36. Pancreatic Injury
Rare ---- 10-20% of all abdominal injury
Crush
Direct blow to abdomen
Seat belt injury
37. Renal Injury
Presentation: Shock, hematuria & pain
Urine: gross or microscopic hematuria
Diagnosis:
X-ray : KUB IVP
USG
CT-scan abdomen
Radionuclide Scan
The degree of hematuria may not predict the severity
of renal injury
38. Diaphragmatic Injury
Incidence -0.8%-1.6% in BTA .
High index of suspicion required , may be missed.
40 to 50% are diagnosed immediately
Presentation may be delayed
Imaging Nasogastric tube seen in the thorax
Abdominal contents in the thorax
Elevated hemidiaphragm (>4 cm Lt vs Rt )
Distortion of diaphragmatic margin. Lt- 69% , Rt -24%
B/L- 15%
40. Hollow Viscus Injuries
InjuryGastric
Penetrating trauma MC
Blunt trauma abdomen 1%
Crushing Against the Spine -CPR -Vigorous
Ventilation with ET Tube in the Esophagus –
Heimlich maneuver
Diagnosis :
X-Ray chest & Abdomen
CT scan
Diagnostic Peritoneal Lavage
During Surgical Exploration
T/t : Expl . Laparotomy with Primary Repair
41. Hollow Viscus Injuries
Duodenum
Isolated Duodenum injury rare Incidence - 3-5% Cause
Penetrating injury: MC
Steering wheel injury
Assault
Fall Associated with other intra-abdominal injury
Diagnosis: Plan X-ray –Free air in abdomen –
Intraoperative diagnosis
T/t : Primary Repair 80% case
Roux-en –Y duodenojejunostomy 20%
42. Hollow Viscus Injuries
Small Intestine& Colonic Injuries
Commonly Injured in Penetrating injury
Blunt Trauma – 5% -20%
Crush Injury
At Fixed point DJ & IC Junction
T/t : Exploratory Laprotomy
43. Bladder Injury
Commonly in BTA
70% of bladder Injury is associated with pelvic fracture.
Hematuria
Type 1.Extraperitoneal Rupture-by bony fragment
Type 2. Intraperitoneal Rupture- at dome when blow in
distended bladder
Diagnosis Clinical / Cystography
T/t:
1. Intraperitoneal –Trans-peritoneal - closure +SPC
2: Extraperitoneal Rupture: Foley’s catheter -10 -14 days
44. Ureteral Injury
Uncommon
Mostly occur after penetrating trauma
Associated with concomitant intra-abdominal or
genitourinary injury
Diagnosis - IVP -15-20%
Retrograde ureteroscopy –
At the time of Laparotomy
T/t : Proximal & mid ureter -End to end Anastomosis
over DJ Stent
Distal –Ureteric Reimplantaion
45. Vascular Injury
Incidence 5-10%
Highly lethal. Associated with extremely rapid rates of
blood loss
Exposure is difficult in Laparotomy
T/t : Lateral suture ,
End to end Anastomosis
Interposition graft
Mortality rate is very high
47. Aetiology
In penetrating abdominal trauma due to gunshot wounds, the
most commonly injured organs are as follows[1] :
Small bowel (50%)
Colon (40%)
Liver (30%)
Abdominal vascular structures (25%)
In penetrating abdominal trauma due to stab wounds, the
most commonly injured organs are as follows[1] :
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
49. Penetrating Trauma
Penetrating abdominal trauma has a slightly higher
mortality rate
Second most common cause of abdominal injury
Gunshot and stab wounds combine to cause 95% of
penetrating abdominal injuries.
50. Penetrating abdominal trauma
Multiple in 20% of cases
Most stab wounds do not cause an intraperitoneal injury
A complete exploration is mandatory
Abdominal Evisceration
Never try to replace organs
Cover with moist gauze, then sterile dressing.
