Abdominal trauma

Types of Injury
Blunt Abdominal Injury Penetrating Injuries
- It occurs with motor vehicle collisions. Gunshot Wounds Stab Wounds
- Mechanism of injury : - Mechanism of injury : • If intraperitoneal violation
violat is suspected , require :
1- Compressive mechanism : 1- Directly : 1- Resuscitation
Shearing or Stretching
tretching forces exceed the tolerance limits of the tissue or organ, - when the bullet itself strikes an organ . 2- Tetanus booster
the tissues are disrupted. 2- Secondarily : 3- Antibiotics
2- Crushing mechanism by energy transmission directly to patient. - When
hen tissues are injured by missiles such as bone or - Traditional teaching :
bullet fragments or by energy transmission from bullet. If the peritoneum has been violated, traditional teaching
- The presence of a seat-belt sign is indicative of intra
intra-abdominal
abdominal injury in at least 25%
of cases. - Traditional teaching : has mandated exploratory laparotomy.
- Evaluation of the lumbar spine is recommended as
as: mandated d that all gunshot wounds with intra-abdominal - ome surgeons observe a carefully selected patients with
Some
these injuries may be associated with transverse lumbar spine fractures trajectory required exploratory laparotomy. : no obvious signs of intraperitoneal injury on :
- Management of low-velocity
velocity gunshot : * physical examination or
Some authors have described a less aggressive approach to a * by imaging modalities such as CT scanning.
carefully selected subset of patients with penetrating trauma to
the abdomen including some low low-velocity gunshot wounds. • if intraperitoneal violation
violation has been ruled out :
- Patients
atients may be safely discharged with local wound
• Patients presenting with hypotension despite crystalloid
care instructions.
resuscitation will need :
1- Immediate
mmediate exploratory laparotomy,
2- Antibiotics
ntibiotics to cover abdominal flora
3- Tetanus
etanus booster.
• For hemodynamically stable patients, once intraperitoneal
invasion has been ruled out :
- conservative management of wounds that are
superficial & tangential to the abdomen
• Seek surgical consultation in all cases of abdominal gunshot wounds.
Patients with abdominal trauma should have : 1- Rapid
apid assessment 2- Stabiliza4on 3- Early
arly surgical consultation to maximize the chances of a successful outcome.
1- Immediate Management of Life-Threatening
Life Injuries 2- Treatment
Rapid primary survey : The same as for all other trauma patients Begin the assessment with ABCE. 1- Fluid Resuscitation
The concept of acute fluid resuscitation has evolved and may
Airway
represent an area of some controversy.
- Administer high-flow
flow oxygen, and intubate the patient if necessary. Maintain cervical spine immobilization until potential injury is ruled out.
Breathing • Rapid infusion of large amounts of crystalloids may :
- Auscultate for breath sounds. Inspect for asymmetry of chest wall movement, open wounds, or flail segments. disrupt
isrupt the formation of the soft clot and dilute the clotting factors,
- Palpate the chest wall carefully
ly as palpable crepitus may indicate a pneumothorax or rib fractures. leading to increased bleeding.
- Pulse oximetry and capnography may be useful. Rapidly perform needle decompression or tube thoracostomy if tension pneumothor
pneumothorax is The Goal of resuscitation :
suspected. - Attempts to make patient normotensive are not recommended.
Circulation - A more reasonable goal may be to obtain :
- Stop gross external hemorrhage with direct pressure. Assess pulses, capillary refill, and blood pressure. Systolic
ystolic blood pressure of 80 - 90 mm Hg or
- Obtain intravenous access with at least two large
large-bore (>=16-gauge)
gauge) catheters. If peripheral intravenous access is inadequate, place a Meaean arterial pressure of 70 mm Hg
central venous catheter. • Crystalloids remain first-line
first fluids,
- Fluid resuscitation is an area of controversy. • followed by infusions of packed red blood cells.
The "FAST" examination is important at this stage of the evaluation, especially in hemodynamically unstable patients. • Other blood products may be indicated on an individual basis.
Disability
- Complete a brief, focused neurologic examination to docum
documentent the patient's baseline.
2- Indications for Emergency Laparotomy
- The examination should include an assessment of pupillary size and reactivity, a determination of the patient's Glasgow Coma Scale score, 1- Once
nce the fascia has been violated High igh incidence of intra-
intra
and notation of any focal neurologic deficits such as unilateral weakness or poor muscle
muscl tone. abdominal injury.
injury
2- Hemodynamically unstable patients sustaining blunt or penetrating
Exposure
trauma with a positive screening test (such as: - focused
- Completely undress the patient although be careful to prevent or recognize and correct associated hypothermia.
assessment with sonography for trauma [FAST] examination - or diagnostic
peritoneal lavage [DPL] )
Secondary survey : require laparotomy to control hemorrhage & evaluate for intra- intra
- Examining
xamining all skin folds, the back, and axillae for occult penetrating injuries.
injuries abdominal injuries.
3- Initially stable blunt trauma patients with identified abdominal
• Any penetrating injury below the level of the nipple line warrants evaluation for intra-abdominal
intra abdominal injury.
injuries should be observed so if they become hemodynamically
• In patients
ts in motor vehicle collisions: unstable rapidly operative intervention.
