Trauma

1. Management
Of
Abdominal
Trauma
BY : CHONG LIH YIN

2. Index
1. classification of abdominal injury
2. Pathophysiology of abdominal injury -PAT
, BAT
3. Primary Survery
4. Secondary Survey- Physical examination,Lab Test
5. Imaging –Plain radiography , FAST scan, CT
6. Other diagnosis method -DPL,LWE,,Laparascopy, Exploratory Laparatomy
7. Management of BAT and PAT
8. Specific Organ injury
9. -Spleen , Diaphragm, stomach , small intestine, Colorectal injury,
10. Damage control resuscitation
11. Abdominal compartment syndrome
12. Reference

4. Abdominal Trauma
Blunt Abdominal Trauma
◦Greater mortality than PAT (more difficult to diagnose, commonly associated with
trauma to multiple organs/systems)
◦Most commonly injured organs?
- spleen > liver, intestine is the most likely hollow viscus.
◦Most common causes?
- MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%)
Penetrating Abdominal Trauma
◦Stabbing 3x more common than firearm wounds
◦Gun shot wound cause 90% of the deaths
◦Most commonly injured organs?
- small intestine > colon > liver

5. Pathophysiology of injury
Penetrating Abdominal
Trauma
Stab Wounds
◦Knives, ice picks, pens, coat
hangers, broken bottles
◦Liver, small bowel, spleen
Gunshot wounds
◦small bowel, colon and liver
◦Often multiple organ injuries,
bowel perforations
Rosen’s Emergency Medicine, 7th ed. 2009

6. Pathophysiology of injury
Rosen’s Emergency Medicine, 7th ed. 2009

7. Pathophysiology of injury
Blunt Abdominal Trauma
• Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal
pressures
• Crushing effect
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
◦ “seat belt sign” = highly correlated with intraperitoneal injury
Rosen’s Emergency Medicine, 7th ed. 2009

8. Primary Survey –ATLS approach
ABCDE pattern: Airway, Breathing, Circulation, Disability (neurologic status), and
Exposure.
A - intubation may be required if patient is shocked, hypotensive or unconscious or in need
for ventilation. *with cervical precaution.
B - watch for hemothorax in both blunt and penetrating thoracoabdominal injuries.
C - start with 2 L crystalloid (If active bleeding you must find source and stop the bleeding)
D – May seen associated with thorocolumbar #
E - Watch for other injury

9. Diagnostic
and
treatment
priorities
Recognize First : recognize presence of shock or intraabdominal
bleeding
Resuscitation Second : start resuscitative measures for
shock/bleeding
Abdomen? Third : determine if abdomen is source for shock
or bleeding
Laparatomy ? Fourth: determine if emergency laparatomy is
needed
Survey Fifth: complete secondary survery,ab,and radiograph
studies to determine if “occult” abdominal injury is
present.
Reassessment Sixth : conduct frequent reassessments.

11. Secondary
Survey History
History for all trauma patients:
-Not necessary making an accurate diagnosis
S.A.M.P.L.E
S: Symptoms:
pain,vomiting,hematuria,hematochezia,dyspnea,respiratory
distress…
A: Allergies
M : Medications
P : PMSHx
L : Last meals
E : Events (mechanism of injury)

12. Physical
Examinatio
n
Inspection : abrasions, contusion,
lacerations, deformity, entrance and exit
wounds to determine path of injury…
(grey Turner, Kehr, Balance,Cullen,seat belt
sign)
Palpation: elicits superficial , deep , or
rebound tenderness; involuntary muscle
duarding
Percussion : subtle signs of peritonitis;
tympany in gastric dilatation or free air;
dullness with hemoperitoneum.
Auscultation : bowel sounds may be
decrease ( late finding).

13. Physical examination
Grey-Turner sign : bluid discoloration of
lower flanks, lower back; associated with
retroperitoneal bleeding of
pancrease,kidney or pelvic fracture.
Cullen sign : bluish discoloration around
umbilicus, indicates peritoneal bleeding,
often pancreatic hemorrhage.
Kehr sign: shoulder pain while supine
;caused by diaphragmatic irritation(splenic
injury, free air, intra-abdominal bleeding)
Balance sign : dull percussion in
LUQ.Sign of splenic injury; blood
accumulation in subcapsular or
extracapsular spleen
In the trauma patient, a ‘normal’ physical exam of the abdomen
doesn’t equate to much. You NEED to do further testing.

