Abdominal trauma

Abdominal trauma
By Dr.sadia Asmat Burki
Tmo Surgical B ward
Saidu teaching hospital

Introduction
Abdominal trauma means any injury occurring to
abdominal cavity.
In civilian life, the majority of abdominal injuries
are due to blunt trauma secondary to high speed
automobile accident.
Penetrating injuries, often associated with wartime
combat, are seen with increasing frequency in ED
particularly in urban areas.
The failure to manage abdominal injuries
successfully accounts for the majority of
preventable deaths following multiple injuries, and
this accounts for the 10% of traumatic deaths that
occur annually in the USA.

Epidemiology
•United States statistics
Tracking trauma is the purview of the National Center
for Injury Prevention and Control (NCICP). Data
collected by this organization suggest that traumatic
injury is the third overall leading cause of death and
the number one cause of death in persons aged 1-44
years. Penetrating abdominal trauma affects
approximately 35% of those patients admitted to
urban trauma centers and 1-12% of those admitted to
suburban or rural centers.[3]
More than 150,000 people die each year as a result
of injuries, such as motor vehicle crashes, fires, falls,
drowning, poisoning, suicide, and homicide. Injuries
are the leading cause of death and disability for US
children and young adults.

International statistics
 In 1990, approximately 5 million people
died worldwide as a result of injury.
 Globally, injury accounts for 10% of all
deaths.
 Estimates indicate that by 2020, 8.4
million people will die yearly from injury.
 A review from Singapore described
trauma as the leading cause of death in
those aged 1-44 years. Traffic accidents,
stab wounds, and falls from heights were
the leading modes of injury. Blunt
abdominal trauma accounted for 79% of
cases.

External
Anatomy
Anterior abdomen; transnipple line
superiorly, inguinal ligaments and
symphasis pubis inferiorly, anterior
axillary lines laterally.
Flank; b/w anterior and posterior
axillary lines from 6th intercostals
space to iliac crest.
Back; Posterior to posterior axillary
lines, from tip of scapulae to iliac
crests.

Internal Anatomy
 Consists of four parts;
 Intrathoracic abdomen
 Pelvic abdomen
 Retroperitoneal abdomen
 True abdomen

Intrathoracic abdomen
Liver
Spleen
Diaphram
Stomach
But cartilagionus and
bony sturctures make
this portion inaccessible
to palpation.Each
sturcturemay be injured
when blunt or
penetrating injury is
delivered to the rib
cage,and peritoneal
lavage becomes useful
in evaluating this are of
anatomy.

Pelvis
Surrounded by pelvic
bones
Urinary bladder
Urethra
Small bowel
Reproductive organs
Iliac vessels
Lower part of
retroperitoneal space
Rectum

Retroperitoneal
Abdomen
Potential space,
Behind true peritoneal
cavity, contents are
Kidneys
Ureters
Pancreas
Duodenum except
pyloric part
Ascending and
descending colon
Abdominal Aorta
Inferior vena cava

Retroperitoneal abdomin
Injury to these sturucters may occur secondary
to penetrating or blunt trauma.The kidneys may
be damaged by injury to the lower ribs
posteriorly,crushing injuries to the front,or sides
of the trunk may damage any of these
structures.As with the thoracic and pelvic
abdomen,injury to these sturctures may result
in few physical findings, and physical
examination and peritoneal lavage may be of
little, or no help. Evaluation of the
retroperitoneal abdomen requires utilization of
radioghraphic procedures like i/v
pyelography,angiography,and CT.

True abdomen
The true abdomen contains
the small and large
intestines, the bladder
when distended, and
uterus when gravid. Injuries
to any of these organs are
usually manifested by pain
from peritonitis and are
associated with abdominal
findings. Peritoneal lavage
a useful adjunct when an
injury is suspected, and a
plain abdominal film when
free air is present.

Classification of injuries
Blunt trauma
Penetrating
trauma
Iatrogenic trauma

Blunt trauma;Mechanism of
injury
A force to the abdomen that
doesn't leave an open wound.
Crushing injury, solid organ
more vulnerable.
(Deceleration injuries:
differential movements of fixed
and non-fixed structures (e.g.
liver and spleen laceration at
sites of supporting ligaments).
External compression(seat
belt syndrome), whether from
direct blows or from external
compression against a fixed
object (e.g., lap belt, spinal
column),it causes sudden rise
in intra abdominal pressure
and culminate in hollow
viscous organ injury.

Pattern of Injury in Blunt Abdominal Trauma
spleen 40.6% pancrease 3%
kidney 12% Diaphragm 3%
intestine 15% Urinary bladder 6%
liver 15% urethra 2%
Retrperitoneal
haematoma
13% vascular 2%
Mesentery 5% stomach 1.3%

Common causes of blunt
injury
Most common causes: MVA (50
- 75% of cases)
 blows to abdomen (15%)
 falls (6 - 9%)

Hollow and solid organs
 The type of injury
will depend on
whether the organ
injured is solid or
hollow.
 hollow organs
include:
◦ Stomach
◦ Intestines
◦ Gallbladder
◦ Urinary bladder
◦ Uterus (female)
 Solid organs
◦ Liver
◦ Spleen
◦ Pancreas
◦ Kidneys
◦ Adrenals
◦ Ovaries
(female)

