This document provides an overview of the types, causes, examination, and management of abdominal trauma from blunt forces. It discusses the different regions of the abdomen that can be injured and mechanisms of injury for hollow and solid organs. Specific injuries to the spleen, liver, pancreas, kidneys, diaphragm, stomach, duodenum, intestines, colon, and bladder are reviewed. Management approaches for stable and unstable patients are described, including non-operative management with monitoring versus exploratory surgery depending on injury grade and hemodynamic status. Imaging tools like ultrasound, CT scan, and diagnostic peritoneal lavage are also summarized.

1. BLUNT TRAUMA ABDOMEN
SURG LT CDR K S PATEL

2. Scope
• Types
• Regional anatomy
• Causes
• Mechanism
• Examination
• Investigation
• Management

3. Types of Abdominal Trauma
1.Blunt Trauma- Any force to abdomen which
does not leave open wound.
2.Penetrating Trauma
-Stab
-Gun shot Injury

4. Regions of Abdomen
• Anterior abdomen
• Flank
• Posterior abdomen

5. Internal anatomy
• Intra-thoracic
• Pelvic
• Retroperitoneal
• True abdomen

6. Mechanism of Injury
• CRUSHING- Direct application of a blunt force to
the abdomen
• SHEARING- Sudden decelerations apply a
shearing force across organs with fixed
attachments
• BURSTING- Raised intraluminal pressure by
abdominal compression in hollow organs can lead
to rupture
• PENETRATION -Disruption of bony areas by blunt
trauma may generate

7. Hollow vs Solid Organ
Hollow organ injury
• Highly irritating and infectious content releases into
peritoneal cavity, producing a painful inflammatory
reaction-Peritonitis
• Stomach, Intestine, Gall bladder, Urinary bladder,
Uterus
Solid organ injury
• Causes several internal bleeding
• Bleed causes peritonitis
• Shock may overshadow peritonitis

8. CAUSES
• RTA with motor vehicle accident 60%
• Direct blow to abdomen 15%
• Fall 9%
• Domestic violence

9. PRIMARY SURVEY
• Identification & treatment of life threatening
conditions
• Airway , with cervical spine precautions
• Breathing
• Circulation
• Disability-AVPU (neurological status)
• Exposure-remove all clothes

10. EMERGENCY CARE
• I V fluids
• Control external bleeding
• Dressing of wounds
• Protect eviscerated organs with a sterile
dressing
• Stabilize an impaled object in place
• Give high flow oxygen
• Keep the patient warm
• Analgesics

11. SECONDARY SURVEY
• General &Systemic Examination-to identify
all occult injuries .
• Special attention to Back, Axilla , Perineum
• P/R - sphincter tone ,bleeding ,perforation ,
high riding prostate
• Foley’s catheter- monitor urine out put
• Nasogastric tube

12. SECONDARY SURVEY
AMPLE History
A: Allergy
M: Medications
P: Past medical history
L: Last meal
E: Event

13. EXAMINATION
Cullen’s Sign: Bluish discoloration around umbilicus.
Diffusion of blood along periumbilical tissues
Hemoperitoneum
Severe pancreatitis
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14. EXAMINATION
Grey-Turner’s Sign: Bluish discoloration of the
flanks.Retroperitoneal Hematoma hemorrhagic
pancreatitis.
Kehr’s sign: Referred pain, Right shoulder
irritation of the diaphragm (Splenic injury, free
air,intra-abdominal bleeding)

15. EXAMINATION
Balance’s Sign: Dullness on percussion of the left
upper quadrant ruptured spleen
Labia and Scrotum : Pooling of blood from
abdominal and pelvic cavities.

16. • Seat belt sign

17. London sign

18. Examination
Palpation: -Mass
-Tenderness
-Rebound tenderness
- Guarding /Rigidity
-Signs of peritonitis
-# Ribs
-Chest & Pelvic compression test
Auscultation :
1. Bowel sounds in the thoracic cavity
(Diaphragmatic rupture)
2. Haemothorax

19. INVESTIGATIONS
• FAST
• X-Ray Chest & Abdomen
• USG
• CT Scan
• Diagnostic Peritoneal Lavage
• Diagnostic Laparoscopy

20. Focussed Assessment with Sonography in
Trauma (FAST)
• Rapid , Accurate
• Sensitivity 86- 99%
• Can detect 100 mL of blood
• Cost effective
• Four different views- Pericardiac
Perihepatic
Perisplenic
Peripelvic space
• Eliminates unnecessary CT scans
• Helps in management plan

