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Abdominal trauma ,an overview
1) Abdominal trauma is commonly encountered and can be life-threatening. Identification of serious intra-abdominal injuries can be challenging. 2) Motor vehicle accidents account for 60% of abdominal trauma, with blunt trauma more common than penetrating injuries. 3) Injuries to solid organs like the spleen, liver, and kidneys require careful assessment and may be graded based on severity. Conservative management is often attempted initially if the patient is stable. 4) Diagnostic tools like FAST ultrasound, CT scans, and laparoscopy can help identify injuries, but repeated examinations are often necessary. Management may involve surgery or conservative approaches depending on injury severity and patient stability.
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Introduction to abdominal trauma, its significance in emergency care, and the challenges in assessment.
Statistics on the occurrence of abdominal trauma, peak incidence age, and global death rates due to injuries.
Different types of abdominal trauma, including blunt and penetrating injuries, and their causes such as accidents and domestic violence.
Focus on rapid transport to trauma centers, airway management, and essential initial care.
Primary survey process, identification of life-threatening conditions, and immediate care practices.
Detailed examination procedures, including systemic surveys and history taking to identify hidden injuries.
Clinical signs such as Cullen’s sign and Grey-Turner’s sign associated with abdominal trauma.
Methods for diagnosing abdominal injuries including FAST, X-Ray, and CT scan, highlighting their effectiveness.
Procedures like paracentesis, diagnostic peritoneal lavage, and the nuances of injuries to solid organs. Injury details focusing on spleen, liver, pancreas, and renal injuries, including diagnosis and management strategies.
Challenges in diagnosing diaphragm injuries and hollow viscus injuries, including strategies for treatment.
Bladder and ureteral injuries, diagnosis methods, and management practices.
Incidence of trauma in pregnant women, causes, and the multidisciplinary approach needed for management.
Characteristics of penetrating injuries, specifics about surgery requirements, and associated risks.
Injury prevention strategies focusing on education, safety measures, and statistical impact on injury rates.
Overall insights on injury preventability, trauma health burden, and the importance of integrated care.
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Abdominal trauma ,an overview
- 1. ABDOMINAL TRAUMA :AN OVERVIEW Dr Tariq Saeed a Associate Professor Department of Surgery KMC/KTH/ KMU Peshawar
- 2. Introduction • Abdominal traumais regularly encountered in the emergency department • 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
- 3. Epidemiology • Peak incidenceAbdominal Trauma 15 - 30yr • More than 1.5 Lac people die every year as a result of injuries by motor vehicle accident , fall, suicide and homicide • Injury accounts for 10% of all deaths • Estimates indicate that by 2020, 8.4 million people will die yearly. • Prevalence: 13%
- 4. Types of AbdominalTrauma 1.Blunt Trauma 2.Penetrating Trauma -Stab -Gun shot Injury
- 5. M.V. Accidents involvinghigh kinetic energy and acceleration or deceleration forces - 60%
- 6. Direct blow toabdomen - 15% Fall- 6-9%
- 7. Blunt Trauma Abdomen(contd.) • Child Abuse • Domestic Violence • Iatrogenic injury -Endoscopic /Laparoscopic surgical procedures -Bag-mask ventilations -Inadvertent esophageal intubation -External cardiac compressions -Heimlich manoeuvre
- 8. Penetrating Trauma Penetrating abdominaltrauma has a slightly higher mortality rate Second most common cause of abdominal injury
- 9. Gunshot Injury Gunshot andstab wounds combine to cause 95% of penetrating abdominal injuries.
- 10. Prehospital Care • Thegoal of prehospital is to deliver the pt to hospital for definitive care as rapidly as possible. ‘Scoop and Run’ • Maintain airway & start I V line • Care of spinal cord • Communicate to medical control • Rapid transport of patient to trauma centre
- 11. Initial Assessment andResuscitation Primary survey Identification & treatment of life threatening conditions • Airway , with cervical spine precautions • Breathing • Circulation • Disability • Exposure
- 12. Emergency Care • IV fluids • Control external bleeding • Dressing of wounds • Protect eviscerated organs with a sterile dressing • Stabilize an impaled object in place • Give high flow oxygen • Immobilize the patient with a fractured pelvis • Keep the patient warm • Analgesics
- 13. 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 • Nasogastric tube
- 14. Secondary Survey(contd.) AMPLE History A:Allergy M: Medications P: Past medical history L: Last meal E: Event - What happened
- 15. Examination • Laceration • Abrasion •Entry/Exit wounds • Involvement chest & Head injury • Seat Belt Sign
- 16. Examination Cullen’s Sign:1918 Bluish discolorationaround umbilicus Diffusion of blood along periumbilical tissues or falciform ligament Hemoperitoneum Severe pancreatitis
- 17. Examination Grey-Turner’s Sign: (1877-1951) Bluishdiscoloration of the flanks Retroperitoneal Hematoma hemorrhagic pancreatitis. Kehr’s sign (1862-1916). Referred pain, Right shoulder irritation of the diaphragm (Splenic injury, free air, intra-abdominal bleeding)
- 18. Examination Balance’s Sign Dullness onpercussion of the left upper quadrant ruptured spleen Labia and Scrotum : Pooling of blood from abdominal and pelvic cavities.
