Abdominal Trauma

Dr. Qiu Xinguang

Department of General Surgery,
First Affiliated Hospital, Zhengzhou University
(450052)
 Mechanism of Injury
 Blunt injury
 Penetrating injury
 Blast injury
 Iatrogenic injury
 Blunt injury
 Commonest mode
 Frequently multi-system injury
 Abdominal injury accounts for 10%
blunt trauma death
 Road traffic accident
 Mechanism of blunt injury
 Direct impact
 Deceleration and rotational forces
 Liver and spleen are the most
commonly injured organs
 Bowel injury (acute increase in
intraluminal pressure / shearing at
mesentery)
 Penetrating injury
 High velocity
Gunshot wounds

 Low velocity
Stab wounds / low-velocity missiles
Mechanism of penetrating injury
 Stab wounds
Injury confined to the tract of
wounding

 Gunshot wounds
Depends on the energy transferred
Penetration is accompanied by shock
wave with cavitating effect (spiral
path of motion)
 Blast injury
 Positive and negative pressure waves
 Cause associated pressure changes
in bowel gas (blowout)
 Victim thrown by the force of
pressure waves
 Shrapnel
 Iatrogenic injury
 Uncommon
 Laparoscopy
 Endoscopy
 Primary survey and resuscitation
 Objectives of this phase:
To identify and correct any immediate life-
threatening conditions
To anticipate problems

 The activities are performed simultaneously with

enough personnel
A- Airway and cervical spine control
B- Breathing
C- Circulation with haemorrhage control
D- Disability
E- Exposure
 Airway and C-spine control
 C-spine injury should be assumed
 No attempt should be made to turn
the patient’s head to one side unless
C-spine injury has been ruled out
 Oxygen provided once airway cleared
and secured
 Beware of aspiration
 Breathing
 Anticipate SIX immediately life-threatening
thoracic conditions:
1. Airway obstruction
2. Tension pneumothorax
3. Open chest wound
4. Massive haemothorax
5. Flail chest
6. Cardiac tamponade

 Respiratory rate and effort are both sensitive

markers of underlying lung pathology (both
should be monitored)
 Circulation
 Key objectives of circulatory care:

Stop haemorrhage
Assess hypovolaemia
Vascular assess
Appropriate fluid resuscitation
 Stop haemorrhage
 Direct pressure (external haemorrhage)
 Long bone fractures be splinted
 Pelvic binding
 Pneumatic anti-shock garment (PASG)
 Pelvic fracture may need external fixation
 Try to avoid:
Vessel clamping
Tourniquets (distal ischaemia)
 Assessment for hypovolaemia
 Skin (colour, clamminess and capillary refill)
 Heart rate and BP
 Pulse pressure
 Conscious level
 ECG monitoring
 Search for common sites of occult bleeding:
Chest
Abdomen / Retroperitoneum
Pelvis
Long bones
Splints and dressings
 Vascular assess
 Large bore IV catheter
 20ml blood taken for grouping and x-
match and for e- + full blood count
 Femoral line / venous cut down /
intra-osseous access (if peripheral IV
assess failed)
 Central venous line insertion is not
essential for initial resuscitation
 Fluid resuscitation
 Initial fluid resuscitation:
2L warmed crystalloid
 Responder: Give maintenance fluids once
initial deficit replaced
 Transient responder: Deteriorate due to
continued haemorrhage, give blood and
urgent surgical opinion
 Non-responder: Ongoing haemorrhage at
a greater rate, need urgent surgical
opinion
 Resuscitation end-point
 Administer sufficient fluids to maintain perfusion
of essential organs
 SBP 80mmHg (previously normotensive)
 Equivalent to a palpable radial pulse
 Permissive hypotension to minimize
Ongoing haemorrhage
Disruption of established thrombus
Dilution of clotting factors
 Monitored vitals:
Resp rate, SaO2, HR, BP, Pulse pressure, Cardiac
monitoring, Temp, Urine output, GCS
 Urethral injury
 Far more common in male patients
 5-25% patients with pelvic fractures have an
associated urethral injury
 Symptoms:
Perineal pain
Dysuria
Failure to void
 Signs:
Blood at urethral meatus
Bruising around scrotum
High-riding prostate
 Urethral injury
 Urinary catheterization is
contraindicated:
Conversion of partial to complete
transection
Stricture formation
Introduce infection
 Diagnosis confirmed by retrograde
urethrogram
 Disability
 Baseline neurological examination:
AVPU response
Glasgow comma scale (if time permits)
Pupillary response
 Repeated assessment to look for signs of
deterioration
 Common causes of deterioration:
Hypoxia
Hypovolaemia
Hypoglycaemia
Raised ICP
 Exposure
 Trauma victims must be kept warm
and covered with blankets when not
examined
 Log-roll
Assess the spine from skull base to
coccyx
Examine the back for signs of injury
Rectal examination
 Secondary survey
(abdominal examination)
 Key objective:
To decide if laparotomy is needed
 Detailed examination of the abdomen,
pelvis and perineum
 Note for bruising and wounds
 Cover exposed bowel loops with warm NS
soaked gauze
 Gastric tube to decompress distended
stomach to facilitate abdominal
examination and reduce risk of aspiration
 Physical examination
 Most alert patients will have abdominal
tenderness
 Initial PE in blunt abdominal trauma is
only 65% accurate
Altered mental state (drugs, alcohol, HI,
etc)
Sensory abnormalities (spinal cord injury)
Distracting injuries (extra-abdominal)
 Serial examinations are often more
important
 Physical findings
 Distension
Usually 20 to ileus or pneumoperitone
um or
haemoperitoneum