Transport immediately
51. Gunshot Injury
Handguns
Rifles
Shotgun
More dangerous than penetrating injury
The degree of injury depends. Amount of kinetic
energy imparted by the bullet to the victim Mass of the
bullet and the square of its Velocity
Injury multiple organ
55. Focused Assessment with
Sonography in Trauma (FAST)
The benefits of the FAST examination include the following:
Decreases the time to diagnosis for acute abdominal injury in
BAT
Helps accurately diagnose hemoperitoneum
Helps assess the degree of hemoperitoneum in BAT
Is noninvasive
Can be integrated into the primary or secondary survey and can
be performed quickly, without removing patients from the
clinical arena
Can be repeated for serial examinations
Is safe in pregnant patients and children, as it requires less
radiation than CT
Leads to fewer DPLs; in the proper clinical setting, can lead to
fewer CT scans (patients admitted to the trauma service and to
receive serial abdominal examinations)[6]
56. Focused Assessment with
Sonography in Trauma (FAST)
An extended version of the standard FAST examination
(E-FAST) has been established and offers additional
information.
In addition to imaging of the abdomen, the E-FAST
examination includes views of bilateral hemithoraces to
assess for hemothorax and views of bilateral upper
anterior chest walls to assess for pneumothorax.[7] For
the remainder of this article, the FAST examination is
referred to as the E-FAST examination, as appropriate.
57. Focused Assessment with
Sonography in Trauma (FAST)
Technique Overview
Focused assessment with sonography for trauma (FAST)should
include views of :
(1) the hepatorenal recess (Morison pouch),
(2) the perisplenic view,
(3) the subxiphoid pericardial window, and
(4) the suprapubic window (Douglas pouch).
If an extended FAST (E-FAST) examination is performed,
views of:
(1) the bilateral hemithoraces and
(2) the upper anterior chest wall should also be obtained.
67. Pediatric Abdominal Trauma
Overview
Trauma is the leading cause of morbidity and mortality in the
pediatric population.
Etiology
More than 80% of traumatic abdominal injuries in children
result from blunt mechanisms;
Prognosis
Nonoperative treatment of children with blunt abdominal
trauma is successful in more than 95% of appropriately
selected cases
Children with abdominal trauma secondary to assault or
abuse have the highest mortality rate
70. Trauma in Pregnancy
physiologic changesMajor
Altered anatomical relationships
Signs and symptoms of injury may be altered
Treatment priorities are the same
Usually the best treatment for the fetus is the best
treatment for the mother
70
71. Trauma in Pregnancy
Resuscitation and stabilization may need to be modified
to accommodate the altered physiologic and anatomic
changes of pregnancy
2 patients
Consult OB/GYN early
Don’t withhold X-rays (10 rads or more are teratogenic
71
72. Importants
A. Oxygen requirements
B. Blood replacement requirements
C. Proper patient positioning
D. Significance of fetal monitoring
E. Vaginal bleeding
72
73. Primary survey
ABC’s
Supplemental oxygen (re-breather mask
If ventilation is required mild hyperventilation
Crystalloid fluid resuscitation and early blood product
administration
73
74. Initial assessment
Position patient to avoid supine hypotension unless
spinal injury is suspected
Left lateral positioning is preferred
If transport is needed displace uterus to left and elevate
right hip
74
75. Initial assessment (Con’td)
Blood is shunted away from the uterus in a hypotensive
state
The gravida can lose up to 35% of her blood volume
before tachycardia, hypotension, and other signs of
hypovolemia occur
The fetus may be in shock and the mother appear stable
75
76. Initial assessment (Con’td)
With gun shot wounds to the abdomen exploration is
mandatory
Stab wounds to the abdomen may be able to be observed
in selected cases
76
77. Secondary Assessment
If possible place patient on fetal monitor to assess
reactivityefetal heart ratcontractions and
is required to looksound examany trauma an ultraWith
for placental separation and possibly to obtain
biophysical profile
77
78. Secondary Assessment - USG
can be useful for determiningUltrasound
gestation age,
placental location,
fetal status,
amniotic fluid volume,
and fetal position
78
79. Injury Prevention
Speed is a critical factor; a 10% increase speed
translates into a 40% rise in the case fatality rate.
Use of seat belt reduces the risk of death or serious
injury by 45%.
Air Bags reduce the risk of fatal injury by 30% & deaths
by 11 %.
Children Below 12yrs should be properly restraints in
the back seat.
Motorcycle experience death rate 35 time greater than
car.
80. Injury Prevention
Primary
Prevent an injury from its occurrence in the first place:
Educational activity such as anti-drink-driving campaigns,
speed limit rule -Children should accompanied with parent
Secondary
Attempts to lessen the consequences of injury – making road
& safer car, anti-locking brakes, air bags, helmets, seat belt
Tertiary
Minimize the effect of injury by health care by individuals &
system
