A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY
PENETRATING ABDOMINAL INJURY
DR. CHONGO SHAPI (BSc. HB, MBChB)

2. PENETRATING ABDOMINAL INJURY
-Gun shot wounds-GSW
-Stab wound
-Blast injury
Introduction
GSW is caused by a missile propelled by combustion of
powder. It implies high-energy transfer and
unpredictability of the extent of intra-abdominal injuries.
Not only is the missile track unpredictable, but also,
secondary missiles such as bone fragments or fragments
of the bullet are capable of inflicting additional injuries
Stab wounds are caused by a sharp object penetrating the
abdominal wall. This type of injury usually is more
predictable with regard to injured organs, but a high index
of suspicion must be maintained to avoid overlooking
occult injuries.
MANAGEMENT
Management should begin with the scene of accident
because in addition to the abdominal injury patients may
have sustained injury to the other systems.
ATLS-Advanced Trauma life support protocol should be
followed. Triage and safe fast transport should be
afforded to the patient.
Triage-Patients most likely to benefit from your
intervention. Very badly off patients who may not make it
to the nearest hospital are unlikely to benefit and the
loudly screaming patients may not be the most critical
A. Primary Survey (Life Support)
1. Airway: guarantee patency and assure that the patient
can protect his/her airway.
a. Possible C-spine injury – cervical column and maintain
in-line stabilization if intubation required.
b. Rapid Sequence Induction (RSI) is appropriate in most
patients when needed, possible exceptions below.
c. Anterior neck injury, stridor, but no acute airway
obstruction: consider awake, fiberoptic intubation or
urgent surgical airway under local anesthesia in OR.
d. Anterior neck injury, stridor, and acute airway
obstruction: consider emergent surgical airway without
prior attempts at intubation.
e. Head injury – intubate when GCS is less then or equal
to 8, consider neurosurgical evaluation prior to intubation
when feasible.
f. Apnea – immediate orotracheal intubation with in-line
stabilization, RSI generally unnecessary.
2. Breathing: assess breath sounds bilaterally. Acute
causes causing dyspnea
a. Airway obstruction.
b. Tension Pneumothorax – immediate needle
decompression, followed by tube thoracostomy
c. Simple Pneumothorax – tube thoracostomy after X-ray
confirmation.
d. Cardiac tamponade-distant heart sounds,distended neck
veins
e. Massive Hemothorax– tube thoracostomy after fluid
resuscitation, consider OR thoracotomy for initial chest
tube output > 1500 cc.
f. Open peumothorax -strap the opening
g. Flail chest-pack gauze and strap hemithorax,Positive
pressure ventilation
h. Confirm position and function of all chest tubes with
CXR.
3. Circulation: assess for signs of obvious and occult
shock via signs of adequate organ perfusion (mental
status, capillary refill, urine production), vital signs,
Arterial Blood Gas (ABG) analysis, cold extremity,
sweating, parlor
All GSW require emergency laparatomy to look for other
abdominal injury. After initial primary survey the patient
should be prepared for laparatomy.
If hemodynamically unstable go directly to exploratory
laparotomy GXM and carry blood to theatre.
With stable patient other investigations may be done
before theatre.
a.Hemostasis – direct pressure to bleeding wounds;
consider immediate, rapid closure for intensely bleeding
scalp wounds.
b. Treat Shock
i. Assess for etiology. Consider hypovolemic shock as
most common cause.
Neurogenic shock considered if evidence of spinal cord
injury. Shock state should never be assumed to result
from head injury.
ii. Initial therapy should consist of 2 liters of isotonic
crystalloid solution, failure to respond or shock state that
is difficult to correct should illicit a search for bleeding
that requires operative or angiographic control.
iv. Cardiac Tamponade – consider diagnosis with shock
that does not respond to volume, especially in penetrating
chest trauma, neck vein distension may or may not be
present. FAST may confirm diagnosis. Consider ED
thoracotomy with loss of vital signs; otherwise proceed
emergently to OR for pericardial window or sternotomy/
thoracotomy.
v. Indications for ED Thoracotomy:
(a) Penetrating Chest Trauma and one of the following:
(b) Loss of vital signs (pulse) en route to ED, with
electrical activity on presentation.
(c) Loss of vital signs or sustained systolic BP <90 in ED.
4. Disability:
a. Calculate GCS. Consider Neurosurgery consult when
GCS <14, consider intubation when GCS <9.
c. Assess for sensory and motor deficits.
5. Exposure and environmental modifications
a. Remove clothing, log roll to examine back, remove
backboard when present.
b. Maintain normothermia – blankets, warm fluids, warm
room.
