(1) Perform a primary survey and assess for ABCDE issues. (2) Consider a seatbelt sign and evaluate for abdominal tenderness or rigidity which suggest occult injury. (3) Perform a FAST exam to check for hemoperitoneum which, if positive, indicates need for surgical consultation given the mechanism of injury. (4) If the patient is stable, further evaluation with CT scan would be most accurate to diagnose potential solid organ or retroperitoneal injuries from the handlebar impact.

1. Abdominal Trauma
30.08.2023
Sr. DR. Assumpta Nabawanuka

2. Outline
• Global context & epidemiology
• Blunt and Penetrating Abdominal/Pelvic trauma
• FAST Scan
• Management strategies/ Ideal treatment
• Case for discussion

3. Global context and epidemiology
• Abdominal injury ; 20% of trauma deaths
• It is frequently missed
• Apparently isolated injuries may have other associated
injuries
– Splenic injuries have a 10% chance
– Co-occuring
• diaphragm
• small bowel injuries
• Falls from heights can present with
• Bowel and bladder lacerations can also occur as well as retroperitoneal
hemorrhage
• Seatbelt sign: 23% of patients will have mesenteric, hepatic,
duodenal or jejunal lacerations

5. Blunt Abdominal Injury Epidemiology
Organ Injury Frequency of Occurrence (%)
Spleen 30
Liver 25
Kidney 20
Small Bowel 6
Diaphragm 4
Bladder 4
Colon 3
Abdominal Vessels 2
Other 6

6. Stereotypical Patterns of Injury
Mechanism of Injury Pattern of Injury
• Seat Belt – lap and sash belts • Jejunal Perforation
• Seat Belt – lap belt only • Duodenal or Pancreatic Injury
• Side Impact • Hepatic or Splenic Injury
• Sporting Injury • Splenic Laceration
• Bicycle Handle Bar Injury • Pancreatic Injury
• Animal (Cow/ Horse) Kick/Bicycle
horns
• Small Bowel Perforation

7. Injuries are often categorized by type of structure
that is damaged:
• Abdominal wall
• Solid organ (liver, spleen, pancreas, kidneys)
• Hollow viscus (stomach, small intestine, colon,
ureters, bladder)
• Vasculature

9. Several pathophysiologic mechanisms can occur in patients with blunt abdominal trauma .
Sudden and pronounced rise in intra-abdominal pressure created by outward forces can rupture a
hollow viscus.
• Sit belt without a shoulder attachment - the belt forcefully compresses the abdomen.
• Blunt forces on anterior abdominal wall can compress abdominal viscera against the posterior thoracic
cage or vertebral column, crushing tissue.
• Susceptible Solid organs (eg, spleen and liver) = laceration or fracture by this mechanism.
• Lax abdominal walls e.g. In Elderly and alcoholic are more likely to sustain such injuries.
• Delayed splenic rupture can occur.
• Retroperitoneal structures, such as the duodenum or pancreas, may be injured.
Mechanism of injury

10. Shearing forces
• Created by sudden deceleration can cause
lacerations of both solid and hollow organs at their points
of attachment to the peritoneum.
• They may also create tears at vascular pedicles or
cause stretch injuries to the intima and media of arteries,
resulting in infarction of the susceptible organ.
• The kidney is most susceptible to such stretch injury.
• Fractured ribs or pelvic bones can lacerate intra-abdominal
tissue.

11. Blunt Abdominal Injury
• Blunt abdominal injury
– Assess for the occurrence of associated abdominal organ injury
in the evaluation of these patients
– Injury may be due to seat belt use, sporting injuries or innocent
scenarios such as handle bar injury

12. Seatbelt Sign:
bruising in distribution of seatbelt

13. Penetrating Abdominal Injury
• Stab wounds:
– Injury generally confined to the tract of the weapon at
wounding however
• Gunshot wounds:
– Injury dependent on type of weapon (pistol vs. shotgun), size of
projectile, distance from assailant
– High energy rifles (i.e. military weapons) produce cavitation
resulting in wide tract of destruction and contamination

14. Trauma Seen sizing

15. Initial Trauma Assessment
Kampala Advanced Trauma Care Course
Last Edited August 2016 by Maija Cheung MD & Michael DeWane MD
Abdominal Trauma
Initial Assessment

17. Abdominal Assessment
• Primary survey
– ABCDE & adjuncts
– Assess hemodynamic stability
– Identify obvious need for surgical intervention (ie. Penetrating
trauma or evisceration)
• Secondary survey
– Classification of injury: blunt vs. penetrating vs. both
– Inspection, palpation, percussion, auscultation
– Location of injury

19. Abdominal Assessment
• Clinical examination of the abdomen is unreliable in
approximately 50% of blunt abdominal trauma patients
• Have a high index of suspicion for occult injury in any of
the following:
• Presence of abdominal tenderness and rebound tenderness
• Rigid abdomen
• Patients with seatbelt marking

20. Abdominal Assessment
• Inspection
– Expose patient from lower chest to upper thighs
– Inspect back (bullet wound pictured)

21. Abdominal Assessment
/Percussion
– Guarding – voluntary (normal reaction) vs. involuntary
(peritoneal irritation)
– Superficial, deep or rebound tenderness
– Look for increased tympany (pneumoperitoneum)
– Useful to detect an enlarged solid viscus or a distended bladder
Auscultation
– Rarely helpful in trauma assessment