- 19. Examination Auscultation :1. Bowelsounds in the thoracic cavity (Diaphragmatic rupture) 2. Haemothorax Palpation: -Mass -Tenderness -Signs of peritonitis -# Ribs -Chest & Pelvic compression test
- 20. Investigations • FAST • X-RayChest & Abdomen • USG • CT Scan • Paracentasis • Diagnostic Peritoneal Lavage • Diagnostic Laparoscopy
- 21. Focused Assessment withSonography 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 space • Eliminates unnecessary CT scans • Helps in management plan
- 22. 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
- 23. 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 500 mL • False –Negative retroperitoneal & Hallow viscus injury
- 25. Paracentasis • Four quadrantaspiration of abdomen • A Positive tap – blood , air , bile stained fluid • Negative tap doesn’t rule out injury. • False negatives are as high as 22-60%
- 26. 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. • A WBC count > 500/cu m.m. • Test is highly sensitive to presence of intraperitoneal blood • However specificity is low
- 27. Diagnostic Peritoneal Lavage Indications •Unexplained Shock • Altered sensorium (Head injury , Drug) • General anesthesia for extra- abdominal procedures Contraindications • Clear indication for Exploratory Laparotomy • Relative -Previous Expl. Laparotomy -Pregnancy -Obesity
- 30. CT Scan •Gold Standard •HaemodynamicallyStable • 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. Vertebral & Pelvic # & injury in the thoracic cavity . •High Specificity-95%
- 32. CT Scan Contraindication: • Clearindication for Laparotomy • Haemodynamically Unstable • Allergy to contrast media
- 33. DIAGNOSTIC LAPAROSCOPY • Haemodynamicallystable patients • Inadequate/equivocal USG • Mild hypotension or persistent tachycardia • Persistent abdominal signs/symptoms • It decreases non-therapeutic laparotomies • Useful in penetrating injury • Limitation :Retroperitoneal Injury
- 34. Solid Organ Injuries •Grading of injured solid organs such as Spleen, Liver & Kidneys are on the basis of subcapsular hematoma ,capsular tear, parenchymal lacerations & avulsion of vascular pedicle • Bleeds significantly and cause rapid blood loss • Difficult to identify injury by physical exam • Repeated assessment is required to make the diagnosis • Slowly oozing blood into peritoneal cavity
- 35. SPLENIC INJURY • Mostcommon intra- abdominal organ to injured (40-55%) • 20% of splenic injuries due to left lower rib fractures • Commonly arterial hemorrhage • Conservative management : -Hemodynamic stability - Negative abdominal examination -Absence of contrast extravasation in CT - Absence of other indication of Laprotomy -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm) Monitoring • Serial abdo. Examinations & Haematocrit are essential • Success rate of conservative m/m is >80%
- 36. Splenic Injuries Operative Management Capsulartears (I)- Compression & topical haemostatic agent Deep Laceration (II)- Horizontal mattress suture or Splenorrhaphy Major Laceration not involving hilum (IV)- Partial Splenectomy Hillar injury (V)–Total Splenectomy Grade IV-V: almost invariably require operative intervention Success rate of Splenic salvage procedure is 40-60%
- 37. Liver injury • Liveris the largest organ in abdomen • 2nd most common organ injured (35- 45%) in BTA • Driving and fighting responsible for 50% of deaths due to liver injury • Usually venous bleeding • 85% of all patients with blunt hepatic trauma are stable • CT is the mainstay of diagnosis in stable pt.
- 38. Liver Injury • 50%liver injury have stop bleeding spontaneously by the time of surgery Non Operative m/m • Haemodynamically Stable • No other intra-abdominal injury require surgery • < 2 units of BT required • Hemoperitoneum <500 ml on CT • Grade I-III(subcapsular & intr-perenchymal hematoma)
- 39. Liver Injury Operative m/m •Packing - Bleeding can be stopped by packing of abdomen -Pack removed after 48 hr -haemostatic agents -34 % survival in packing only
- 40. • Suturing: -Simplesuture -Deep mattress suture • Laceration: -Mesh hepatorrhaphy -Omental flap to cover the laceration - Debridement • Lobar Resection • Liver Transplantation • Ligate or repair damaged blood vessels & bile duct • Mortality of liver injury is 10% Liver Injury Operative Management(Contd.)
- 43. Pancreatic Injury • Rare10-20% of all abdominal injury • Crush , Direct blow to abdo & Seat belt injury • Associated with abdo. Duodenal injury, Vascular injury & liver injury • Diagnosis – Difficult, High index of suspicion • CECT Scan is helpful • Serum amylase is a poor indicator • Usually diagnose on Laparotomy • Distal Pancreatic injury - Distal resection • Pancreaticojejunostomy – Injury to Ampulla of Vater, Head & Body of Pancreas
- 44.