B.Secondary Survey (head to toe exam, adjuncts)
With focus on abdomen injury
History
Gunshot-range of shot, from front or back, whether shot
while fleeing or confrontation, presence of exit wound,
bleeding and features of shock-dizziness and confusion or
loss of consciousness, sweating.
Abdominal pain or chest pain afterwards. Description of
the pain.
-Exact circumstances mechanism of injury
-if gunshot range of shot and how many shots
-If stab the size and type of knife and direction of stab
from the side, front or back .Number of stabs
-If there was a struggle and if the assailant twisted the
knife and shoved it in.
-Knife left sticking or withdrawn by the assailant of
patient
-Immediate period after the stab-abdominal pain location
and radiation relieved by bending forward or bending to
the side, worsened by cough or walking.

3. -Whether patient was able to walk or lost consciousness.
-Wound the location, bleeding, intestinal evisceration,
fecal matter
-Hematemesis, hematochizia-upper GI or lower GI injury
-Abdominal swelling progressive?
-Chest pain-diaphragmatic injury
-signs of shock if bleeding
-Any other injury other any place in the body.
Physical exam
For physical examination, completely undressing the
patient for the primary survey and examining the entire
body surface for entry and exit wounds is important.
Wounds that look like entry and exit marks actually may
be 2 separate entry wounds.
Patients brought in as presumed cases of blunt trauma
may have penetrating injuries that have been overlooked
initially. Carefully record the pattern of the wounds and
characteristics.
Patients with penetrating abdominal trauma who present
with abdominal pain, tenderness, and guarding should
undergo exploration without unnecessary delays
Stab wound :Indications for laparatomy include
a. Hemodynamic instability-vital sings
b. Evisceration of the intestines
c. Extrusion of feces through the stab wound
d. Peritoneal signs.
Stable patients may be investigated further to determine
presence of other visceral injury which is indication for
laparatomy.
Other examination
1. Head/Maxillofacial – examine wounds, control
bleeding, pupil exam, and assess facial stability.
2. Neck – examine for wounds, palpate for tenderness,
deformity, etc…
3. Chest – examine for wounds, etc.., re-evaluate breath
sounds.
4 Pelvis – examine for wounds, assess for tenderness,
avoid excessive motion/compression, x-ray to diagnose
fracture.
6. Extremities
a. Complete pulse exam.
b. Reduce fracture dislocations.
c. Splint as needed.
7. Spine – assess for tenderness or deformity.
8. Adjuncts:
a. Naso/orogastric tube – consider placement in all blunt
trauma victims.
b. Foley – place after rectal exam
c. X-rays -c-spine, supine CXR and pelvic x-ray for blunt
trauma.
D. Frequent Re-Assessment:
1. Vital Signs should be documented no less then every
30 min. until initial work-up is complete and patient has
stabilized.
2. Outputs (chest tubes, urinary) – to be recorded at
frequent intervals.
3. Patients with shock/blood loss or high base deficit need
serial determinations of perfusion status i.e. ABG, Hb,
Lactate.
Imaging Studies:
1.Chest radiographs (CXR) are part of a routine workup
in all patients with penetrating abdominal trauma.
-In patients with a GSW, findings can reveal hemothorax
or pneumothorax secondary to penetration of the missile
into the chest.
-In patients with thoracoabdominal stab wounds, x-ray
films can indicate violation of the thoracic cavity by the
stab wound. Air under the diaphragm indicates peritoneal
penetration. The cardiac silhouette needs to be evaluated
to help rule out penetrating cardiac trauma.
2.Abdominal radiographs- predict the pattern of the
injury based on the location of the missile. AP erect/
lateral decubitus and Supine views
3.Ultrasound (FAST-focused Abdominal Sonography
for Trauma)
-Four views are used in trauma, with visualization of the
right upper and lower quadrants, left upper and lower
quadrants, pelvis, and pericardium. Ultrasound is up to
95% sensitive for helping detect intra-abdominal
hemorrhage but is not sensitive for helping detect hollow
organ injuries.
4. CT scan of the abdomen with triple contrast (ie, oral,
intravenous, rectal) is indicated in stable patients with
stab wounds to the flank and back.
Extravasation of the contrast, hematoma, violation of the
peritoneum, and free fluid in the abdomen are indications
for exploration.
5.Exploratory Laparoscopy-Evaluating the injury and
can be therapeutic as well
Laboratory Tests
1.PCV- Findings may indicate hemorrhage. Acute
bleeding frequently does not reflect the hemoglobin level
until fluid resuscitation is in progress.