22. Initial Trauma Assessment
Kampala Advanced Trauma Care Course
Last Edited August 2016 by Maija Cheung MD & Michael DeWane MD
Abdominal Trauma
Diagnostic Adjuncts

23. AXR
• Trauma series- Chest XR, Pelvic XR. Head CT
• Upright Abdominal X-Ray: free air under
the diaphragm indicates hollow viscous injury

24. Ultrasound- FAST/ e-FAST
• (extended) Focussed Assessment with Sonography in Trauma
• FAST is rapid, noninvasive, accurate, inexpensive and can be
repeated multiple times.
• A positive FAST examination (hemoperitoneum) is useful and
reliable in the hemodynamically unstable blunt trauma patient
• However, if the FAST examination is negative or equivocal, it
may be followed by a DPL or CT Scan

26. Where to scan

28. VIEWS
RIGHT UPPER QUADRANT
• Mid axillary line-pleural
cavity
• Below diaphragm
• Hepatorenal
recess(morrisons pouch)
• Inferior pole of kidney-
right paracolic gutter
LEFT UPPER QUADRANT
• Pleural cavity
• Below
diaphragm(perisplenic
space)
• Splenorenal recess
• Inferior pole of kidney-left
paracolic gutter

29. VIEWS
SUB XIPHOID SPACE
• Heart chambers-
pericardial space
SPRAPUBIC
• Retrovesical space/
retrouterine space in
women(pouch of
douglas)

30. Focused Assessment with Sonography for Trauma (FAST)

31. Abdominal Assessment: Ultrasound

32. CT Scan
• In the hemodynamically stable patient, CT is preferred
because it is noninvasive and highly accurate
• CT reliably diagnoses solid-organ injuries and evaluates
the retroperitoneum, but it is less sensitive and specific
for hollow viscus injuries and mesenteric injuries than
DPL is

34. DPL

35. Diagnostic Peritoneal Lavage
• Positive exam
– Initial aspiration of gross blood (>10ml), bile, vegetable fibers,
GI contents
• If nothing is aspirated
– Infuse 1L warm crystalloid into peritoneum, allow time to mix
then let it drain by gravity.
• Positive:
– if you see gross blood, bile, vegetable fibers, other gastrointestinal contents
– >100,000 RBC/mm3, >500WBCs/mm3
– 175 units of amylase/mm3
– Intestinal Contents
– Bacteria present on gram stain

36. Comparison of Diagnostic Options

37. Laboratory Analysis
• Full blood count
– Elevated white cell count may help point towards a
gastrointestinal perforation
• Urinalysis
– Macroscopic or Microscopic hematuria may indicated
bladder/kidney injury
– 98% of bladder rupture is accompanied by hematuria (10%
microscopic)

38. Evaluating Genitourinary Tract Injury
• CT with IV contrast
– Excellent for kidney and ureter
• Retrograde cystogram
– Excellent for bladder injuries
– Can be performed at the bedside
• Retrograde urethrogram
– Necessary to rule out urethral injury if:
• Blood at the urethral meatus
• High riding prostate on rectal exam
• Edema/ecchymosis in perineum

39. Intraperitoneal Bladder Rupture
• Contrast extravasation
into the peritoneal cavity
• Contrast outlines loops of
bowel, filling the paracolic
gutters, and pooling under
the diaphragm

40. Initial Trauma Assessment
Kampala Advanced Trauma Care Course
Last Edited August 2016 by Maija Cheung MD & Michael DeWane MD
Abdominal Trauma
Initial Mangement

41. Hemoperitoneum
• Hemoperitoneum is seen on abdominal ultrasound scan
– Note that the injured organ is not known
– Not seen on AXR
• If the patient is not hemodynamically unstable surgery
may not be indicated
• Surgical Consult
• Lack of CT scan services does not and should not lower
the threshold for exploratory laparotomy to find the cause
of hemoperitoneum

42. Hollow Organ Injury
• Sudden abdominal pain,
distension, vomiting, fever
• Serial abdominal Exams
– Peritoneal signs can manifest
at anytime after injury (up to
6-12 hours) and may manifest
as rapid gaseous distension,
fever and features of intestinal
obstruction
– These signs warrant surgical
evaluation

43. Solid Organ Injury
• Abdominal ultrasound is not sensitive for diagnosis of
solid organ injury but is not sensitive
• If the ultrasound findings are inconclusive with absence
of free peritoneal fluid and one suspects solid organ
injury, the patient’s hemodynamic status should
determine the need for laparotomy

44. Retroperitoneal Injuries
• The site of the injury, like trauma to the flank should raise
suspicion on the possibility of retroperitoneal injury
• Ultrasound scan can be used to diagnose a retroperitoneal
hematoma by a skilled operator
• Use repeated ultrasound scans every 12-24 hours to
ascertain if the hematoma is expanding indicating
continuous bleed that warrants exploration

47. Penetrating injury

50. PELVIC TRAUMA

51. Pelvic Binder

52. Case
• A 20 year old male was thrown off of his bicycle and his
his abdomen on his handlebars. He has a GCS of 15,
blood pressure 105/80, heart rate 112, and respiratory
rate of 18.
What are your initial steps in management?