ABDOMINAL TRAUMA

DR.R.SRIVATHSAN
PG-II
OUTLINE
Anatomic definition of abdomen
Mechanism of injury
Typical injury patterns
Assessment of abdominal trauma
Diagnostic algorithms

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Abdominal trauma
Common site of injury for both blunt and penetrating
injuries
29% of polytrauma patient requires abdominal
exploration
Rapid, life-threatening bleeding can be hidden in the
abdomen
Unrecognized abdominal injuries in the multi-system
trauma patient

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Abdomen – anatomic boundaries
External:

Anterior abdomen: transnipple line superiorly, inguinal

ligaments and symphasis pubis inferiorly, anterior
axillary lines laterally.
Flank: between 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.

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Internal:

Upper peritoneal cavity: covered by lower aspect of bony

thorax. Includes diaphragm, liver, spleen, stomach,
transverse colon.
Lower peritoneal cavity: small bowel, ascending and
descending colon, sigmoid colon, and (in women)
internal reproductive organs.
Pelvic cavity: contains rectum, bladder, iliac vessels, and
(in women) internal reproductive organs.
Retroperitoneal space: posterior to peritoneal lining of
abdomen. Abdominal aorta, IVC, most of duodenum,
pancreas kidneys, ureters, and posterior aspects of
ascending and descending colon.

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Intraperitoneal and retroperitoneal cavities

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Mechanisms and
Pathology
Blunt vs Penetrating

Often both occur simultaneously

Blunt injury is the most common mechanism

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Direct impact

Acceleration-deceleration:
differential movements of fixed and nonfixed
structures (e.g. liver and spleen lacerations at sites of
supporting ligaments)

Compression, crush, or sheer injury

abdominal viscera  deformation of solid or hollow
organs, rupture (e.g. small bowel, bladder,gravid
uterus)

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Key points
No correlation between size of contact area and
resultant injuries
Abdomen = Pandora’s box
A potential site of major blood loss with little evident
signs/symptoms.

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Assessment: History
Mechanism
Symptoms, Medications, drugs
MVC:
Speed
Type of collision (frontal, lateral, sideswipe, rear,
rollover)
Vehicle intrusion into passenger compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle

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Assessment: Physical Exam
Inspection, auscultation, percussion, palpation
Inspection: abrasions, contusions, lacerations, deformity

Percussion: subtle signs of peritonitis; tympany in

gastric dilatation or free air; dullness with
hemoperitoneum

Palpation: superficial, deep, or rebound tenderness;

involuntary muscle guarding

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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:
 Left shoulder pain while supine; caused by diaphragmatic irritation
(splenic injury, free air, intra-abd bleeding)
Ballance sign:
 Dull percussion in LUQ. Sign of splenic injury; blood accumulating
in subcapsular or extracapsular spleen.

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Diagnostic modalities
Labs:
 Complete Blood profile
 Coagulation profile
 Serum Amylase/Lipase
 Urine analysis
 Toxicology screen

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Radiological profile
Plain films:
- Chest XRay,
- Pelvic XRay
- Abdomen XRay

FAST
CT

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DPL - Procedure
Foleys & RT

2cm incision midway between umblicus and pubic bone under LA

dialysis catheter is passed through the opening in the peritoneal cavity and advanced towards the hollow of the pelvis.

Normal Saline is now connected to the dialysis catheter.

The wound is closed with a stitch

fluid inside the abdomen is now swished around by gentle agitation of the abdomen so that it is distributed all over the peritoneal cavity
allowed to stay for up to 10 minutes

siphoned off by bringing the fluid bag or bottle down to the

floor.

the returning fluid is clear then no gross internal injury to the

abdomen and no major hemorrhage
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DPL
Standard criteria
10cc gross blood
RBC > 100,000/mm2
WBC > 500/mm2
Amylase > 175 IU/dL
Bile, bacteria, fiber or food.