Hollow organ injuries
when hollow organs rupture,
their highly irritating and
infectious contents spill into the
peritoneal cavity, producing a
painful inflammatory reaction
called peritonitis

Solid organ injuries
Damage to solid organs
such as the liver can
cause severe internal
bleeding
blood in the peritoneal
cavity causes peritonitis
when patients injure
solid organs, the
symptoms of shock may
overshadow those from
peritonitis

Penetrating trauma
Energy imparted to body
•Low velocity: (distance is
more than 7 yards)Knife, ice
pick
•Medium velocity: (distance
is 3 to 7 yards)Gunshot
wounds, shotgun wounds
•High velocity: (when
distance is less than 3
yard)High-power hunting
rifles, military weapons
Ballistics
Distance
Trajectory

Penetrating abdominal trauma due to
GSW
Small bowel (50%)
Colon (40%)
Liver (30%)
Abdominal vascular
structures (25%)

Penetrating abdominal trauma due to
stab wound
Liver (40%)
Small bowel
(30%)
Diaphragm
(20%)
Colon (15%)

Iatrogenic abdominal
trauma
Endoscopic procedures
External cardiac massage
Peritoneal dialysis
Paracentesis
Percutaneous trashepatic
cannulation
Liver biopsy
Barium enema

Pre hospital care
Little can be done for the patients with abdominal
injuries in the field.
General features of stabilization and evaluation
include ensuring an adequately functioning airway,
inserting i/v lines in upper extremity, and beginning
of fluid resuscitation.
For penetarting wound sterile dressing should be
applied.
Any foreign body embedded in the trunk should
not be removed, as major bleeding may follow.
Evisceration is best left undisturbed,except to
apply a sterile dressing and protect the patient
from further injury.
Proper position
Early rapid transport

Hospital care and diagnosis
 Dx; requires history, examination,
investigation
 History; Primary goal is to identify that injury
exists, not necessary making an accurate
Dx
 History from prehospital care, or
transferring team; vital signs, physical
assessment, prehospital course, and
response to therapy should be obtained.
 Mechanism of injury is important factor in
making high index of suspicion, so detailed
history is helpful if available.

History contd…
 In case of blunt trauma, determine
 The types of vehicles involved
 – The speed they were traveling
 – Collision patterns
 – Use of seatbelts
 – Air bag deployment
 – The patient’s position in the vehicle
 In case of penetrating trauma by gunshot,
determine
 Type of weapon used
 – Number of shots
 – Distance from victim

History contd…symptoms
Back pain associated with compression fracture
of the upper limbs or spinal region carries an
associated 20% chance of renal injury.
Associated symptoms
Pain, vomiting, hematuria, hematochezia,
dyspnea, respiratory distress.
Thus in combination with the aspects of
physical diagnosis and adjuncts to physical
diagnosis as discussed below,assists in the initial
assessment of abdominal injury.
If the patient has sustained rib fracture on the
lower left chest, there is a 20% chance of
associated splenic injury,and with rib fracture on
the right there is 10% chance of liver injury.

Resuscitation
The ABCDE should be initiated.
Patent air way, if necessary ETT with assisted
ventilation should begin particularly in
comatose patients.
Upper extremity,large bore i.v cannulae and
i.v fluids with RL should begin immediately
Next, perform a rapid neurologic examination
and assess him head to toe
to identify obvious injuries and signs of
prolonged exposure to heat or cold.
If your patient sustained blunt trauma, as in a motor
vehicle crash (MVC), keep his neck and spine
immobilized until X-rays rule out a spinal injury.

Resuscitation
Vitals monitoring
Blood sampling,for
hematologic,biochemical,serologic investigations
should be carried out.
Abgs,and are repeated to assess ventilatory
status and acidosis.
Control the patient’s pain without sedating him, so
you can continue to assess his injuries and ask him
questions. Generally, I.V. analgesics such as
morphine can adequately manage pain without
sedation.
An early rapid assessment of the abdomen is
performed.

Resuscitation
Insert an indwelling urinary catheter, unless you
suspect a urinary tract injury. For example,
bloody urine or a prostate gland
found to be in a high position during
a rectal exam could indicate damage to the
urinary tract.
If the patient is to have a rectal examination,
delay catheter insertion until
afterward.
If •
urethral injury is ruled out,u.catheter is
placed, and sample of urine is taken to check for
microscopic heamaturia.

Insert a gastric tube to decompress the patient’s
stomach, prevent aspiration, and minimize leakage of
gastric contents and contamination of the abdominal
cavity. This also gives you access to gastric contents
to test for blood, the presence of blood becomes
indication for operation in penetrating trauma.
Administer tetanus prophylaxis and antibiotics as
ordered.

Physical Examination
Inspection, palpation, auscultation,
percussion,
Inspection: abrasions, contusions,
lacerations, deformity, entrance and exit
wounds to determine path of injury.
Grey-Turner, Kehr, Balance, Cullen sign
 palpation: elicit superficial, deep, or
rebound tenderness; involuntary
muscle guarding
Percussion: subtle signs of peritonitis;
tympany in gastric dilatation or free air;
dullness with hemoperitoneum.
Auscultation: bowel sounds may b
decreased(late finding).

