abdominal trauma.ppt

Management
Of
Abdominal
Trauma
BY : CHONG LIH YIN

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

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

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

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

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

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.

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)

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).

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.

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

• 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?

Plain radiograph
Findings on chest radiograph that suggest
intraabdominal injury include:
Lower rib fracture
•Diaphragmatic hernia
•Free air under the diaphragm

(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

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

FAST-Morrison’s pouch (hepato-renal space)

FAST-Retrovesicle (Pouch of Douglas)
trauma.org
th

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

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%.

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

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

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…

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

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)

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

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

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

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

Management of penetrating abdominal trauma
Mandatory laparotomy
vs
Selective nonoperative management

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

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

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

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?

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

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

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

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

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.

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’

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.

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

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

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

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.

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

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

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.

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

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

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

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).

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

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

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

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

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

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

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

abdominal trauma.ppt

More Related Content

What's hot

Similar to abdominal trauma.ppt

Recently uploaded

abdominal trauma.ppt