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Indications:
 Equivocal physical examination
 Unexplained shock or hypotension   
 Altered sensorium (closed head injury, drugs, etc.)   
 General anesthesia for extra-abdominal procedures   
 Cord injury

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Contraindications :
Clear indication for exploratory laparotomy   
Relative contraindications:   
- Previous exploratory laparotomy   
- Pregnancy   
- Obesity

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DPL
Highly sensitive to intraperitoneal blood, but
low specificity  nontherapeutic explorations.
Supraumbilical if pelvic fracture present
Significant injuries may be missed
Diaphragm
Retroperitoneal hematomas
Renal, pancreatic, duodenal
Minor intestinal
Extraperitoneal bladder injuries

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Focused Assessment with Sonography for
Trauma (FAST)

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 FAST: Strengths and
Strengths

Limitations
Limitations
Does not typically identify
Rapid (~2 mins)
Portable
Inexpensive
Technically simple, easy to
train (studies show
competence can be
achieved after ~30 studies)
Can be performed serially
Useful for guiding triage
decisions in trauma
patients

source of bleeding, or detect
injuries that do not cause
hemoperitoneum
 Requires extensive training to
assess parenchyma reliably
 Limited in detecting <250 cc
intraperitoneal fluid
 Particularly poor at detecting
bowel and mesentery damage
(44% sensitivity)
 Difficult to assess
retroperitoneum
 Limited by habitus in obese
patients
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 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

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 CT Scan
Hemodynamically stable patient

The patient should be in a transportable condition

Triple contrast CT is the preferred mode

IV + ORAL + RECTAL

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 Indications and Contraindications for
Abdominal Computed Tomography
Indications
 
Blunt trauma   
Hemodynamic stability  
Normal or unreliable physical examination
Mechanism: Duodenal and pancreatic trauma

Contraindications
Clear indication for exploratory laparotomy
Hemodynamic instability
Agitation
Allergy to contrast media
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Advantages
Adequate assessment of the retroperitoneum
Nonoperative management of solid organ injuries
Assessment of renal perfusion
Noninvasive
High specificity

Disadvantages
Specialized personnel
Hardware
Duration: Helical versus conventional
Hollow viscus injuries
Cost

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 CT FAST DPL
Accuracy 96% 95-99% 95%
Sensitivity 97% 90-92% 100%
Specificity 95% 88-90% 85%
Drawback Stable pts Cannot evaluate
only retroperitoneum. Cannot
identify source of fluid.
0.5% miss
intestinal
perforation;
cannot distinguish
blood vs bowel
contents

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 Laparoscopy
Role still being defined
Good for diaphragm injury evaluation
Cons
Invasive
Expensive
Missed small bowel, splenic, retroperitoneal injuries

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 ROLE OF DIAGNOSTIC LAPAROSCOPY

Hemodynamically stable patients

Inadequate/equivocal FAST or borderline DPL
(80 * 103 - 120 * 103 RBC/HPF)
Intermittent mild hypotension or persistent
tachycardia
Persistent abdominal signs/symptoms
Potential to decrease incidence of
nontherapeutic laparotomies

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 Diagnosis
Test of choice dependent on hemodynamic stability
and severity of associated injuries.
Stable blunt trauma  FAST or CT
Unstable blunt trauma  FAST or DPL
Stab wounds without peritoneal signs, evisceration, or
hypotension  wound exploration or DPL.
Gun shot wounds  surgical exploration.

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EAST Algorithm: Unstable

Eastern Association for the Surgery of Trauma, 2001

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EAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

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LIVER INJURY

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 Initial hemostasis
Rapid mobilisation of injured lobe with bimanual
compression
Perihepatic packing
Pringle maneuver
Failure of pringle maneuver – major hepatic venous
involvement

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In the event of continued bleeding a vascular clamp can be placed
around porta hepatis- hepatoduodenal lig.
Pringle Maneuver
If bleeding continues…
A. It is coming from the portal vein or hepatic artery
OR
B. It is coming from the retrohepatic vena cava or
hepatic veins
Schrock shunt: atrial-caval shunt can be life saving.
Total hepatic isolation: vascular clamps at
hepatoduodenal ligament, descending aorta at infra
diaphragmatic region and suprahepatic suprarenal
vena cava.
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 Definitive hemostasis
Surface ooze: cautery;argon beam laser; parenchymal
sutures; topical hemostatics
Deeper wounds: hepatotomy – finger fracture tech

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Packing
Used when other techniques
fail in controlling hemorrhage
Use in patients that are
hypothermic, acidotic,
coagulopathic
ICU for rewarming
Re-explore 48-72 hours
Intra-abd abscesses <15%
Arteriography/embolization
useful adjunct

