this ppt consists of abdominal injuries - blunt and penetrating - cause, presentation, investigations and management.

1. ABDOMINAL INJURIES
Dr. Prasenjit Gogoi
Masters in Emergency Medicine,
3rd
Yr Resident
Fortis Hospital, Kolkata

2. Introduction
• One of the 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.

4. Blunt Trauma Abdomen
----Seat
Syndrome
Crush Injury--

5. Penetrating Trauma Abdomen
Stab Injury
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 (ATLS protocol)
• Airway with cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability : neurologic status
• Exposure/Environment control

8. Adjuncts to primary survey
• 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 (ATLS protocol)
• 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 (ATLS protocol)
AMPLE history
• Allergies
• Medications
• Past illness/Pregnancy
• Last meal
• Events/Environment related to injury

11. Clinical Features- Abdominal Injury
Physical examination
• Inspection
Handlebar Injury

12. Inspection
Cullen’s Sign
Grey Turner’s Sign

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
• Evaluation of penetrating wound
• Assessing pelvic stability
• Penile, perineal
and rectal examination
• Vaginal examination
• Gluteal examination

15. Clinical Features- Abdominal Injury
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 -Abdominal Injury
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
Grade Description
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 that need 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

28. X-ray Chest/Abdomen

29. X-ray Abdomen

30. X-ray Abdomen

31. USG-FAST

32. USG-FAST

33. USG-FAST

34. USG-FAST

35. CT SCAN

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

45. Diagnostic Peritoneal Lavage

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 penetrating trauma
• USG – FAST
• CT SCAN
• DPL
• Local exploration

48. CT Scan Abdomen -evidence of bullet in intra-
abdominal (intrahepatic) topography

49. EAST GUIDELINE

50. EAST GUIDELINE

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 of blunt
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 Emergency Medicine – 8th
edition
• Advanced Trauma Life Support Guidelines
• Eastern Association for the Surgery of Trauma
Guidelines
• Abdominal trauma imaging –
www.intechopen.com

56. THANK YOU