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Abdominal injuries
The document discusses abdominal injuries, including their causes, types, and management protocols in emergency medicine, emphasizing the importance of rapid identification and treatment to prevent complications like hemorrhage and sepsis. It outlines the procedure for pre-hospital care, primary and secondary surveys according to ATLS protocols, and detailed clinical features associated with various types of abdominal injuries. The document also covers diagnostic techniques and surgical treatment indications for penetrating and blunt abdominal trauma.
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Abdominal injuries
- 1. ABDOMINAL INJURIES Dr. PrasenjitGogoi Masters in Emergency Medicine, 3rd Yr Resident Fortis Hospital, Kolkata
- 2. Introduction • One ofthe leading cause of death and disability. • Identification of serious intra-abdominal injuries is often challenging. • Peak incidence of abdominal trauma is 15-30 years. • Injury accounts for 15-20% of all trauma deaths. • Uncontrolled haemorrhage - major cause of death immediately after abdominal trauma. • Most common delayed cause of mortality and morbidity following abdominal trauma is sepsis.
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- 5. Penetrating Trauma Abdomen StabInjury Gun Shot Injury
- 6. Pre-hospital care • Goal– deliver the patient to hospital for definitive care as soon as possible. Scoop and Run • ABC & care of spinal cord • Start IV line • Communicate to medical control • Rapid transport of patient to trauma centre
- 7. Primary Survey (ATLSprotocol) • Airway with cervical spine protection • Breathing and ventilation • Circulation with hemorrhage control • Disability : neurologic status • Exposure/Environment control
- 8. Adjuncts to primarysurvey • ECG monitoring • Urinary catheter • Gastric catheter • Monitoring – ABG – Pulse oximeter – Blood pressure • X-rays – AP CXR – AP PELVIS – C-SPINE • DPL • ABD USG - FAST
- 9. Secondary Survey (ATLSprotocol) • Head to toe evaluation • Complete history and physical examination • Reassessment of all vital signs • Complete neurological examination • Indicated x-rays are obtained • Special procedures • Tubes and fingers in every orifice
- 10. Secondary Survey (ATLSprotocol) AMPLE history • Allergies • Medications • Past illness/Pregnancy • Last meal • Events/Environment related to injury
- 11. Clinical Features- AbdominalInjury Physical examination • Inspection Handlebar Injury
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- 13. Physical examination • Palpation– mass & tenderness – peritonitis • Auscultation – bowel sounds in thorax- diaphragmatic rupture • Percussion – Balance’s sign - dull note on percussion in left upper quadrant – ruptured spleen
- 14. Physical examination • Evaluationof penetrating wound • Assessing pelvic stability • Penile, perineal and rectal examination • Vaginal examination • Gluteal examination
- 15. Clinical Features- AbdominalInjury Abdominal Wall Injuries • Direct blow • Indirectly by sudden muscle contraction • Pain with flexion and rotation of trunk. • Palpable hematomas – rectus hematomas
- 16. Clinical Feature -Abdominal Injury Solid Visceral Injuries • Hypotension • Tachycardia • Skin changes • Mental confusion • Late – abdominal tenderness distention tympany
- 17. Solid Visceral Injury •Splenic Injury – most common (40-55%) – 20% occur due to left lower rib fracture • Liver Injury – 2nd most common (35-45%) – 50% liver injury stop bleeding spontaneously by the time of surgery – Mortality 10%
- 18. Clinical Feature -AbdominalInjury Gastrointestinal Injuries • Incidence – 1-12% • Perforation of stomach, small bowel and colon. • Gastric injuries cause chemical irritation. • Small bowel and colonic injuries cause suppurative peritonitis. • Inflammation may take 6-7 hours to develop.
- 19. Clinical Feature -Abdominal Injury Retroperitoneal Injuries • Pancreatic Injuries • 4% of patient with abdominal trauma. • No specific signs and symptoms. • Mechanism of injury – rapid deceleration • Duodenal injuries • Relatively asymptomatic on presentation – small hematomas may go undiagnosed. • Gastric outlet obstruction • Duodenal rupture – high velocity deceleration
- 20. Clinical Feature -Abdominal Injury • Kidney injuries – 10% patients with abdominal trauma – Injuries consist of lacerations, avulsions and hematomas to the kidney itself and renal pelvis – Renal vascular injuries are uncommon
- 21. Renal Injury Scale GradeDescription I Hematuria with normal anatomic studies (contusion) or subcapsular, nonexpanding hematoma; no laceration II Perirenal, nonexpanding hematoma or <1 cm renal cortex laceration with no urinary extravasation III >1 cm renal cortex laceration with no collecting system involvement or urinary extravasation IV Laceration through cortex and medulla and into collecting system or segmental renal artery or vein injury with hematoma V Shattered kidney or vascular injury to renal pedicle or avulsed kidney
- 22. Clinical Feature -Abdominal Injury • Ureteral Injury – Isolated urethral injury is rare in trauma – Penetrating trauma – 90% & blunt trauma 10% – 70% cases will have gross or microscopic hematuria
- 23. Clinical Feature -Abdominal Injury • Bladder Injury – 2% of blunt abdominal trauma – 70-97% associated with pelvic fracture – Lower abdominal pain, tenderness and gross hematuria – Lower abdominal bruising, abdominal swelling from urinary ascites, perineal or scrotal edema from urinary extravasation, and inability to void – secondary to penetrating trauma - injuries to the rectum or buttocks.