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 Splenic injury
Most frequently injured intra-abdominal organ in
blunt trauma.
Suspected in all c/o LUQ injury; L lower ribs fracture
Splenic preservation when possible
 OPSI (0.6% in children, 0.3% in adults)
More than 70% can be treated non-operatively

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Criteria for conservative mng
Hemodynamic stability
Negative abdominal exam
Absence of extravasation of contrast on CT
Absence of bleeding diasthesis
Absence of other indications of laprotomy
Grade I - III

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Monitoring in the ICU setup
NG tube
Strict bed rest
Serial abdominal examinations
Serial hematocrit

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Extravasation / Blush on CECT:
Stable: angiography and selective embolisation
Unstable: surgery
SURGERY : splenectomy / splenic salvage surgery
Deep lacerations: horizontal absorbable mattress
sutures
Major laceration < 50% parenchyma : segmental/partial
splenic resection
Extensive injury of hilum/ central portion of spleen :
spleenectomy + autotransplantation

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Predictive factors for nonop success:

Localized trauma to flank/abdomen

Age<60
No associated trauma
Transfusion <4 units
Grade I-III

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Transarterial embolisation

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 Pancreatic Injury
Rare 10-12% of abdominal injuries, but mortality
10-25%, mostly from associated intra-abd injury
Most caused by penetrating trauma - 75%
associated with major vascular injury
Blunt trauma  compression of pancreas against
vertebral column
Retroperitoneal location delays diagnosis.
Elevated amylase/lipase (serum and urine)
Role of CT improving
Pancreatic duct injury key factor in morbidity.
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Pancreatic Injury

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GSW to Pancreatic Head

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PANCREAS INJURY SCALE
GRADE[*] TYPE OF INJURY DESCRIPTION OF INJURY
I Hematoma Minor contusion without duct injury

  Laceration Superficial laceration without duct

injury

II Hematoma Major contusion without duct injury

or tissue loss

  Laceration Major laceration without duct injury

or tissue loss

III Laceration Distal transection or parenchymal

injury with duct injury

IV Laceration Proximal transection or parenchymal

injury involving the ampulla[†]

V Laceration Massive disruption of the pancreatic

head

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 Pancreatic Injury
Divided into proximal or distal according to
location on the R or L of SMV
Contusions (Grade I-II) should be drained.
Distal duct injury (Grade III)  distal resection
with splenic preservation
Proximal injury (Grade IV)
Oversewing and distal resection or
pancreaticojejunostomy
Extensive pancreatic head injuries (Grade V)
40% pancreatic fistula development
Simple external wide drainage
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Complications after Pancreatic Trauma
High complication rate 35-40%
Most common are pancreatic fistulas &
abscesses
Most fistulas close spontaneously if well drained
Somatostatin / Octreotide to expedite healing
Abscesses - surgical debridement & drainage
Incidence of pancreatitis 8-18%
Pseudocysts are infrequent

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 Gastric Injury
Mostly penetrating trauma.
<1% from blunt trauma
Including iatrogenic injury from CPR/ ET in esophagus
NGT + aspirate for blood
Intraop evaluation includes good visualisation of
EG junction; ant gastric wall; opening of
gastrocolic ligament and complete visualization of
posterior wall
Most penetrating wounds treated by debridement
and primary closure in layers.
Evacuation of hematomas.
Major tissue loss may necessitate gastric resection.64
Gastric Injury
Post-op complications
Bleeding, abscesses,
gastric fistula with
peritonitis,empyema
Recent meal 
neutralization of gastric
acidity  increased
lower GI tract bacteria
(Bacteroides, E. coli,
Strep faecalis) 
increased infection

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 Duodenal Injury
Incidence: 3 – 5%
Majority due to penetrating trauma.
Blunt injury usually secondary to steering wheel blow
to the epigastrium (difficult to diagnose)
Retroperitoneal location is protective, but also
prevents early diagnosis.
Isolated injury to the duodenum is rare
Hyperamylasemia in 50% with blunt injury.