Physical Exam:
Eponyms
Grey-Turner sign:
Bluish discoloration of lower flanks, lower back; associated
with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
Cullen sign:
Bluish discoloration around umbilicus, indicates peritoneal
bleeding, often pancreatic hemorrhage.
Kehr sign:
L shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
Balance sign:
Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.

Physical examination
contd..
Assess for pelvic stability,supra pubic tenderness,
pelvic lateral wall tenderness are assessed for pelvic
fracture.
Penile, vaginal, perineal, and rectal evaluation
should be done, and sphincter tone is checked.
The integrity of rectal wall. the position and mobility
of the prostate are evaluated, and the examining
finger should be tested for occult or gross blood.

Interpretation of physical
findings
Intraperitoneal injuries can occur in
vascular,solid,and hollow organs. Interpretation
of the physical findings associated with these
different structures is often a function of the
amount of the time that each of these types of
organs requires to create peritoneal irritation.
The spectrum of injury can vary from a patient with
rapid intra-abd bleeding,sec to a mesenteric artery
laceration, with no physical finding except for
hypovolaemic shock,to a patient with immediate
peritoneal irritation from inflammation injury to
stomach or colon.
Small bowel injury may not produce significant intra-abd
findings for 24 hours.
So frequent re-evaluation becomes an essential
component of any management protocol that is short
of definitive diagnosis.

Radiological and Ancillary
diagnostic procedures
Plain x-ray
chest,abdomen,and
pelvis
Fast
Diagnostic peritoneal
lavage
Contrast studies, CT
scan.
Urethrography
Cystography
Ivu
Angiography

Imaging
Plain films;
In blunt trauma, fracture
with associated visceral
injury
Intraperitoneal free air
Retroperitoneal stippling
associated duodenal
injury
Loss of psoas shadow
indicating retroperitoneal
bleeding
In penetrating trauma,
injuring trajectory

Angiography
To embolize
bleeding vessels or
solid visceral
hemorrhage from
blunt trauma in an
unstable pt.
Rarely for
diagnosing
intraperitoneal and
retroperitoneal
hemorrhage after
penetrating
abdominal trauma

Angiography and
embolization
initial angiogram Post
embolization
Right iliac angiogram: acute extravasation
(left) from the right superior and inferior lateral
sacral arteries. Post-embolization (right)
showing no evidence of acute arterial bleeding

Focused assessment with
sonography for trauma (FAST)
To diagnose free intraperitoneal fluid.
Evaluate solid organ hematoma
4 areas:
Perihepatic & hepato-renal space
(Morrison’s pouch)
Perisplenic
Pelvis (Pouch of Douglas/rectovesical
pouch)
Pericardium (subxiphoid)
sensitivity 60 to 95% for detecting
100 mL - 500 mL of fluid
Extended FAST (E-FAST):
Add thoracic windows to look for
pneumothorax.
Sensitivity 59%, specificity up to 99% for
PTX (c/w CXR 20%)

Fast
Retrovesicle, and pericardium(subxiphoid)
views

Fa
st
Advantages
•Portable, fast (<5 min),
•No radiation or contrast
•Less expensive
rapid results, ability to repeat
Hemodynamic ally unstable pt who cannot go to CT
Disadvantages
•Not as good for solid parenchyma damage,
retroperitoneal, or diaphragmatic defects.
•Limited by obesity, substantial bowel gas, and subcut
air.
•high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture
•Operator dependent
•Particularly poor at detecting bowel and mesentery
damage (44% sensitivity) Limited in detecting <250 cc
intraperitoneal fluid

FAST: Accuracy
For identifying hemoperitoneum in blunt
abdominal trauma:
Sensitivity 76 - 90%
Specificity 95 - 100%
The larger the hemoperitoneum, the higher
the sensitivity. So sensitivity increases
for clinically significant
hemoperitoneum.
How much fluid can FAST detect?
250 cc total
100 cc in Morison’s pouch

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.

Ct scan
Accurate for solid visceral lesions and its
grading and intraperitoneal hemorrhage.
guide nonoperative management of solid
organ damage.
Sensitivity for solid organ is 97%,for
enteric 61% to 94%,for
diaphrgmatic,61%,for pancreatic,30%
Disadvantages : insensitive for injury of the
pancreas, diaphragm, small bowel, and
mesentery.contrast allergies.

CTscan
Indications;
Blunt trauma
Hemodynamic ally stable pt
Normal or unreliable physical examination
Contraindications
Clear indication for exploratory laparotomy
Hemodynamic ally unstable patient
Contrast allergic pt

Comparison of Dpl,Fast,Ct
DPL FAST CT
DOCUMENTS BLEEDING FLUID ORGAN
BP STATUS LOW LOW NORMAL
SENSITIVITY 98% 82% -97% 92%-98%
SPECTIFITY LOW(MID80) MOD(MID
90)
HIGH(HIGH 9O)
DISADVANTAG
ES
INVASIVE OPERATER
DEPENDEN
T
HIGH COST
AND TIME