 Bruising
 Palpation
 Lower ribs fracture
 Abdominal tenderness, guarding or
rebound
 Pelvic stability
 Lumbar spine for tenderness
 Rectal examination
Anal tone
Prostate position (?high riding)
Blood over examination glove
 Plain radiographs
 CXR
The most important plain film
Obvious intra-thoracic and
diaphragmatic injuries
 Pelvis (AP view)
 C-spine (Lat view) make sure C1-C7
are well shown
 AXR seldom helpful (not routine)
 Laboratory studies
 Laboratory tests play limited role in the
diagnosis of IAI (normal test never R/O
IAI)
 Baseline Hb level
 Acid-base status
 Amylase (not sensitive / specific)
 Urinalysis (gross haematuria is the most
consistent sign of serious renal injury)
 Diagnostic peritoneal lavage
 Before the introduction of DPL ~20%
patient with abdominal trauma died of
unrecognized injury
 Sensitive 97-99%
 Fast (5-15 min)
 False +ve 1.4%
 Complication rate 1%
 No information on retroperitoneal organs
 Not sensitive to detect diaphragmatic or
bladder injuries (these result in minimal
bleeding)
 Contraindication of PDL
 Absolute
Obvious need for laparotomy
Evisceration
 Relative
Pregnancy (>12 wks)
Previous abdominal surgery
 Criticism of PDL
 Overly sensitive
 Non-bleeding solid organ injuries
(which can be managed
conservatively)
 Non-therapeutic laparotomies
 Best preserved for hypotensive,
unstable, multi-injured patients
 Techniques
 Closed percutaneous
 Semi-closed
 Open