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GRADE[*] TYPE OF INJURY DESCRIPTION OF INJURY
I Hematoma Involving a single portion of the
duodenum
  Laceration Partial thickness, no perforation
II Hematoma Involving more than one portion
  Laceration Disruption <50% of the
circumference
III Laceration Disruption 50%-75% of the
circumference of D2
    Disruption 50%-100% of the
circumference of D1, D3, D4
IV Laceration Disruption >75% of the
circumference of D2 and involving
the ampulla or distal common bile
duct
V Laceration Massive disruption of the
duodenopancreatic complex
  Vascular Devascularization of the
duodenum

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Plain films of the abdomen
 mild scoliosis
 obliteration of the right psoas shadow
 absence of air in the duodenal bulb
 air in the retroperitoneum outlining the kidney

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Duodenal Injury
Gastrograffin UGI or
CT with contrast
Extravasation of
contrast  OT
If CT eqivocal –dilute
barium UGI
May see retro-
peritoneal air on CT
DPL unreliable but
may be positive from
an associated injury
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 Duodenal Hematoma
The radiographic finding
of a duodenal hematoma
(coiled spring or stacked
coin sign) is not an
indication for surgical
exploration
NGT until peristalsis
resumes.
Slow introduction of food.
OR if obstruction persists
> 10 –15 days.

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Stacked coin sign

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 Duodenal Injury
Appropriate repair depends on
injury severity and elapsed time
80-85% can be primarily
repaired.
Duodenal decompression
advisable if injury >6 hours old
(transpyloric nasogastric tube,
tube jejunostomy, or tube
duodenostomy)

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Grade III injuries (major disruption of the duodenal
circumference ) : primary repair, pyloric exclusion, and
drainage or by Roux-en-Y duodenojejunostomy.
Grade IV injuries (involving the ampulla or distal
common bile duct) : primary repair of the duodenum,
repair of the common bile duct and placement of a T-
tube with a long transpapillary limb or a
choledochoenteric anastomosis
If repair of the CBD is impossible, ligation and a
second intervention for a biliary enterostomy
Pancreaticoduodenectomy - grade V injuries
(massive disruption of the duodenum and pancreatic
head or massive devascularization of the duodenum)
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 Duodenal injury severity
MILD SEVERE
AGENT Stab Blunt/missile
SIZE < 75% wall >75% wall involvement
LOCATION D3,D4 D1,D2
INJURY TO REPAIR < 24 hrs >24 hrs
INTERVAL
ADJACENT INJURY CBD - CBD +
OUTCOME
MORTALITY 6% 16%
DUODENAL 0% 6%
MORTALITY
DUODENAL 6% 14%
MORBIDITY

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 COMPLICATIONS
Duodenal fistulas (5 – 15%) – conservative mng
Abscess (10 – 20%) – percutaneous / open drainage

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 Small Intestine Injury
Most common organ
injured after penetrating
trauma

 
Blunt trauma(5 – 20%)
 Crushing injury against
vertebral bodies                                                          
 Shearing at fixed points
 Closed loop rupture
Seat-belt sign should
raise suspicion.
DPL/CT not reliable

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Small Intestine Injury

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 Small Intestine Injury
13% perforated small
bowel have a normal CT
scan
Suggestive findings
include free air, free
fluid without solid
organ injury,
thickening of small
bowel wall or
mesentery

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Operative management
 Bleeding initially
controlled/leakage clamped
 Penetrating injuries by
firearms should be
debrided.
 Small tears closed primarily.
 Adjacent holes connected
and closed transversely.
 Extensive lacerations and
devascularization require
resection and
reanasatomosis.
 Explore all mesenteric
hematomas
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 Colon Injury
Second most frequent injured organ, usually from
penetrating trauma
Repair within 2 hours dramatically reduces
infectious complications.
Pre-operative antibiotics important adjunct.
PE blood per rectum, stab to flanks or back
CT with rectal contrast, XR- pneumoperitoneum
WWI primary repair led to 60% mortality.
WWII colostomy led to 35% mortality.

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 Colon Injury
Primary repair criteria
Early diagnosis (within 4-6 hours)
Absence of prolonged shock/hypotension
Absence of gross contamination
Absence of associated colonic vascular injury
Less than 6 units blood transfusion
No requirement for use of mesh for closure
Extensive wounds
Right colon  hemicolectomy +/- ileostomy
Left colon  resection + colostomy

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 Rectal Injury
Most from GSW
Other causes - foreign body, impalement, pelvic
fractures, and iatrogenic
Lower abdomen/buttock penetrating injury
should raise suspicion.
May be intra- or extraperitoneal
Rectal exam may reveal blood or laceration
Work-up includes anoscopy and rigid
sigmoidoscopy.