Diagnostic peritoneal
lavage
Introduced by Root (1965)
Indications for DPL in blunt trauma:
1. Hypotension with évidence of abdominal
injury
2. Multiple injuries and unexplained shock
3. Potentiel abdominal injury in patients who
are unconscious, intoxicated, or paraplegic
4. Equivocal physical findings in patients who
have sustained high-energy forces to the
torso
5. Potentiel abdominal injury in patients who
will undergo prolonged general anesthesia
for another injury, making continued
reevaluation of the abdomen impractical or
impossible

Dpl
In stab wounds, for
immediate dx of
hemoperitoneum,
determination of
intraperitoneal organ
injury, and detection of
isolated diaphragm injury.
In GSW, not used much

Contraindication
s
Absolute :
Peritonitis
Injured diaphragm
Extraluminal air by x-ray
Significant intraabdominal injury by CT scan
Intraperitoneal perforation of the bladder by
cystography
Relative :
Previous abdominal operations (because of adhesions)
Morbid obesity
Gravid Uterus
Advanced cirrhosis (because of portal hypertension and
the risk of bleeding)
Preexisting coagulopathy

Preferred sites for DPL
Standard adult :Infraumbilical midline
 Standard pediatric: Infraumbilical midline
2ed &3ed trimester pregnancy :Suprauterine
 Midline scarring :Left lower quadrant
• Pelvic fracture: Supraumbilical

Evaluation of DPL
INDEX POSTIVE VALUE
ASPIRATE BLOOD >10ml
FLUID ENTERIC CONTENT
LAVAGE RBC >100,000ML
WBC >500/ML
AMYLASE 175U/DL
ALK PHOS >3IU
BILE CONFIRMED
NEGATIVE RBC <50,000ML
WBC <100/ML
AMYLASE <75U/DL

DPL
RBC COUNT INCIDENCE OF VISCERAL INJURY
>100,000/ML 95%
20,000-100,000ML 15-25% WARRENTS FURTHER
<20,000ML <5%
Complications
INVESTIGATION
Perforation of small bowel,mesentry,and bladder.
Now rarely used, have replaced by fast and ct.
Limitations
Gives no information about retroperitoneal organ
status
Nor allow determination of which organ has been
damaged.

Establishing priorities and
indications for surgery
Signs of peritoneal injury
Unexplained shock
Evisceration
Positive DPL,Fast,or ct
Deterioration of findings during routine
follow up

Operative Approach
All abdominal explorations in adults are
performed using a long midline incision because of
its versatility.
Liquid and clotted blood is rapidly evacuate
with multiple laparotomy pads and suction.
Additional pads are then placed in each quadrant to
localize hemorrhage, and the aorta is palpated to
estimate blood pressure.

If exsanguinating hemorrhage is encountered
upon opening the abdomen, it is usually caused
by injury to the liver, aorta, inferior vena cava, or
iliac vessels.
If the liver is the source, the hepatic pedicle
should be immediately clamped
(a Pringle maneuver) and the liver compressed
posteriorly by tightly packing several laparotomy
pads between the hepatic injury and the
underside of the right anterior chest wall.(

If exsanguinating hemorrhage originates
near the midline in the retro peritoneum,
direct manual pressure is applied with a
laparotomy pad and the aorta is exposed at
the diaphragmatic hiatus and clamped.
The same approach is used in the pelvis
except that the infrarenal aorta can be
clamped.
venous injuries are not controlled with aortic
clamping. A helpful maneuver in these
instances is pelvic vascular isolation.(

For stable patients with large midline
hematomas, clamping the aorta proximal
to the hematoma is also a wise precaution.
Many surgeons take a few moments, once
overt hemorrhage has been controlled, to
identify obvious sources of enteric
contamination and minimize further
spillage.
This can be accomplished with a running
suture or with Babcock clamps.

All abdominal organs are systematically
examined by visualization, palpation, or
both.
Missed injuries:
In penetrating trauma failure to explore
retroperitoneal structures such as the
ascending and descending colons, the
second& third portion of the duodenum,
and ureters.
Injuries of the aorta or vena cava may be
temporarily tamponaded by overlying
structures.
Blunt abdominal injuries of the pancreas,
duodenum, bladder, and even the aorta
can be overlooked

Damage control surgery
 Patients with major exsanguinating
injuries may not survive complex
procedures
 Control hemorrhage and
contamination with abbreviated
laparotomy followed by resuscitation
prior to definitive repair

 . initial resuscitation
 1. Control of hemorrhage and
contamination
◦ Control injured vasculature, bleeding solid
organs
◦ Abdominal packing
 2. back to the ICU for resuscitation
◦ Correction of hypothermia, acidosis,
coagulopathy
 3. Definitive repair of injuries
 4. Definitive closure of the abdomen

Diaphragmatic injuries
Following blunt trauma, is
involved in 3% of injuries.
Commonly left hemi diaphragm
Dx is suspected when there is
respiratory distress and radiologic
evidence of pleural effusion not
relieved by intercostal catheter
decompression, or when upright
radiograph demonstrate visceral
herniation.
Penetrating injuries,5%
Evaluation through
DPL,thoracoscopy in patients with
haemo or pneumothorax,or
laparoscopy in those with normal
chest film.

