Most important surgical topics. Enjoy 😉

1. Group 4A presentation
BLUNT VS PENETRATING ABDOMINAL TRAUMA
GROUP MEMBERS
1.SIBUSISO MYEZA
2.TOKELO LEBESA
3.LEBOGANG MAAKE
4.KEMISETSO DARIUS SEOSETSO
5.SIBUSISO MNGOMEZULU
6. PFANO TRUST

2. Case presentation
A 25 year old male patient came to emergency department and alleged that he was bitten twice on the left arm and stabbed
once by his spouse in stomach with a kitchen knife after an argument.
He has no known comorbidities , no past surgical history, no known allergies and he maintains sober habits.
On examination: he was awake, alert and responsive, he appeared comfortable and was not using any accessory muscles.
Vitals: BP 140/83, HR 106, Sats 94% RA, Temp 36.5
No pallor, jaundice, cyanosis, clubbing nor lymphadenopathy

3. case presentation continuation
ATLS Protocol:
C:Patient haemodynamically stable with good peripheral perfusion.S1S2 normal.No
murmurs.Insertion of urinary catheter.
A.Airway self maintained,C Spine clinically cleared
B;No respiratory distressed.Good Airway Entry Bilaterally.Good lung Expansion.No added
sounds.
D.GCS15/15 positive .Pupil equally active and reactive to light.No focal neurological history
E:wound:inferior to xiphoid. +- 1.5cm deep epigastrium laceration and 2x circular superficial
abrasions (teeth bite marks) .
In the abdomen: No distention,normal bowel sounds and tenderness in the epigastrium in
palpation

4. Case presentation continuation
secondary survey
In the abdomen: No distention, normal bowel sounds and tenderness in the epigastrium in palpation
CVS: Apex bit palpable at 5th intercostal space midclavicular line. S1S2 normal. No murmurs. Capillary refill <2sec.
Tachycardia.
Respiratory: good air entry bilateral, clear to percussion and auscultation
neurology: GCS score 15/15
Other systems not remarkable.
Assessment: 25 year old male, no comorbidities, presenting with epigastrium stab wound +- 1.5cm. No
distension, BS normal, no vomiting. Tender epigastrium. ATLS protocol done, Hemodynamically stable.
Plan:
Investigation: 1. eFAST: no abnormal findings 2. VBG: 3. X ray: no air under diaphragm, normal bowel
Treatment: 2 IV line, ABG, Antitatunus, 1.2 g Augmentin , refer for exploratory laparotomy

5. Description
Abdominal trauma is the injury of the abdomen. The abdomen extend from diaphragmatic to
the pelvic floor which consist of abdominal large vessels, liver, spleen, kidney, urinary bladder
pancreas, stomach and intestines.
there are two types of abdominal trauma
1. Blunt abdominal trauma: are injuries caused by impact or other forces applied from or with
a blunt object
2. Penetrating abdominal trauma: is cause when the body is pierced by an object that can be
sharp such as stab wound or gunshot.

6. Pathophysiology
Penetrating abdominal trauma Blunt abdominal trauma
penetrating abdominal trauma happens when a
foreign objects enters in the body by breaking
through the skin, the object may remain in the body
or pass through the body depending on the
sharpness and length of object, type of object,
velocity by which it travelled and angle of entry
Two types of injuries from penetrating abdominal
trauma
1. High velocity injury: commonly due to
firearms: gunshots wounds
2. Low velocity injury: commonly due to knifes
:knife stab wounds
Blunt abdominal injury is an injury that does not
penetrate the body through the skin, usually the
skin is not broken, and result commonly from motor
vehicle collisions (MCVs), assaults, recreational
accidents, or falls.
In blunt abdominal trauma we are concerned about
injury of organs such as spleen, liver,
retroperitoneum, small bowel, kidneys, bladder
colorectum, diaphragm and pancreas
1. Solid organ injury
2. Hollow viscus injury with rupture
3. Vascular injury with bleeding