14. Laboratory tests
- limited
-Hematocrit – below 30% increases the likelihood of intra-
abdominal injury.
-Leukocyte count – In BAT, the white blood cell (WBC) count is
nonspecific and of little value. Catecholamine release due to
trauma can cause demargination and may elevate the WBC to
12,000 to 20,000/mm3 with a moderate left shift. Solid or
hollow viscus injury can cause comparable elevations
-Pancreatic enzymes – Normal serum amylase and lipase
concentrations cannot exclude significant pancreatic injury . And
while elevated concentrations raise the possibility of pancreatic
injury,
-Liver function tests – Hepatic injury is associated with
elevations in liver transaminase concentrations
-Urinalysis – Gross hematuria suggests serious renal injury and
mandates further investigation
-Base deficit and lactate - Base deficit less than -6 was
associated with intra-abdominal hemorrhage and the need for
laparotomy and blood transfusion

15. • FAST ultrasound
• Diagnostic Peritoneal Tap
• CT Scan, contrast study
• Local wound exploration
• Angiography
• Urethrocystography
• IVU
Imaging in Abdominal Trauma
Plain films generally have NO
ROLE in acute abdominal
trauma
What else do we have?

16. Plain radiograph
Findings on chest radiograph that suggest
intra- abdominal injury include:
Lower rib fracture
•Diaphragmatic hernia
•Free air under the diaphragm

17. (FAST) Focused assessment with
sonography for trauma
- To diagnosed free intraperitoneal fluid.
- evaluate solid organ hematoma
- Four areas:
1. Pericardium (subxiphoid)
2.
3.
4.
Perihepatic &hepatorenal space (morrison’s pouch)
Perisplenic
Pelvis (pouch of Douglas /rectovesical pouch)
Sensitivity 60-95% for detecting 100ml -500 ml of fluid
E-fast(extended)
-add thoracic windows to look for pneumothorax.
Sensitivity 59%,specificity,specificity up to (99% for
pneumothorax. )
1 3
2
4

18. FAST Ultrasound
Advantages
• Sensitivity at detecting 100cc fluid is 60-
95%
• Portable(bedside),fast(<5 min) and ability
to repeat
• No radiation or contrast
• Noninvasive
• Rapid results, hemodynamically unstable
patient that unable to go for CT scan
• Less expensive
Disadvantages
• -Injury to solid parenchyma, the retroperitoneum,
or the diaphragm is not well seen.
• -Uncooperative patients, obesity, bowel gas, and
subcutaneous air interfere with image quality.
• -Low sensitivity in comparison to CT, particularly for
non-hypotensive patients. Cannot reliably exclude
clinically significant injuries
• -Blood cannot be distinguished from ascites or
urine.
• -Subcapsular injuries cannot be detected.
• -Insensitive for detecting bowel injury
• -Limited in detecting<200cc intraperitoneal fluid

19. Pericardium
(subxiphoid)

20. FAST-Morrison’s pouch (hepato-renal space)
Rosen’s Emergency Medicine, 7th ed. 2009

21. FAST Perisplenic view

22. FAST-Retrovesicle (Pouch of Douglas)
trauma.org
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23. CT Imaging
◦ Accurate for solid visceral lesions and intraperitoneal hemorrhage
◦ guide nonoperative management of solid organ damage
◦ IV not oral contrast
◦ Disadvantages : insensitive for injury of the pancreas, diaphragm, small
bowel, and mesentery
Rosen’s Emergency Medicine, 7th ed. 2009

24. Diagnostic Peritoneal Taps
DPA - The recovery of 10 cc of frank blood (or more) from the
peritoneum is a strong predictor (90% PPV in blunt trauma) of
intraperitoneal injury, and the procedure is then terminated.
DPL - If aspiration findings are negative, lavage is conducted in which the
peritoneal cavity is washed with saline. RBC count exceeding
100,000/cc is considered positive and generally specific for injury.
Sensitivity 90%.