1 Liter of warm normal saline is instilled

in adults
15 ml/kg in children
A minimum of 300 ml of lavage fluid must
return to give a representative sample
 Positive results of DPL
 10ml gross blood or bowel contents
with initial aspiration
 RBC count >100,000 cells/ml in
blunt trauma
 RBC count >10,000 cells/ml in stab
wounds
 RBC count >5000 cells/ml in
penetrating chest trauma
 WBC count >500 cells/ml
 Ultrasound
 Kristensen et al first reported the use of
USG in abdominal trauma in 1971
 Non-invasive and inexpensive
 Portable (bed side)
 No radiation / contrast required
 Well tolerated (excellent for unstable
patients)
 Quick (within 3 mins in experienced
hands)
 Serial examination easy to perform
 Best screens for haemoperitoneum
 FAST technique
 Focused Abdomianl Sonography for Traum
a (Rozycki et al)
 A standard approach which involves imagi
ng a limited number of US windows to det
ect fluid:
RUQ (Morison’s pouch)
LUQ (to view the spleen)
Pelvis (Douglas pouch)
Pericardial window to assess for pericardial
effusion (epigastric)
 Reliability of FAST
 Sensitivity 93.4%
 Specificity 98.7%
 Accuracy 97.5%
A collected review of ~5000 patients
(with FAST performed by surgeons)
Rozycki and Shackford J Trauma 1996; 28: 483-9
 Results interpretation
 Unstable patients with a +ve US
requires laparotomy
 Stable patients can be followed by
serial US or employ CT for further
evaluation
 Limitations
 Operator dependent
 Uncooperative / agitated patients
 Obesity
 Surgical emphysema
 Ileus
 Cannot assess retroperitoneal organs
 Like CT, US is insensitive for bowel injury
 Poor sensitivity for penetrating trauma
 Abdominal computed tomography
 Introduced in late 1970s for trauma
management
 CT quantifies intraperitoneal blood
and grades organ injury
 IV and oral contrast
 Accuracy is extremely reader-
dependent
 Modern spiral scan requires 3-5 mins
 Dome of diaphragm to pelvis
 Precautions
 Haemodynamically stable
 More time consuming than DPL /
FAST
 30-50 min
 Adequate monitoring
 Resuscitation facilities must be
available in the CT room
 Diagnostic laparoscopy
 DL is a relatively new investigation
 Little evidence to support its role in blunt t
rauma
 Not sensitive in Dx hollow viscus and retro
peritoneal injury
 Penetrating trauma (stab wounds) in stabl
e patient
100% sensitivity for identification of pe
ritoneal penetration
 Most effective for diagnosing ruptured diap
hragm
 Limitation of DL
 Time consuming
 Invasive
 General anaesthetic
 Difficult to exclude hollow viscus
perforation
 Management approach for
blunt abdominal trauma
 Unstable patient with abdominal sign
Operation
 Unstable patient with uncertain abdominal injury
DPL or FAST
 Stable patient with associated severe injuries
DPL or FAST
 Stable patient with associated minor injuries and
equivocal abdomen
CT scan
 Stable patient with abdominal signs
CT scan (allowing non-operative Tx if appropriate)
 Stab wounds
 Penetrates peritoneum in 2/3 cases
 Only 50-70% of these have significant
visceral or vascular injury
 Selective laparotomies to reduce morbidity
and hospital stay in haemodynamically
stable patients
 Diagnostic aids:
Wound exploration
DPL
Laparoscopy
Serial examinations
 Lumbar and flank wounds
 Significantly less risk (<15%) for
intra-abdominal injuries than those
with anterior wounds
 A more selected approach is
warranted
 Contrast enhanced CT scan
combined with serial examinations is
recommended
 Renal injuries occur in 6-8%
 Management approach for
penetrating abdominal trauma
 Sensitivity of CT or US are far too low to
exclude intra-abdominal injury
 Stab wounds
Peritoneal penetration  Laparotomy
Diagnostic laparoscopy  Laparotomy
Wound exploration  Laparotomy
 Gunshot wounds
Obligatory laparotomy
Diagnostic laparoscopy  Laparotomy
 Incidence of IAI requiring
exploratory laparotomy
Blunt Penetratin
% g%
Spleen 47 7
Liver 51 28
Pancreas / 10 11
Duodenum
Colon 5 23
Stomach / 9 42
Small bowel
 Management “Prioritization”
 Concurrent head injuries
An exsanguinating abdominal injury
demands a laparotomy to control
bleeding before assessment of the HI
 Pelvic fracture
Rapid application of external fixator
to stabilize the pelvis before
laparotomy
Non-operative management of solid
organ injury
 Increasing evidence to support non-
operative Mx
 Parallels with the wide-spread use of
CT
 Clinical criteria (not CT grading) are
used for decision making
 Must be continuously monitored in
HDU or ICU setting
 Criteria for non-operative Mx
 Solid organ injury shown on CT scan
 Minimal abdominal signs
 Haemodynamically stable
 Requires <2 units of blood
 HDU or ICU available
 Surgeons committed for repeated
evaluation
 Success rate of non-operative Mx
 Liver
50-80%
 Spleen
93% for minor injuries
 Renal
Majority can be Mx conservatively
unless there is injury to renal pedicle
or massive damage
 Intervention radiology
 Angiography  embolization
Both diagnostic and therapeutic
 Common use
Pelvic fracture with bleeding
uncontrolled by fixation
Solid organ injury
 Damage control surgery
 10% trauma patients cannot tolerate defin
itive procedure at initial laparotomy
 Survival benefit demonstrated with the us
e of “damage control” approach
Control bleeding
Injured bowel stapled without anastomosis
Solid organ injury packed
Abdomen rapidly closed with towel clips or
plastic bag
 Indications for damage control
 Hypothermia 350C
 Acidosis pH <7.2
 Coagulopathy

Definitive surgery is deferred for 24-

48 hrs when resuscitation in ICU has
corrected these physiological
parameters
Abdominal compartment syndrome
 ACS: A group of adverse progressive
physiological effects of raised intra-
abdominal pressure
 Abdominal trauma is the commonest
cause
 Pressure required to precipitate ACS
is unknown (varies with individuals)
 Most will require decompression at
25-35 cmH2O
 Predisposing factors in trauma
patients
 Massive intra-abdominal bleeding
 Visceral edema (ischaemia-
reperfusion)
 Vigorous fluid resuscitation
 Surgery
 Packing
 Pathophysiology
 Diaphragmatic splinting (Resp)
 Pressure on IVC (Decreases venous
return and thus cardiac output)
 Oliguria (Direct renal compression
+/- reduced systemic blood flow)
 The condition is fatal unless treated
before irreversible physiological
insult occurs
 Major systems affected
 Pulmonary
 Cardiovascular
 Renal
 Treatment of ACS
 Urinary manometry to monitor the intraab
dominal pressure
 Nasogastric decompression
 Abdominal decompression
Control of haemorrhage
Evacuation of gauze packs and blood
Delayed wound closure (temporary plastic
wrap)
 Ventilatory support till definitive closure (o
ptimally in 2-3 days time)
Thank you!
 PhD. Qiu Xinguang
 qxg2000@yahoo.com
 0371-6511 5777
 13803710710