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 Rectal Injury
Extraperitoneal injury
Primary closure
Diverting colostomy
Washout of rectal stump
Wide presacral drainage
Intraperitoneal injury
Primary closure
Diverting colostomy

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Complications
Sepsis
Pelvic abscess
Urinary/rectal fistulas
Rectal incontinence / stricture
Loss of sexual function
Urinary incontinence

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 Renal trauma
Classified as major and minor injuries (85%)
MC injured part of urinary tract

American association for surgery of trauma classification:

GRADE I: contusion or contained subcapsular hematoma, without parenchymal

laceration.
GRADE II: non expanding, confined perirenal hematoma or cortical laceration less
than 1 cm deep, without urinary extravasation.
GRADE III: parenchymal laceration extending less than 1 cm into the cortex
without urinary extravasation.
GRADE IV: parenchymal laceration extending through the corticomedullary
junction and into the collecting system. There can be also thrombosis of a
segmental renal artery without a parenchymal laceration.
GRADE V: three situations are possible:
- thrombosis of the main renal artery;
- multiple major lacerations;
- avulsion of the main renal artery and/or vein. 85
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Renal contusion is the most common type and is
managed conservatively.
Major renal trauma includes deep cortical medullary
lacerations, large perinephric hematomas and pedicle
injury.
All perinephric hematomas by penetrating injuries
must be explored

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Surgical techniques

Nephrectomy - Shattered kidney, multiple concurrent

injuries,uncontrolled hemorrhage and hilum injury.

Partial nephrectomy - Avulsed fragments, polar

penetrating mechanism, and collecting system repair

Adjuncts - Absorbable mesh wrap, topical thrombostatic

agents, and omentum

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Complications of renal injuries :
- secondary hemorrhage, usually due to infection (10 to 14
days after trauma)
-paralytic ileus (4 to 5 days) d/t retroperitoneal hematoma
-hypertension as a result of the constricting effect of
reorganizing perirenal hematoma
-arterio-venous fistula;
-renal failure;
-renal atrophy;
-hydronephrosis;
-chronic pyelonephritis;
-renal calculi;
-renal artery stenosis.

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 Bladder injury
The majority of bladder injuries occur as a result of blunt
trauma, and the association of bladder rupture and pelvic
fractures is extremely high(75%)
Hematuria is the most frequent sign
Bladder rupture may be extraperitoneal or intraperitoneal.
Extraperitoneal rupture usually results from perforation by
adjacent bony fragments.
Intraperitoneal rupture of the bladder results from injuries
located in the dome- full bladder sustains a direct blow.
The diagnosis is made by cystography - a postvoid film is
necessary to identify lateral or posterior injuries.

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Intraperitoneal injuries are repaired primarily by
three-layer closure +/- Suprapubic cystostomy
Extraperitoneal rupture of the bladder: primarily
nonoperative –Foley’s catheter for 10 to 14 days
Severe pelvic fractures and massive
retroperitoneal bleeding : initially managed
nonoperatively. delayed repair of the
extraperitoneal rupture is performed

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Complications of bladder rupture
Hemorrhage
Urinoma
Abscess formation
Sepsis.

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Retroperitoneal hematoma
Zone 1
Explore regardless of
mechanism.
Zone 2
Explore penetrating
trauma.
Observe blunt trauma
(nonexpanding,
nonpulsatile, no
urologic indications)
Zone 3
Explore penetrating.
Observe blunt.
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 Damage Control
Abbreviated laparotomy and temporary packing
Effort to blunt physiologic response to shock and
hemorrhage
Severe metabolic acidosis, coagulopathy, and
hypothermia
ICU resuscitation
Return to OR in 48-72 hours

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Damage Control Surgery

Phase I
 Rapid termination of operative procedure
 Arrest of bleeding
 Removal of contamination

Phase II
Correction of physiologic abnormalities
Acidosis, hypothermia, coagulopathy
Phase III
Definitive surgery

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Abdominal compartment syndrome
End organ dysfunction secondary to intraabdominal
hypertension
Tense abdomen,
Elevated peak airway pressure
Inadequate ventilation
Inadequate oxygenation
Oliguria
Reversed with decompression
Bladder pressure >16mmHg
Full blown syndrome >35 mmHg
Worse with fascial closure
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THANK YOU

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