25. Diagnositic Peritoneal ‘Lavage’
Is actually a 2 Step Process.
Step 1. DPA (closed).
◦ Patient supine
◦ Landmark is 2 finger widths below umbilicus
◦ Local freezing, puncture skin 30-degrees to the head
◦ Seldinger technique to introduce a DPL catheter
◦ Aspirate using 30cc syringe

28. DPA
Advantages
◦ Highly accurate for hemoperitoneum (SENS 90-100%)
◦ Most sensitive test for hollow viscus injury
Disadvantages
◦ Invasive (complication rate 1-5%)
◦ Time consuming (20 minutes)
◦ False positives. Up to 25% non-therapeutic laparotomies

29. DPA
•If 10cc frank blood or more is aspirated, you are
done, patient needs to go to the OR.
If the DPA is negative, you proceed to Step 2…

30. Diagnostic Peritoneal Lavage
Step 2. DPL.
◦Hook up 1L of Ringer’s to the peritoneal catheter, and
squeeze into the abdomen.
◦Once infused, put the empty Ringer’s bag on the floor,
and let it back-fill via gravity
◦Send off 10cc for analysis, if 100,000 RBC/cc it is positive

31. Is there still a role for DPA?
FAST has largely replaced DPA, likely due to
ease of use.
However, 2 areas where still is warranted:
◦Hemodynamically unstable and an equivocal FAST
◦No FAST available
“DPL is safe, sensitive, and reduces the use of
CT” (Journal of Trauma 2007)

32. Local Wound Exploration
To determine the depth of penetration in stab wounds
If peritoneum is violated, must do more diagnostics
Prep, extend wound, carefully examine (No blind probing)
Indicated for anterior abdominal stab wounds, less clear for
other areas
Rosen’s Emergency Medicine, 7th ed. 2009

33. Laparoscopy
Most useful to eval penetrating wounds to thoracoabdominal
region in stable pt
esp for diaphragm injury: Sens 87.5%, specificity 100%
Can repair organs via the laparoscope
diaphragm, solid viscera, stomach, small bowel.
Disadvantages:
poor sensitivity for hollow visceral injury, retroperitoneum
Complications from trocar misplacement.
If diaphragm injury, PTX during insufflation

34. Exploratory laparatomy
Potential indications include the following:
Haemodynamic instability
 Evidence of Peritonitis to achieve control of haemorrhage and control of spillage
Traumatic diaphragmatic injury with herniation
 Severe solid organ injury (e.g. kidney and spleen)
 Infarction due to post traumatic occlusion of the blood supply
 Mesenteric tear/s
 Unexplained Moderate to large amounts of free fluid (200-≥500mls)
 Failed non-operative management

35. Management
of BAT
• NOM: nonoperative management
• Abd CT: abdominal CT scan;
• DPT: diagnostic peritoneal tap;
• LAP: laparotomy

36. Management of penetrating abdominal trauma
Mandatory laparotomy
vs
Selective nonoperative management

37. Management of penetrating abdominal trauma
Mandatory laparotomy
◦ standard of care for abdominal stab wounds until 1960s, for GSWs until
recently
◦ Now thought unnecessary in 70% of abdominal stab wounds
◦ Increased complication rates, length of stay, costs
◦ Immediate laparotomy indicated for shock, evisceration, and peritonitis

38. Management of penetrating abdominal trauma
Selective management used to reduce unnecessary
laparotomies
Diagnostic studies to determine if there is intraperitoneal injury
requiring operative repair
Strategy depends on abdominal region:
Thoracoabdomen
Nipple line to costal margin
Anterior abdomen
Xiphoid to pubis
Flank and back
Posterior to anterior axillary line

39. Management of penetrating abdominal trauma
Thoracoabdomen
Big concern is diaphragmatic injury
◦ 7% of thoracoabdominal wounds
Diagnostic evaluation:
◦ CXR (hemothorax or pneumothorax)
◦ Diagnostic peritoneal lavage
◦ FAST
◦ Thoracoscopy
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

40. Thoracoabdomen

41. Management of penetrating abdominal trauma
Anterior abdomen
◦ Only 50-70% of anterior stab wounds enter the abdomen
◦ of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?

42. Management of penetrating abdominal trauma
Back/Flank
◦Risk of retroperitoneal injury
◦Intraperitoneal organ injury 15-
40%
◦Difficulty evaluating
retroperitoneal organs with exam
and FAST
◦In stable pts, CT scan is reliable
for excluding significant injury:
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

43. Management of PAT
Anterior abdomen
laparoscopy (LPY), or serial physical examinations (SPEs)

44. Management of penetrating abdominal trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal penetration have injury requiring
operative management
Most centers proceed to lap if peritoneal entry is suspected
Expectant management rarely done

45. Management of PAT
Gunshot wounds
-assess peritoneal entry by missile path,
LWE, CT
, US, laparoscopy (all limited)
laparoscopy (LPY), or serial physical examinations (SPEs)

46. Specific Organ Injury
Specific organ
trauma:
1.peritoneal
2.retroperitoneal
3.diaphragm
-Treatment of an organ injury is
similar whether the injury
mechanism is penetrating or
blunt
-An exception to the rule is a
retroperitoneal hematoma
-explore all retroperitoneal
hematoma caused by
penetrating injury.