- Look
ook for ecchymosis or erythema in the area of the clavicles or across the abdomen. 4- Diaphragmatic
iaphragmatic injury noted on chest X-ray
X require emergency laparotomy
- The classic "seat-belt
belt sign" : marker for intra-abdominal
abdominal injury.
3- Surgical Consultation
• Examine the abdomen for any tenderness, distention, rigidity, or guarding. Seek surgical consultation early in management of patients with abdominal
• Evaluate the pelvis for anteroposterior or lateral instability with gentle pressure trauma, especially if patient is hemodynamically unstable.
• Examine the genitalia for blood at the urethral meatus
meatus,, especially in males.
• Examination of rectum for : gross blood, assess sphincter tone and note any other evidence of trauma.
SOLID VISCERAL INJURIES
• Injury to the solid organs cause morbidity & mortality primarily as a result
• If blood at the urethral meatus or a high
high-riding prostate is present: of acute blood loss.
loss
etrograde urethrogram is required to evaluate for potential
- Retrograde ial urethral injury. • The spleen is the most frequently injured organ in blunt trauma
- Placement
lacement of a urinary catheter is contraindicated - Kehr’s sign, representing referred left shoulder pain, is a classic
finding in splenic rupture.
Diagnostic testing - Lower left rib fractures clinical suspicion for splenic injury.
Laboratory Evaluation • The liver is also commonly injured in both blunt & penetrating injuries.
3- Hemoglobin and Hematocrit
ematocrit and Platelet count . • Tachycardia, hypotension, and acute abdominal tenderness are the
4- Blood-type in case transfusion of packed red cells is needed. primary findings on physical examination.
examination
5- Lactate level & Base deficit if elevated, is an excellent indicator of shock. • It is important to note that patients with solid organ injury may present to
6- Examination of the urine : may reveal gross hematuria, suggests significant injury to the urogenital tract . ED with minimal symptoms & nonspecific findings on physical examination.
Plain Radiography HOLLOW VISCUS INJURIES
1- Plain X-ray : • These injuries produce symptoms by the combination of:
of
7- Allll major trauma patients require plain X
X-rays of : the chest, pelvis, and cervical spine. 1- Blood
lood loss :
8- It's helpful in penetrating trauma as in evaluating a retained intra-abdominal
abdominal missile. - Perforation of the stomach, small bowel, or colon is accompanied
by blood loss from a concomitant mesenteric injury.
2- Intravenous pyelogram: may useful in patients with flank wounds or gross hematuria who unable to undergo further diagnostic testing prior to operative intervention.
2- Peritoneal
eritoneal contamination :
Diagnostic Peritoneal Lavage
- GIT contamination will produce peritoneal signs over period of time.
9- It's sensitive for intra-abdominal
abdominal blood
blood. - Patients with head injury, distracting injuries, or intoxication may
10- The use of DPL in conjunction with CT scanning or laparoscopy,, particularly in low-velocity
low velocity penetrating trauma (i.e., stab wounds), tend not exhibit peritoneal signs initially.
to decrease the number of nontherapeutic laparotomies. RETROPERITONEAL INJURIES
CT Scanning • Signs and symptoms of retroperitoneal injuries may be subtle or absent
In the hemodynamically stable patient, CT scanning is an excellent diagnostic modality
mo to detect intraperitoneal AND retroperitoneal injuries. upon initial presentation to the ED.
1- Duodenal injuries :
Ultrasonography - Most
ost often associated with high-speed
high speed vertical or horizontal
The
he primary initial diagnostic examination of the abdomen in multisystem injured blunt trauma patients. decelerating trauma.
11- Emergency ultrasonography is rapid & accurate in the identification of intraperitoneal free fluid. - Clinical signs of duodenal injury are often slow to develop.
12- FAST examination is a bedside test that has demonstrated good accuracy with relatively minimal operator experie
experience (at least 30 - may from an intramural hematoma to an extensive laceration.
- Duodenal ruptures are usually contained within retroperitoneum.
retro
examinations).
They may present with abdominal pain,pain, fever, nausea, and vomiting.
- The standard FAST examination consists of an initial subx
subxiphoid
iphoid view of the pericardium followed by examination of the right 2- Pancreatic injury :
upper quadrant looking for the Morison pouch (hepatorenal space). - It' most common with penetrating trauma
The Morison pouch is one of the most dependent parts of the abdomen
abdomen in the supine trauma patient and often shows the - The classic case is a blow to the mid epigastrium.
first signs of intraperitoneal fluid collection (blood). DIAPHRAGMATIC INJURIES (most often diagnosed on the left)
- Subsequently the splenorenal interface in the left upper quadrant is evaluated followed by the pelvis. • The presentation of diaphragmatic injuries is often insidious.
• Only occasionally is the diagnosis obvious, when bowel sounds can be
auscultated in the thoracic cavity.
• On chest radiograph:
- With
ith herniation
hern of abdominal contents into the thoracic cavity, the
diagnosis
iagnosis is confirmed.
- In most
ost cases,
ca there is no herniation, and only finding
nding rad
radiograph is :
blurring
lurring of the diaphragm or an effusion.