21. PLAIN X-RAY CHEST & ABDOMEN
• Pneumotharax, Haemothorax
• Free air under diaphragm
• Nasogastric tube, bowel loops
in the chest
• Elevation of the both /Single diaphragm
• Lower Ribs # -Liver /Spleen Injury
• Ground Glass Appearance – Massive Hemoperitoneum
• Obliteration of Psoas Shadow –Retroperitoneal
Bleeding
• #vertebra

22. USG
ADVANTAGE
• Easy & Early to Diagnose
• Noninvasive
• No Radiation Exposure
• Resuscitation/Emergency
room
• Used in initial Evaluation
• Low cost
DISADVANTAGE
• Examiner Dependent
• Obesity
• Gas interposition
• Low Sensitivity for free fluid
less 500 mL
• False –Negative
retroperitoneal & Hallow
viscus injury

24. DIAGNOSTIC PERITONEAL LAVAGE
• Rapid & Accurate test used to identify intra-
abdominal injuries
• Predictive value of greater than 90%
• The RBC count for lavage fluid is >
1,00,000/cu m.m.
• A WBC count > 500/cu m.m.
• Test is highly sensitive to presence of
intraperitoneal blood
• However specificity is low

25. DPL
Indications
• Unexplained Shock
• Altered sensorium (Head injury , Drug)
Contraindications
• Clear indication for Exploratory Laparotomy
• Relative
-Abdominal wall infection
-Pregnancy
-coagulopathy

26. CT SCAN
• Gold Standard
• Haemodynamically Stable
• Excellent imaging of pancreas, duodenum and GU
system
• Standard for detection of solid organs injury.
• Source and amount of bleeding
• Other assoc injuries e.g. Vertebral & Pelvic # &
injury in the thoracic cavity .
•High Specificity-95%

28. CT SCAN
Contraindication:
• Clear indication for Laparotomy
• Haemodynamically Unstable
• Allergy to contrast media

30. RECOMMENDATIONS
• Hemodynamically unstable or with diffuse abdominal
tenderness emergently for laparotomy (level 1)
• Hemodynamically stable with unreliable clinical
examination (i.e., brain injury, spinal cord injury,
intoxication) should have further diagnostic
investigation performed for intraperitoneal injury or
undergo exploratory laparotomy (level 1).
• A routine laparotomy is not indicated in
hemodynamically stable patient without signs of
peritonitis or diffuse abdominal tenderness (away
from the wounding site) in centers with surgical
expertise (level 2).

31. • A routine laparotomy is not indicated in
hemodynamically stable patients with abdominal
GSWs if the wounds are tangential and there are no
peritoneal signs (level 2).
• In patients selected for initial NOM, abdomino-pelvic
CT should be strongly considered as a diagnostic tool
to facilitate initial management decisions (level 2).
• Diagnostic laparoscopy may be considered as a tool to
evaluate diaphragmatic lacerations and peritoneal
penetration (level 2)

32. SOLID ORGAN INJURIES
• Grading of injured solid organs such as Spleen, Liver &
Kidneys are on the basis of
• subcapsular hematoma
• capsular tear
• parenchymal lacerations
• avulsion of vascular pedicle
• Bleeds significantly and cause rapid blood loss
• Difficult to identify injury by physical exam
• Repeated assessment is required to make the diagnosis

33. SPLENIC INJURY
• Most common intra- abdominal organ to injured (40-55%)
• 20% due to left lower rib fractures
• Arterial hemorrhage

34. Splenic injury
• Conservative management :
-Hemodynamic stability
- Negative abdominal examination
-Absence of contrast extravasation in CT
- Absence of other indication of Laprotomy
-Grade 1to 3 (Subcapsular Hematoma ,Laceration <3
cm)
Monitoring
• Serial abdo examinations & Haematocrit are essential
• Success rate is >80%

35. SPLENIC INJURIES
Operative Management
Capsular tears (I)- Compression & topical haemostatic agent
Deep Laceration (II) and (III) - Horizontal mattress suture
or Splenorrhaphy
Major Laceration not involving hilum (IV)-
Partial Splenectomy
Hillar injury (V)–Total Splenectomy
Grade IV-V: almost invariably require operative intervention
Success rate of Splenic salvage procedure is 40-60%

36. LIVER INJURY
• 2nd most common organ injured (35-45%) in BTA
• RTA and fights are responsible for 50% of liver
injury
• Venous bleeding
• Around 85% of all patients remain stable
• CT mainstay in stable pt.