- 24. Clinical Feature -Abdominal Injury Urethral Injury – Anatomical Classification • Posterior urethral injuries – Major blunt force trauma- rapid deceleration mechanism – Triad of urinary retention, blood at the meatus and high riding prostate. – 10% of patients with pelvic fractures. • Anterior urethral injuries – Direct perineal trauma – blunt / penetrating – Straddle injury is classic mechanism – Can also occur with penile fracture
- 25. Clinical Feature -Abdominal Injury Diaphragmatic Injuries • Diaphragm spasm – secondary to direct blow to epigastrium. • Diaphragmatic rupture – penetrating trauma or blunt force mechanism. • Failure to diagnose – delayed herniation or strangulation hernia of abdominal contents.
- 26. Investigations • Blood tests •X-rays – plain abdominal x rays/cxr • Diagnostic Peritoneal Lavage • USG abdomen • CT abdomen • Diagnostic Laparoscopy
- 27. Diagnosis Abdominal injuries thatneed expanded evaluation Prasence of pain, tenderness, distention and external signs of trauma Mechanism of injury with a high likelihood of causing abdominal injury Suspicious lower chest, back or pelvic injury. Inability to tolerate of delayed diagnosis Presence of distracting injuries Altered consciousness/sensorium
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- 36. CT Scan –Normal Abdomen
- 37. CT Scan –liver injury involving majority of right lobe
- 38. CT Scan –Liver laceration
- 39. CT Scan –Pancreas Injury
- 40. CT Scan –Splenic injury CT shows a subcapsular hematoma with a splenic laceration extending from the capsule to the hilum with an intraparenchymal hematoma (blue arrow)
- 41. CT Scan –Splenic injury This CT shows Rupture of the anterior half of the spleen caused by blunt trauma.Haemorrhage is seen within the splenic bed (arrow)
- 42. CT Scan –Kidney injury Left kidney multiple lacerations
- 43. CECT Scan –Ureter injury Right ureteric injury from penetrating rauma
- 44. CT Scan –Bladder injury Intraperitoneal bladder injury
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- 46. Penetrating Abdominal Trauma •Gunshot wounds – Small bowel (50%) – Colon (40%) – Liver (30%) – Abdominal vascular structures (25%) • Stab wounds – Liver (40%) – Small bowel (30%) – Diaphragm (20%) – Colon (10%)
- 47. Diagnosis in penetratingtrauma • USG – FAST • CT SCAN • DPL • Local exploration
- 48. CT Scan Abdomen-evidence of bullet in intra- abdominal (intrahepatic) topography
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- 52. Treatment • Gold standard- LAPAROTOMY
- 53. Treatment • Gold standard- LAPAROTOMY Indications for LAPAROTOMY Blunt Penetrating Absolute Ant. Abdominal wall injury with hypotension Injury to abdomen, back and flank with hypotension Abdominal wall disruption Abdominal tenderness Peritonitis GI evisceration Free air under diaphragm on cxr High suspicion of trans abdominal trajectory after gunshot wound Positive FAST/DPL in hemodynamically unstable patient CT diagnosed injury requiring surgery CT diagnosed injury requiring surgery Relative Positive FAST/DPL in hemodynamically stable patient Positive local wound exploration after stab wound. Solid visceral injury in stable patient Hemoperitoneum on CT without clear source
- 54. Non-operative management ofblunt trauma • Patient hemodynamically stable after initial resuscitation. • Continious patient monitoring for 48 hrs • Surgical team immediately available. • Adequate ICU support and transfusion services available. • Absence of peritonitis. • Normal sensorium. • Angioembolization may be an alternative to surgery
- 55. Reference • Tintinallis EmergencyMedicine – 8th edition • Advanced Trauma Life Support Guidelines • Eastern Association for the Surgery of Trauma Guidelines • Abdominal trauma imaging – www.intechopen.com
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