Diaphragmatic
injuries
Penetrating injuries to the diaphragm are graded as
follows:
(I) Contusion
(II) Laceration, < 2 cm
(III) Laceration, 2-10 cm
(IV) Laceration, >10 cm
(V) Total tissue loss, >25 cm2
Lower-grade injuries may be repaired either via
laparotomy or with laparoscopic or thoracoscopic
techniques.
Essential components of repair include an airtight closure
with nonabsorbable suture and liberal saline lavage of the
hemi thorax if there has been a concomitant bowel injury
with soliage of the field. The closure may be running or
interrupted, and a chest tube is often placed for drainage.
Large defects may require placement of a prosthetic

Spleen Anatomy
Spleen lies in left upper
quadrant of the abdomen,
and in the intrathoracic
abdomen, slightly behind
the stomach, and
surrounded by bony cage,
less supproted.break at
ligaments attachments.
Important component of
reticoendothelial and
immune system
Got rich blood supply

Spleen
History of blow, fall or sport injury to the left
chest,flank,left upper abdomen is usually
associated with splenic injury.
The diagnosis is confirm by abdominal CT in
the hemodynamic ally stable patients or during
exploratory laparatomy in the unstable patient
with a postive dpl,
Hemodynamic ally stable patient undergo US.
If US show free fluid &patient remain stable CT is
obtain to
identify the source of bleeding , evaluate for
contrast agent extravasation,other abdominal
injury,grade and severity of the splenic injury.

GRADE LESIONS
1
Sub capsular hematoma <10% surface area
Laceration <1 cm in depth
11 Sub capsular hematoma 10-50% surface area
Laceration 1-3 cm in depth w/o vessels involved
Intraparenchymal hematoma <5cm diameter
111 Sub capsular hematoma >50% surface area or
expanding/ruptured hematoma
Laceration >3 cm in depth or w/ vessels involved
Intraparenchymal hematoma >5cm diameter
1V Devascularization of >25% of spleen

The classic criteria for non
operative management;
☺ Hemodynamic stability
☺ Negative abdominal examination
☺ Absence of contrast extravasation on CT
☺ Absence of other clear indication for
exploratory laparatomy or associated
injuries requiring a surgical intervention
☺ Absence of associated health condition
that carry an increased risk of bleeding
(coagulopathy,hepatic failure, use of anti
coagulant,specific coagulation factor
deficiency)
☺ Grade 1-3 injury

Non-operative
steps
☺Admit to ICU
☺Bed rest
☺NG tube
☺Serial abdominal examination
☺Serial Hct
If falling Hct,hypotension,persistent ileus, repeat
CT
IF Extravasation,pseudoaneurysm ,angiography
embolization.

Splenorrhaphy
During laparatomy ,splenic salvage in the
form of
Capsular tears Topical hemostatic agent
Lacerations into splenicsubtance can be
controlled with interlocking absorbable
sutures.
Major laceration involving less than 50% of
the SS can be treated with Segmental or
partial splenic resection.

Spleenectomy is
indicated when
If the patient has protracted hypotension
despite spleenorraphy
Undue delay is anticipated in attempting to
repair the spleen
The patient has other serious injuries
 Grade 4,5 splenic injuries

Complications
Early
 Bleeding
 Acute gastric distention
 Gastric necrosis
 Recurrent splenic bed
bleeding
 Pancreatitis
 Subpherinic abscess
Late Complications:
 Thrombocytosis
 OPSS
 DVT

Stomach injuries
Common in penetrating, rare in blunt trauma
Intrathoracic, partially protected by rib cage,
Gastric injuries difficult to diagnose
Any penetrating injury to left upper
quadrant,epigastrium,left thoracoaabdomen
region
+NG aspirate for blood raise suspicion
The intraoperative evaluation includes
visualization of esophageal hiatus, ant aspect of
stomach, division of gastro colic ligaments, post
aspect of stomach.
If in doubt, stomach distended with saline and
vital dye to see leeking.
Penetrating wounds debrided,and primary
closure is done.

Stomach injuries
contd…
Post opt complications
Lesser sac abscess
Gastric fistula
Empyema
T/M,
Abscess drainage
Fistula ,immediate re-operation and repair using
healthy tissue
Empyema needs chest intubation and drainage

Duodenum injuries
Isolated injury does not cause significant
hypotension, and signs of peritonitis delayed if
retroperitoneal duodenum
Failure to recognize this injury high mortality and
morbidity, due to lesser sac abscess n sepsis.
Entry wound on ant abdomen
Crushing injury where i/P, and R/P duodenum
macerated against spine
Seat belt injury, Closed loop compression of air filled
loop
Hyperamylasaemia +adjunctive lab
Plain x-ray shows obliteration of psoas shadow,
absence of air in in the duodenal bulb, air in
retroperitoneum,,associated lumbine spine
abnormalilties.