7. Signs and symptoms
Penetrating abdominal trauma Blunt abdominal trauma
General signs and symptoms
pain, cold, pallor, anxious, shivering, thirsty and
profusely perspiring patient.
active bleeding wound, tachycardia, vomiting and
nausea, haematuria, entry and exit wound.
General signs and symptoms
pain, cold, pallor, anxious, shivering, thirsty and
profusely perspiring patient.
Abdominal examination findings: lap belt marks(
small intestine rupture); steering wheel shaped
contusions; grey turners sings or Cullen sign(
retroperitoneal haemorrhage) ; local or generalized
tenderness, guarding, rigidity or rebound
tenderness(peritoneal injury); fullness or doughy
consistency on palpitation(intraabdominal
haemorrhage); crepitation or instability of lower
thoracic cage( potential for hepatic or splenic
injuries)
Red flags: resting tachycardia HR > 100bpm ( < 15% loss of blood); orthostatic hypotension ( > 15% loss of
blood); supine hypotension< 90/60mmhg( >40% loss of blood); loss of consciousness ( loss of brain
perfusion); pallor , hematemesis and hemachezia

8. Causes and Risk factors
Blunt abdominal trauma Penetrating abdominal trauma
1. Driving under influence of alcohol or drugs
2. Driving a high velocity vehicle
3. Being an unrestraint passenger or the driver
4. Driving a vehicle without sit seatbelt
1. Crime
2. Parties with alcohol
3. Guns, knifes and potential weapons
4. Abuse and domestic violence
5. Robbery

9. Differential Diagnosis
Pelvic fracture Spinal lesions
Femoral fracture Rib fracture
Aortic rupture Hepatic and splenic rupture
Diaphragmatic rupture Genitourinary trauma

10. Investigations
If gunshot wounds injuries will all go for exploratory laparotomy
Bedside test:
urine dipstict, pregnancy test
ABG to check Hb and Sats
Imaging investigations
1. FAST (focused abdominal sonography for trauma)
2. Chest x ray
3. Book for CT abdominal
Bloods( FBC, Hb, WCC, LFTs, U and E and cross

11. Management ( PENETRATING ABDOMINAL TRAUMA)
A. primary survey ATLS PROTOCOL
This is traumatic emergency. Acute management in casualty will include ATLS principles , CABDE gunshot or deep stab wound patients will usually
be hemodynamically unstable or deteriorating due intraabdominal injuries, they must go to Theater immediately for explorative laparotomy.
C-circulation: stop active bleeding by applying pressure using a heavy gauze pad , give 2 large bores both sides :16 gauge(grey) iv line in the
antecubital veins. Give 1 liters of ringers lactate in each line of 40 dropper running at 150ml/hr;.The group cross match to order blood for
transfusion , packed RBC transfusion if HB< 8 and platelet transfusion if < 50 000/mcl .Check the vitals by attaching monitors:ECG,SpO2,BP cuff.
Insert Urinary Catheter. Give tramadol 100mg/IV 6 hrly every 2 minutes/g + panado 1000 mg IV 4-6hrly metoclopramide 10mg iv 8 hrly Gentamycin
6mg/kg less than 1hr .
A-Airway: check if they can talk, immobilize cervical spine
B- give oxygen if Sats are low, if chest is involved chest tube if necessary
D- glucose check give glucose if < 3.5, GCS score intubate if 8 or less
E- expose all the body by removing clothes, check for hidden wounds, then cover patient ASAP to prevent hypothermia
Other measures
B. Secondary survey: repeat examination from head to toe and take SAMPLE history

12. Management
CNS:Asses the GCS,look out focal neurology deficit.Meningism
Respiratory:Esses if the patient is in respiratory distress.Examine for equal air entry
bilaterally,auscultate for any additional sounds.
Cardivascular system: examine pulse,auscultate for S1 S2 and murmurs
Abdomen:Inspect bruising,wounds and previous scars.
Palpate for any tenderness and organomegally and auscultate for bowel sounds.