- 45. Renal Injury • Clinicallynot suspected & frequently overlooked • Mechanism: Blunt , Penetrating # lower ribs or spinous process, Crush abdominal Pelvic injury Direct blow to flank or back Fall MVA
- 46. Renal Injury Diagnosis 1.History ,Clinicalexamination 2. Presentation :Shock, hematuria & pain 3. Urine: gross or microscopic hematuria
- 47. Renal Injury Diagnosis (contd.) 5.X-rayKUB IVP 7. USG 6.CT Scan abdomen 8. Radionuclide Scan The degree of hematuria may not predict the severity of renal injury
- 48.
- 49. Renal Injury . Classification ofInjury • Grade I : Contusion or Subcapsular Hematoma • Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation • Grade III: Laceration >1cm with urinary Extravasation • Grade IV: Parenchymal Laceration deep to CM Junction • Grade V: Renovascular injury
- 51. Management of RenalInjury About 85% of blunt renal trauma can be manage by conservatively Renal Contusion : Conservatively Renal exploration : Indication • Deep cortico-medullary Laceration with extravasation • Large perinephric Hematoma • Renovascular injury • Uncontrolled bleeding Before Nephrectomy ,Contralateral Kidney should be assessed
- 52. 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%
- 53. Diaphragm Rupture /Hernia •S Lal, Y Kailasia , S Chouhan , APS Gaharwar, GP Shrivastava . Delayed presentation of post traumatic diaphragmatic hernia.
- 55.
- 56. Hollow Viscus Injuries GastricInjury : Penetrating trauma MC Blunt trauma abdomen 1% Causes Penetrating Injury -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
- 57. Hollow Viscus Injuries(Contd.) 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 Rx : Primary Repair 80% case Roux-en –Y duodenojejunostomy 20%
- 58. Hollow Viscus Injuries SmallIntestine& Colonic Injuries Commonly Injured in Penetrating injury Blunt Trauma -Incidence 5% -20% Mechanism : -Crush Injury -At Fixed point DJ & IC Junction Rx : Exploratory Laprotomy
- 59. Bladder Injury • Commonlyin BTA • 70% of bladder Injury are associated with pelvic fracture . • Hematuria Type 1.Extraperitoneal Rupture-by bony fragment • 2. Intraperitoneal Rupture- at dome when blow in distended bladder • Diagnosis -1. Clinical 2. Cystography T/t 1. Intraperitoneal –trans-peritoneal - closure +SPC 2:Extraperitoneal Rupture : Foley’s catheter -10 -14 days
- 60. 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 • Operative procedure Proximal & mid ureter -End to end Anastomosis over DJ Stent Distal –Ureteric Reimplantaion
- 61. Vascular Injury • Incidence5-10% • Highly lethal. • Associated with extremely rapid rates of blood loss • Exposure is difficult in Laparotomy • Initial Control by digital pressure • Heparinized saline (50U/ml) injected in both end of vessel • Rx Lateral suture ,End to end Anastomosis & Interposition graft • Mortality rate is very high
- 62. Trauma in Pregnancy •Incidence- 10-20% • Causes: 1.Domestic violence 2.Sexual Assault 3. Accident • Third trimester- mc- balance & coordination disturbed • Multidisciplinary team- Obstetrician, surgeon, and neonatologist • Peritoneal sign are delayed • “Supine hypotensive syndrome” > 20 weeks’ gestation. COMPLICATIONS • Fetal Injury & Death –fetoplacental injury, maternal shock, • Placental Abruption • Rupture of Uterus
- 63.
- 64. Penetrating Abdominal Trauma •Patients with deep penetrating injuries always require surgery • Common Organs –Small int.(29%) liver(28%) Colon(23%)
- 65. EAST Algorithm: Stable EasternAssociation for the Surgery of Trauma, 2001
- 66. Penetrating Abdominal Trauma(Contd.) •Multiple in 20% of cases • Most stab wounds do not cause an intraperitoneal injury • A complete Laparotomy is mandatory
- 67. Penetrating Abdominal Trauma(Contd.) AbdominalEvisceration
- 69. Stab wound toright lower quadrant with caecal evisceration. No colon injury at laparotomy
- 70. Penetrating Abdominal Trauma(Contd.) AbdominalEvisceration • Never try to replace organs • Cover with moist gauze, then sterile dressing. • Transport immediately
- 71. Gunshot Injury • Handguns,Rifles, and 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 Distance . • Injury multiple organ
- 72. Injury Prevention 1.Primary: Preventan injury from its occurrence in the first place: Educational activity such as anti- drink-driving campaigns , speed limit rule -Children should accompanied with parent 2.Secondary: Attempts to lesson the consequences of injury – making road & safer car, anti-locking brakes, air bags , helmets, seat belt 3. Tertiary: Minimize the effect of injury by health care by individuals & system.
- 73. Injury Prevention (Contd.) •Speed is a critical factor ; a 10% increase speed translate 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 reduces 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.
- 74. Summary • Injuries arePreventable • Trauma is a massive & growing health burden worldwide ,which increasingly afflicts the young & productive age group. • Repeated assessment is required to make the diagnosis • Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of Hemoperitoneum • Conservative approach in Liver & Renal Injury • Successful m/m of trauma requires integration of Prehospital ,in-hospital ,& rehabilitative care.