2.U/E/C-Renal function and theatre preparation
3. Prothrombin/partial thromboplastin time (Findings may
indicate coagulopathy.
4. Arterial blood gas determination (ABG) (all patients):
hemodynamic status of the patient. Patients with profound
metabolic acidosis may require immediate exploration.
5.Type and cross match blood
6.Urine dipstick test for blood (all patients): This is a
quick test to help evaluate for potential genitourinary
injuries
7.Serum amylase levels-Pancreatic injury.

4. Diagnostic Procedures:
1.Nasogastric intubation
Is needed for all patients to decompress the stomach
before endotracheal intubation.
Nasogastric intubation can help detect gastric injury by
the presence of blood in the nasogastric tube (NGT).
2. Foley catheter insertion (all patients)
can help indicate injury to the urogenital system by the
presence of blood. Catheter insertion also enables
monitoring of the fluid resuscitation at least 30-50ml/hour
urine or 0.5ml/Min
3. Diagnostic peritoneal lavage
DPL used in stable patients detect hollow organ injuries.
Two commonly accepted methods of DPL are open DPL
and closed DPL.
a)-The open method involves exposure of the peritoneum
through a small infraumbilical midline incision and
insertion of the lavage catheter into the peritoneal cavity
under direct vision.
-This step is followed by aspiration, and if aspirate is
grossly negative for blood, 1 liter of warm peritoneal
dialysate (or isotonic sodium chloride solution) is infused
into the peritoneum. Fluid then is retrieved by gravity
siphonage
Positive DPL:
1. Presence of RBCs (Blunt injury>20,000/ml); But
>100,000/ml in penetrating abdominal injury
2. WBCs (>500/mm3
);
3 Bile or feccal matter
4. Food particles;
5. Lavage fluid from the Foley catheter, NGT, or chest
tube.
6.Serum Amylase levels >20 IU/L
7.Alkaline phosphatase >10 IU/L
The closed technique involves blind insertion of the
catheter into the peritoneum over the guide wire through a
small skin puncture.
4.Tube thoracostomy- is indicated in thoraco abdominal
injuries
Intra-operative
-Systematic inspection of the abdominal quadrants
-Hollow organs and solid organs
-Retroperironeal structures
-Vessels
-Any immediate bleeding is packed first as inspection
continues
NB. special attention to the retroperitoneal structures.
Injury to small bowel.
Small laceration-freshen the edges and anastomosis.
If circumferential or large defect – resection of the
segment and anastomosis
Large bowel injury
Resect the involved part and fashion a colostomy.
Closure of the colostomy after gut preparation in 6 weeks
time.
SPLENIC INJURY
Causes;
1.Blunt abdominal trauma
2.A fall with a diseased or enlarged spleen
3.Fractured overlying ribs - 9, 10, 11
4. Iatrogenic complications of any surgical procedure
especially those in the LUQ when adhesions are present.
Clinical presentation
-The patient succumbs rapidly from massive
haemorrhage, usually as a consequence of trauma
-Initial shock, recovery, signs of late bleeding
Physical examination
Splendid syndrome;
-Pain in LUQ
-Kerr’s sign - Referred pain felt in the left shoulder or
cervical region - Demonstrated 15mins following
elevation of the foot of the bed.
-Balance sign - On percussion;
Dull note on Left is wider than Right
When the patient is turned on the Right, the dull note
persists on the Left. When the patient is turned on the
Left, the dull note on the Right side goes
Investigation
CXR - 2 gastric bubbles
Management
Conservative Management
Indications;
Stable patients <55yrs in whom associated abdominal
injuries have been excluded
Children - Haemodynamically stable or requires
replacement of <½ of estimated blood volume (i.e.
Requires <40mL/Kg)
Absence of hilar involvement & massive disruption of the
spleen
-Admit & observe for 10-14days, then Bed rest for 1wk
-No strenuous activity for 6-8wks
-No contact sport for 6 months
Surgery
Spleen conserving surgery for Minor capsular
parenchymal injuries;
Topical haemostatic agents
Careful compression of the spleen to control bleeding -
Can be achieved using the omentum
Parenchymal injuries involving the lower or upper pole
may be managed by partial segmental resection.
Immediate splenectomy + Polyvalent pneumococcal
vaccine;
Severe multiple injuries
Splenic avulsion
Fragmentation or rupture (Delayed rupture of contained
subcapsular hematoma can occur several days after
splenic injury, usually within 48hrs)
Extensive hilar injuries
Failure of haemostasis
Peritoneal contamination from GI injury
Rupture of diseased spleen