Duodenum
injuries
Injuries to the duodenum are graded as follows:
(I) Hematoma,
(II) Partial-thickness laceration
(III) Laceration disrupting < 50% circumference of
D1, D3, or D4, or 50-75% circumference of D2
(IV) Laceration disrupting 50-100% circumference
of D1, D3, or D4, or >75% circumference of D2, or
involving the ampulla or distal common bile duct
(V) Massive disruption of the duodenopancreatic
complex or devascularization of the duodenum

Intraoperative evaluation of
duodenum
Complete mobilization of duodenum(kocher
manoeuvre)
Hepatic flexure is taken down to expose the anterior
aspect of 2nd part, and inspection of 3rd and 4th part at
the base of transverse colon.
Retroperitoneal haemotomas in the areas must
explored and lesser sac should be entered to exclude
associated pancreatic injuries
Limited perforations or simple lacerations are treated
with primary closure within 6 hours, after that chance
of leak increases
Suction decompression with transpyloric NG,tube
jejnostomy or tube duodenostomy is advisable if
repair is any way compromised.

Duodenum injuries
If laceration of the ist and 2nd portion of duodenum is
extensive,and primary closure is associated with
obstruction, Roux-en-Y jejunoduodenostomy is indicated.
Another option is pyloric exclusion, in which proximal
duodenum is defunctionlized by closing the pylorus, and
doing gastrojejunostomy.wounds of first and 2nd portion of
duodenum are closed primarily, and duodenum is drained
with tube duodenostomy.
The distal duodenum can be primarily closed if injury is
treated within 6 hours, more than 6 hours ,or when there is
extensive maceration resection of distal duodenum and
duodenal jejunostomy should be performed.
Grade v needs pancreaticoduodenectomy.
Hematomas treated with NG suction until peristalsis
returns and slow introduction of solid foods,persistant
obstruction require operative treatment.

Post opt complications
Bleeding
Duodenal fistula, occurs in 5-10% of the patients
which unlike gastric fistula is managed non-operatively,
with Ngsuction,nutritional support, and
aggressive stoma care, and antibiotics if infection,
uncomplicated fistulas will close in 6
weeks,persistance beyond 6 weeks indicate
operative management

Pancreatic injuries
The pancreas, because of its protected
retroperitoneal location, is less commonly injured.
However, penetrating abdominal trauma accounts for
70-80% of pancreatic injuries, and mortality rates
exceed 30%. Most pancreatic injuries are diagnosed
intraoperatively. Pancreatic duct status and injury
location are determinants in the management of
pancreatic injuries.
Associated with other retroperitoneal tissue injury,
mostly with duodenum
Elevation of serum and urine amylase following blunt
trauma not diagnostic, but persistent elevation
suggests pancreatic injury
Contrast duodenography may reveal widening of c-loop,
loss of psoas shadow, ant displacement of
stomach and duodenum from pancreatic

Grades of pancreatic injuries
Proximal injuries are to the right of the mesenteric
vessels, while distal injuries are to the left. Proximal
injuries are managed by closed suction drainage only.
Distal pancreatic traumas with duct involvement
undergo distal pancreatectomy and closed suction
drainage.
Pancreatic injuries are graded according to the
presence or absence of ductal injuries, as follows:
(I) Superficial laceration or minor contusion without
ductal injury
(II) Major laceration or contusion without ductal injury
(III) Distal transections without duct injury or tissue
loss
(IV) Proximal transection or parenchymal injury
involving the ampulla

Pancreatic injuries
management
After hemorrhage is controlled and the pancreas is
exposed, the extent of the injury, and associated duodenal
tranverse mesocolon,trauma to stomach and spleen must
be identified. Debridement must be selective to preserve
as much endocrine and exocrine function as possible.
Grade I and II injuries may need simple d.d with or
without drainge.but grade III injuries are best treated with
distal pancreatectomy and splenectomy. Grade IV injuries
require near total pancreatectomy with reconstruction of
pancreatic drainage into the gastrointestinal tract with
either Roux-en-Y pancreaticojejunostomy or
pancreaticogastrostomy. If the patient is too unstable,
wide drainage of pancreatic tissue without anastomosis
may be necessary. Grade v needs
pancreatoduodenectomy.wide drainage is the rule.
Post opt complication include pancreatic fistula

Small bowel injury
15-20% of patients who require laparotomy after blunt
trauma, and 25-30% after penetrating trauma.
Dx is often directly apparent secondary to peritoneal
injury, or indirectly due to bleeding.
At operation, after bleeding control, non-crushing clamps
must be applied to prevent further leakage of small bowel
contents.
The small bowel should be carefully examined from
ligaments of triets to ileocecal valve.
Contusion of antimesenteric wall my result in delayed
perforation, and seromuscular sutures can be used to
imbricate the contusion into the lumen
Mesenteric haemotoma extending the bowel should be
incised and evacuated.
Single holes from stab wounds,or shotgun pellets can be
closed without debridement.