47. Splenic Injury - Grading System(AAST)
I.- Hematoma, subcapsular <10% SA Capsular Laceration <1cm
II.- Hematoma, subcapsular 10-50% SA; intraparenchymal
<5cm Capsular Laceration 1-3cm
III.- Hematoma, subcapsular >50% SA; intraparenchymal >5cm
Capsular Laceration >3cm (or parenchymal depth)
IV.- Hematoma ruptured into parenchyma Hilar Injury
devascularizing spleen >25%
V.- Vascular hilar injury devascularing spleen 100%, or
‘Shattered’

48. WSES classification
Minor spleen injuries:
WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and penetrating lesions.
Moderate spleen injuries:
WSES class II includes hemodynamically stable AAST-OIS grade III blunt and penetrating lesions.
WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating
lesions.
Severe spleen injuries:
WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and penetrating
lesions.

50. Diaphragmatic injury
Its possible in injuries to the thoracoabdominal region
Can be due to blunt(>85%) or penetrating injury and is larger in the blunt
Possible cardiac injury if the penetrating wound is more central
The weakest point of diaphragm is the left posteriorlateral(80%)
Often missed in multitrauma
In isolated injury it may go unnoticed and there is often a delay between the injury and the diagnosis
Patients present with non specific symptoms and may complain of chest pain,abdominal pain,dyspnea
,tachypnea and cough
Rupture with herniation is diagnosed by CXR or CT but without herniation is difficult to diagnose
Thoracoscopy or laparascopy is diagnostic

51. Treatment
Once identified must be repaired because it will not close spontaneously regardless the size.
Early diagnosis needs abdominal approach using the interrupted nonabsorbable suture and
the large defect(>25cm2) may need nonabsorbable mesh.
In the event of a gross contamination, endogenous tissue can be utilized for a definitive
repair as latissimus dorsi flap, tensor fascia lata or omentum.
There are some who advocate using biologic tissue grafts, such as AlloDerm(human acellular
tissue matrix).The durability of such a repair is questionable.
Place chest tube on the surgery side at the time of repair

52. Stomach
More common in penetrating trauma than blunt &
its about 10% of penetrating injuries of the abdomen
Diagnosis:
Physical exam:
-epigastric tenderness,
-peritoneal signs,
-bloody gastric aspirate.
Plain radiography in <50%:
-free air under diaphragm
• FAST examination:-
unreliable
• DPL: WBC, RBC < Gross
contamination
• CT scan:
pneumoperitoneum
• Laparoscopy:-operator
dependent

53. Stomach treatment is according to the
severity
administer preop abx
Hematoma is evacuated ,hemostasis and closure with nonabsorbable suture.
Small perforation can be closed in one or two layered
Large injuries near the greater curvature can be closed by suture or GIA stapler
Certain defects may be closed using a TA stapler
A pyloric wound may be converted to pyloroplasty
Destructive wound may need proximal or distal gastrectomy
In rare cases a total gastrectomy and Roux-en –y esophagojejunostomy are necessary for severe
cases.

54. Small intestine
The small bowel is the mc injured intraabdominal organ in penetrating
tauma, a blunt trauma cause is less common,but not rare(10%)
Small isolated perforation probably result from blowout of
pseudoclosed loops(seatbelt related injuries)
Larger perforation, complete disruptions and injuries associated with
large mesenteric hematoma or laceration are caused by direct blows or
shearing injury or contusion
Perforation from blunt injury is the mc at the ligament of triez,ileocecal
valve,midjejunum or in the areas of adhesion

55. Small intestinee
•CT has a significant false negative rate in the diagnosis of small-
bowel injury.
•CT findings in small-bowel injury include:
Fluid collections without solid viscus injury
Bowel wall thickening
Mesenteric infiltration
Free intraperitoneal air
Oral contrast extravasation

57. Colon and rectum
-Diagnosis
• Peritoneal signs or free intraperitoneal air.
• At laparotomy, small injuries in the wall of the colon can be missed so explore all blood staining
or hematomas of the colonic wall.
• Consider proctoscopy or proctosigmoidescopy in :
- Gross blood on PR in the presence of a pelvic fracture
- Penetrating abdominal, buttock, thigh or pelvic wound.
- Any patient with a major pelvic fracture if the patient is stable.
• The location of the injury can be important in planning the operation. Even if the hole cannot
be visualized on proctoscopy, assume the patient has a colorectal injury, if there is intraluminal
blood.
• In hemodynamically unstable patients, proceed with laparotomy first.