37. Liver injury

38. LIVER INJURY
• 50% stop bleeding spontaneously by the time of surgery
Non Operative Mx
• Haemodynamically Stable
• No other intra-abdominal injury require surgery
• < 2 units of Blood Transfusion required
• Hemoperitoneum <500 ml on CT
• Grade I-III(subcapsular & intr-perenchymal hematoma)
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40. LIVER INJURY
OPERATIVE MANAGEMENT
• Packing
- Bleeding can be stopped by
packing
-Pack removed after 48 hr
-Haemostatic agents
-34 % survival in packing only

41. • Suturing: -Simple suture
-Deep mattress suture
• Laceration: -Mesh hepatorrhaphy
-Omental flap to cover the laceration
• Lobar Resection
• Ligate or repair damaged blood vessels & bile duct
• Mortality due to liver injury is 10%
LIVER INJURY
OPERATIVE MANAGEMENT

43. PANCREATIC INJURY
• 10-20% of abdomen injury.
• Crush, direct blow to abdo & Seat belt injury
• Associated with duodenal injury, Vascular injury &
liver injury
• Pancreatic enzymes are caustic, source of massive
systemic inflammation and subsequent poor
outcomes.
• Diagnosis – Difficult, CECT :- malperfusion of the
pancreatic parenchyma surrounding fluid
• Hematoma
• Extent of parenchymal injury and degree of ductal
involvement poorly characterize
• High index of suspicion –rib/ vertebra fracture

44. Pancreatic Injury
The injury involves the pancreatic neck and appears as a 2-cm segment of
nonperfused pancreas tissue with surrounding edema as identified by the arrow

45. PANCREATIC INJURY
Management
• Exposure of the entire pancreas is required
• Mobilization:- hepatic flexure gastrocolic
ligament to retract the transverse colon and
mesocolon inferiorly.
• Ext drainage imp component
• Distal feeding access provide early enteral
nutrition

47. RENAL INJURY
• Frequently overlooked
• Mechanism: Blunt , Penetrating
# lower ribs or spinous process,
Crush abdominal
Pelvic injury
Direct blow to flank or back
Fall
RTA

48. RENAL INJURY
Diagnosis
1.History ,Clinical examination
2. Presentation :Shock, hematuria & pain
3. Urine: gross or microscopic hematuria
5.X-ray KUB
IVP
6.CT Scan abdomen
7. USG
The degree of hematuria may not predict the
severity of renal injury

49. RENAL INJURY
Classification of Injury
• Grade I : Contusion or Subcapsular Hematoma
• Grade II: Non Expanding Hematoma, <1 cm deep
,no extravasation
• Grade III: Laceration >1cm with urinary
Extravasation
• Grade IV: Parenchymal Laceration deep to CM
Junction
• Grade V: Renovascular injury

50. MANAGEMENT OF RENAL INJURY
About 85% of trauma can be managed conservatively
Renal Contusion : Conservatively
Renal exploration : Indication
• Deep cortico-medullary Laceration with extravasation
• Large perinephric Hematoma
• Renovascular injury
• Uncontrolled bleeding

51. DIAPHRAGMATIC INJURY
• Incidence -0.8%-1.6% in BTA
• High index of suspicion required , may be
missed.
• Presentation may be delayed
• Imaging
Nasogastric tube seen in the thorax
Abdominal contents in the thorax
Elevated hemidiaphragm
Distortion of diaphragmatic margin.-
-Primary repair with interrupted horizontal mattress
suture

53. HOLLOW VISCUS INJURIES
Gastric Injury : Penetrating trauma
Blunt trauma abdomen 1%
Causes
Penetrating Injury
-Crushing Against the Spine
-CPR
-Vigorous Ventilation with ET Tube in the Esophagus
-Heimlich Maneuver
Diagnosis : X-Ray chest & Abdomen
CT scan
Diagnostic Peritoneal Lavage
During Surgical Exploration
T/t : Expl. Laparotomy with Primary Repair

54. DUODENAL INJURY
Isolated Duodenum injury rare Incidence - 3-5%
Cause :Penetrating injury: most common
Steering wheel injury
Assault
Fall
Associated with other intra-abdominal injury
Plain X-ray –Free air in abdomen
-Intraoperative diagnosis
Mx : Primary Repair 80% case
Roux-en –Y duodenojejunostomy 20%

55. HOLLOW VISCUS INJURIES
Small Intestine& Colonic Injuries
Commonly Injured in Penetrating injury
Blunt Trauma -Incidence 5% -20%
Mechanism : -Crush Injury
-At Fixed point DJ & IC Junction
Mx : Exploratory Laprotomy
Primary repair
Resection with anastomosis
End colostomy
Primary repair with diverting colostomy

56. BLADDER INJURY
• 70% of bladder Injury are associated with pelvic fracture .
• Hematuria
Type 1.Extraperitoneal Rupture-by bony fragment
• 2. Intraperitoneal Rupture- at dome when blow in
distended bladder
• Diagnosis -1. Clinical 2. Cystography
T/t 1. Intraperitoneal – closure with absorbable sutures +SPC
2:Extraperitoneal Rupture : Foley’s catheter -10 -14 days

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