Advances in Abdominal Trauma

Febiansyah Ibrahim
 Introduction

• Care of trauma patient is demanding and

requires speed and efficiency.

• Evaluating patients who have sustained blunt

abdominal trauma remains one of the most
challenging and resource-intensive aspects of
acute trauma care.
 Introduction

• Lack of historical information, altered mental

status, distracting injuries → challenge in
management
• New approach and diagnosis with modern medical
equipment → lower mobidity and mortality
 Abdominal Trauma

BLAST INJURY
BLUNT INJURY
→ Military
→ Terrorism

PENETRATING INJURY
→ Stab Wound
→ Gunshot wound (GSW)
 BLUNT ABDOMINAL TRAUMA
Commonly injured
organs

Diaphragm BAT
Liver Pancreas
Spleen

Retroperitoneum

Small Bowel 75%

Kidney Kidney
→ motor vehicle collisions
→ Assaults
→ recreational accidents
Bladder → falls
Colorectum
 Abdominal Injury Diagnostic Modalities

• Initial Assessment
• Physical Exam
• Diagnostic Peritoneal Lavage (DPL)
• Computerize Tomography (CT)
• Focused Assessement with Sonography for
Trauma (FAST)
 Initial assessment

• Historical data
– The extent of vehicular damage
– Whether prolonged extrication was required
– Whether the passenger space was intruded
– Whether a passenger died
– Whether the person was ejected from the vehicle
– The role of safety devices such as seat belts and airbags
– The presence of alcohol or drug use
– The presence of a head or spinal cord injury
– Whether psychiatric problems were evident
 Physical examination

• The evaluation of a patient with blunt abdominal

trauma must be accomplished with the entire
patient in mind, with all injuries prioritized
accordingly.
• This implies that injuries involving the head, the
respiratory system, or the cardiovascular system
may take precedence over an abdominal injury.
 Abdominal Examination

Inspected :for abrasions or ecchymosis, seat belt sign,

abdominal, peritoneal irritation, Grey Turner sign or Cullen sign.

Palpation: may reveal local or generalized

tenderness, guarding, rigidity, or rebound tenderness,
which suggests peritoneal injury. Rib fractures involving
the lower chest may be associated with splenic or liver
injuries.
Percussion
Looking for free air & fluid

Auscultation :
bowel sounds in the thorax may indicate the presence of a
diaphragmatic injury.
 Work Up

• NGT
• IV line
• Urine Cateter
• Blood & Urine test
• DPL
• FAST
• Plain ABD Xrays
• CT scan
 Management BAT

• Priorities in resuscitation and diagnosis are

established based on hemodynamic stability and
the degree of injury.

• The goal of the primary survey, as directed by the

ATLS protocol, is to identify and expediently treat
life-threatening injuries.
 Diagnostic peritoneal Lavage

• Patients with a spinal cord injury

• Those with multiple injuries and unexplained shock
• Obtunded patients with a possible abdominal injury
• Intoxicated patients in whom abdominal injury is
suggested
• Patients with potential intra-abdominal injury who
will undergo prolonged anesthesia for another
procedure
 Focused Assessment with Sonography for
Trauma

FAST Exam
- Ultrasound examination of 4 areas to determine whether
or not there is fluid present

4 acoustic windows:
▪ Peri cardiac,
▪ Peri hepatic,
▪ Peri splenic,
▪ Pelvic
• Example of
positive
FAST Exam
 FAST >< DPL

• With the availability of FAST, noninvasive, and

better imaging modalities (FAST ex, CT scan), the
role of DPL is now limited to the evaluation of
unstable trauma patients in whom FAST results are
negative or inconclusive.
 Indications for Laparotomy in a BAT

• Signs of peritonitis
• Uncontrolled shock or hemorrhage
• Clinical deterioration during observation
• Hemoperitoneum findings after FAST or DPL
examinations
 Surgeon Strategy on BAT

• Hemodynamic Status

• On Demand Laparotomy.
 Hemodynamic Stable BAT

• CT Scan and Ultrasound Advances

• If FAST (+) → CT
• If FAST (-) with negative Physical examination
followed by 12-24 hours observation → exclude
intra abdominal injuries
• Serial abdominal US
Tampak laserasi
hepar pada segmen
7-8
 Penetrating Abdominal Trauma

Before • Penetrating trauma was managed

World War I expectantly

During • Early laparotomy improved

World War II survival

By the late • laparotomy was the standard

1950s treatment
 Penetrating Abdominal Trauma

• Shaftan suggested the selective

In 1960 management

• Expectant management has also

been used in the treatment of
More recently specific gunshot wounds (GSWs)
to the abdomen.
 Penetrating Abdominal Injury

• A BC
• Wound must be Confirmed Penetrated the
ABDOMINAL Cavity (Cross the peritoneal layer)
• NGT
• IV line
• Mandatory Abdominal exploration :
Laparoscopic/Laparotomy.
 Surgery Procedure

• Stop Bleeding
• Stop Contamination
• GI reconstruction

• Triad Of Death :
Hypothermia, Metabolic acidosis, DIC
DAMAGED CONTROLE
TN. B, 20 THN, 4428862
TN. B, 20 THN, 4428862
 Conclusions

• Initial treatment improve the outcome

of abdominal trauma cases
• Hemodynamic stability indicated the
Exploration

• Save surgery are better than excellent

surgery
Thank You