Small bowel injuries
Two adjacent holes can be connected across the
bridge of bowel and trasverse closure effected, so as
not to narrow the lumen
Large lacerations are debrided and closed
Transection is debrided and closed in routine fashion,
and mesenteric defect should be closed
Any large segment that are devascularized ,or
multiple defects, should be resected,and re-anastomosed.
Patients are maintained on post opt Ng
decompression until bowel sounds return
Complications are,i/abd abscess,anastomotic
leakage,enetrocutaneous fistula, intestinal obstruction

Injuries to colon and
rectum
Mostly penetrating injuries 17%,out of which 95% by stab
wounds,gunshot,shot gun, blunt 5%
Rectal injuries can occur in association with pelvic
abdomen trauma
S/S are not specific, indirectly will produce peritoneal
irritation and tenderness,DPL is of valve when
intraperitoneal part is involved.
DRE shows blood and suggestive of colonic and rectal
inujry.therefore proctoscopic and sigmoidoscopic
examinations should be performed
Primary repair can be selected when known associated
complication factors have been exluded, which are
Pre-opt hypotension,intraperitoneal hemorrage exceeding
one litre,more than two associated organs
injure(hepatic,pancreatic, and splenic injuries are
dangerous)

Colon/rectum injuries repair
Significant fecal spillage, or more than 6 hours have
been elapsed
Low risks patients should be treated with primary
closure or resection and primary anastomosis
High risk patients should be treated with resection
and colostomy
Post-opt complications,abscess,anastomotic
leak,parastomal hernia, and morbidity and mortality
with colostomy closure.
Rectal injuries must be suspected when there is
penetrating injury, sacral fracture, that produces pelvic
ring disruption.
Sigmoidoscopic examination is essential

Principles of operative management
for rectal injuries
Placement of patient in the lithotomy position for
proper exposure
Wide debridement of all dead and devititalized tissues.
Totally defunctioning colostomy
Rectal wall closure, if possible
Retrorectal drainage with coccgectomy,when
necessary to attain adequate rectal drainage
Antibiotics, nutritional support, and repeat debridement
Complete rectal destruction requires APR
Complications are
Pelvic abscess
Urinary or rectal fistulas, rectal and urinary
incontinence, and stricture
Loss of sexual function

Retroperitoneal
haematomas
Can be divided into 3 anatomical regions
zone 1 includes pancreaticoduodenal injuries, major
abdominal vascular (aorta,vena cava) injury
Zone 11 includes flank area,perinephric haemotomas,
genitourinary tract injuries, and colon.
Zone 111 are confined to pelvis
Retroperitoneal haemtomas in Zone 1 are explored
regardless of aetiology,or size,
Retroperitoneal haematomas caused by the penetrating
mechanism should be routinely explored, the only
exception to this rule would be those located in Zone 11
which should be explore only if;
They are adjacent to colon, and may be concealing an
occult colonic injury.
They are expanding
Pre opt evaluation with ct has demonstrated a major renal
injury, that is amenable to repair.

Retroperitoneal haematoms
Zone 11 RH are mostly managed non-operatively, like
renal injuries with urine extravasation, if urinoma develops
it can be managed with percutaneous drainage.
Proximal control of renal pedicle should be gained in any
exploration of perinephric haematoma.
Zone 11 blunt injuries can be left alone if they are not
expanding, or if ct, ivu is normal.
Zone 111RH are generally explored in patients with
penetrating trauma in order to explore major vascular or
ureteral injuries, and local bleeding is easy to control
Zone 111 RH in patients with blunt trauma have
associated pelvic fratures,and exploration of the
haemtoma can be hazardous
There is often extensive injury to the rich presacral
venous and arterial circulation, incision to the peritoneum
destroys the tamponade effect, and dissection in the
hematoma may produce catastrophic bleeding.
Exploration of this haemtoma is associated with
increased transfusion requirement and high mortality ,as
discrete bleeding points can rarely be identified.

Management of pelvic
fractures
Pelvic fractures is the major cause of mortality and
morbidity in pts with blunt abdominal trauma.
MvA and pedestrian account for the majority of these
injuries with mortality b/w 10 and 25%
Massive haemorrhage and coagulopathy accounts
for 40-60% of mortality in this group of patients.
Classification of pelvic fractures by trunkey
Type 1 injuries represent crush fracture of the pelvis
and involve three or more elements of the pelvic ring.
Type 11 injuries are unstable injuries and involve
atleast two breaks in the pelvic ring
Type 111 are stable fractures involving single
element in the pelvic ring,or fracture of pubic rami.

Pelvic fractures
The initial management of patient with pelvic will
depend on associated injuries
In patients with severe pelvic fractures who are
haemodynamically unstable,intracavitary
haemorrhage must be excluded by radiological and
DPL.
The incidence of false+ results are high due to free
dissection of blood from the pelvis into abdominal
cavity and passage of lavage catheter into expanded
preperitoneal space, it can be minimized by
performing DPL through supra-umblical incision.
Laparotomy is performed with positive lavage,intra
abdominal injuries are treated and pelvic haemotoma
is not explored

Pelvic RH bleeding control
methods
Control of ongoing pelvic RH bleeding is a challenge,
both arterial and venous bleeding may be present,
and patient may loss 20units of blood, methods to
control are given below;
Application of military antishock trousers(MAST)(field
and hospital resuscitation)
Pelvic arteriography and arterial embolization(if
transfusion requirement exceed 4-6 units within first 2
hours following injury)
Early reduction of pelvic fracture using external pelvic
fixation(open book fracture)

kidneys
High on posterior wall of abdominal cavity in
retroperitoneal space
Held in place by renal fascia
Cushioned by layer of adipose tissue
Partially protected by lower rib cage
Kidney most commonly injured
Injury often due to direct blows to back or flank
Children more susceptible than adults—less
perirenal fat/rib cage less ossified
Preexisting renal anomalies—hydro, puj
obstruction, tumors, abnl position (incidence 1-5
%)

Renal injuries treatment
Grade I-III renal injuries can often be observed
Grade IV and V renal and lower urinary tract
injuries often require surgery, and it involves partial
nephrectomy, or radical nephrectomy.