58. Colon
and
rectum
Current operative options include :
-Primary repair of the injury,
-.Resection and anastomosis, and
-Colostomy..

59. Traditional contraindications to primary repair include :
• Patients with shock, underlying disease, significant associated injuries, or peritonitis
• Extensive intraperitoneal spillage of feces,
• Multisegmental or extensive colonic injury requiring resection, and
• Major loss of the abdominal wall or mesh repair of the abdominal wall; Colon and rectum
Treatment is operative
If a primary repair cannot be
performed safely for anatomic
reasons (bowel wall edema,
vascular compromise), a
colostomy may be a safer option.
The guidelines for primary repair include :
• Minimal fecal spillage,
• No shock (defined as systolic blood pressure <90 mmHg),
• Minimal associated intraabdominal injuries,
• <8-hour delay in diagnosis and treatment, and
• <1-L blood transfusion.
Colon and rectum

60. Rectum -intraperitoneal or extraperitoneal
1.Often, intraperitoneal rectal injuries can be managed as in colonic injury (primarily
repaired). 2.Treat extraperitoneal rectal tears by diverting sigmoid colostomy. Acceptable
options include:
• Hartmann resection with end colostomy,
•End colostomy with a mucus fistula, or
•Loop colostomy with a stapled distal end.
3.If the defect is not readily identified on proctoscopy…..
4.Presacral drainage and irrigation of the distal rectal stump…..
5.If a colostomy is necessary in a patient with a pelvic fracture requiring fixation……
6.Perioperative broad-spectrum antibiotics should be administered for colon and rectal
wounds

61. Damage
control
Resuscitatio
n
-can be applied to unstable
patient who are with life
threatening hemorrhage &
going to need massive
transfusion.
It’s an alternative resuscitation approach to hemmorhagic
shock which involves:
1.rapid control of surgical bleeding
2.Early and increased use of RBC, plasma and platelets in
a 1:1:1 ratio.
3.limitation of excessive crystalloid use
4.prevention and treatment of
hypothermia,hypocalcemia and acidosis.
5.Permissive hypotension. (hypotensive resuscitation
strategies).

63. Approach
Before:
ER->OR ->death
Now:
ER->OR->DCS->ICU->OR->ICU

65. Major complication of abdominal
trauma- Abdominal Compartment
Syndrome
Common problem with abdominal trauma
Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg,
with single or multiple organ system failure
◦± APP below 50 mm Hg
Primary ACS: associated with injury/disease in abdomen
Secondary (“medical”) ACS: due to problems outside the abdomen
(eg sepsis, capillary leak)
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

66. Abdominal Compartment Syndrome
Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

67. Abdominal Compartment Syndrome
Effects of elevated IAP
◦Renal dysfunction
◦ Decreased cardiac output
◦Increased airway
pressures and decreased
compliance
◦ Visceral hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

68. Abdominal Compartment Syndrome
Management
◦Surgical abdominal decompression
◦Nonsurgical: paracentesis, NGT,
sedation
◦Staged approach to abdominal
repair
◦Temporary abdominal closure

69. Conclusions
Watch out for implements and missiles violating the abdomen
Laparotomy is mandatory if shock, evisceration, or peritonitis
Diagnostic studies used to determine need for laparotomy in PAT and BAT
FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal
blood
Damage Control is a principle of staged operative management with
control and resuscitation prior to definitive repair
Abdominal compartment syndrome is a common problem in abdominal
trauma

71. Reference
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care
2010;16:609-617
https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0151-4#
http://www.aast.org/library/traumatools/injuryscoringscales.aspx#pancreas
https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-abdominal-trauma-
in-
adults?search=abdominal%20trauma&source=search_result&selectedTitle=1~150&usage_type=d
efault&display_rank=1#subscribeMessage