Ureteral injuries
Uncommon, occurs mostly with penetrating trauma.
The presence of haematuria is not a consistent
finding
Suspected pre-opt by the location of penetrating
injury, or in case of blunt trauma, by the presence of
concomitant
Injury or other genitourinary tract injuries.
In 80-85% IVP will confirm, but in 15-20% require
retrograde ureterography.
In unstable patients diagnosis of ureteral injury may
be made at the time of laparotomy by chromo-ureterography.
This procedure is carried out by the intravenous
injection of 5ml of methylene blue, extravasation of

Surgery According to ureteric injury
For upper third of ureteral injury,uretero-ureterostomy,
in case of extensive ureteral
loss,auto-transplanation of kidney into iliac fossa.
For middle third injuries, reimplanatation of
damaged ureter in to normal ureter across the
midline, or renal or bladder mobilization to allow for
tension free anastomosis.
For lower third injuries creation of anterior bladder
flap tube into which a shortened ureter may be
reimplanted.

Urinary bladder
Majority are blunt external trauma, suspected in
patients with haematuria and pelvic fractures.
Bladder rupture may be extra peritoneal or
intraperitoneal.
Extra peritoneal rupture is perforation by adjacent
bony fragment in pelvic fractures
Intra peritoneal rupture mainly of dome of bladder as
a result of direct blow to distended bladder.
Dx is made by cystography,IVP is often necessary to
evaluate the upper urinary tract.
T/M of I/P rupture includes suprapubic cystostomy
with drainage

Bladder injuries
The management of extra peritoneal is primarily
non-operative by the use of Foley catheter drainage
for prolonged period of time, requires that the patient
has no other intra-abdominal injuries, no significant
local haemorrhage,and no urinary tract injury.
When associated with above mentioned
complications, delayed repair can be done when
retroperitoneal bleeding is controlled and their
condition stabilized.
Complication rate is 20-25% and even more with
non-operative management

Injuries to urethra
Disruption of the urethra is found mostly in pelvic
fractures, in males only, so called straddle injury.
Posterior urethral tears are present in 10% of
pelvic fractures.
Urethral injuries are suspected on the basis of
mechanism, associated pelvic fractures,perineal
injury, blood at the urethral meatus,and
displacement of prostate gland.
Dx is made by retrograde urethrogram.
T/M is suprapubic cystotomy and delayed urethral
repair.
Delayed repair has served to markedly diminish the
incidence of striture,impotence,and incontinence .

Complications of genitourinary
trauma
 Early complications are
 Hemorrhage
 Urinary extravasations
 Infection
 Late complications
 Hypertension, AV fistula and pyelonephritis with
renal injuries
 Stricture formation and hydronehrosis with
ureteral transections
 Stricture incontinence and impotence with
urethral ruptures

Abdominal compartment
syndrome
 Trauma patients with severe intra-abdominal
injuries, presenting in profound
shock and requiring large amounts of
intravenous fluids are those most
susceptible to the development of sudden
increase in intra abdominal pressure.
 This syndrome is characterized by
abdominal distension,oliguria,hypoxia,and
increased pulmonary pressure.
 The diagnosis is confirmed by the
measuring the intra abdominal pressure
directly or the intravasical pressure.
 Types are primary and secondary

Pressure values
◦ Abdominal pressures over 20 mmHg
◦ Abdominal perfusion pressures (APP)
less than 50mmHg
 Abdominal perfusion pressure equals
the mean arterial pressure minus the
abdominal pressure. (MAP – ACP =
APP)

Normal values
 At rest 0 – 5mmHg
 Valsalva 60 – 80mmHg
 Cough 80cmH2O
 Vomiting 60cmH2O
 Active lifting Over 150mmHg
◦ During lifting the pressure is related to
the velocity of muscle contraction and
comes back to baseline once the
movement has ended

ACS grading
 Grade I 10 – 15mmHg
 Grade II 16 - 25mmHg
 Grade III 26 – 35mmHg
 Grade IV >35mmHg

Constellation of Symptoms
 Renal failure
◦ Decreased urine output
 Respiratory failure
◦ Dec compliance, inc pulmonary edema / airway
pressure
 Cardiac failure
◦ Decreased cardiac output (dec preload / inc after
load)
 Visceral failure
◦ Dec blood flow to liver, bowel (bacterial
translocation)
 Neurologic complications
◦ Increased intracranial pressure
 Abdominal wall “failure”
◦ Dehiscence, hernia formation

ACS management
◦ Surgical abdominal decompression
◦ Nonsurgical: paracentesis, NGT, sedation
◦ Staged approach to abdominal repair
◦ Temporary abdominal closure

Summary
 Mechanism of injury – Blunt vs. Penetrating
 ABC  Stability of trauma patients
 Select appropriate diagnostic imaging
 Think about associated injuries
 Multi-modality
◦ Clinical
◦ FAST
◦ CT Scan
◦ Interventional Radiology
◦ Surgical exploration

Abdominal trauma

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