ABDOMINAL TRAUMA

INTRODUCTION

In initial assessment, when the patient is unstable, we should start treatment of shock and diagnose
significant abdominal injury that requires lapatotomy without specific organ diagnosis. Stable patients
need specific diagnosis of the injured abdominal organ by full evaluation and investigations.

1. Evaluation of abdominal injuries is challenging.

2. Any patient with blunt trauma, deceleration injury and penetrating injuries between the nipple lines and
perineum should be evaluated for abdominal injury.
3. In hemodynemically unstable patient abdominal injuries should be ruled out.
4. Causes include: solid organs, hollow viscera or vascular injuries.
5. Evaluation may be compromised by intoxication by alcohol or drugs, injury to brain or spinal cord.
6. Evaluation may be compromised by injury to adjacent structures as ribs spine or pelvis
7. Significant amount of blood may be present in abdomen without obvious signs of peritonitis.
8. Retroperitoneal organs do not show signs of peritonitis.

EXTERNAL ANATOMY

A. Anterior abdomen: Trans-nipple line superiorly to inguinal ligaments and symphysis pubis
inferiorly and anterior axillary line laterally.
B. Flank: From 6th intercostal spaces superiorly to iliac crest inferiorly. Between anterior and
posterior axillary lines laterally.
C. Back: tip of scapula superiorly to iliac crest inferiorly posterior to posterior axillary lines.

The flank and back have thick musculature that resists penetrating injuries.

INTERNAL ANATOMY

A. PERITONEAL CAVITY
1. Upper peritoneal cavity ( thoraco-abdominal ): covered by the lower part of thoracic cavity: It
contains the diaphragm, liver and spleen, stomach, and transverse colon.
2. Lower peritoneal cavity: small intestines, ascending and descending and sigmoid colon, and female
internal reproductive organs.

B. PELVIC CAVITY: surrounded by pelvic bones.

C. RETROPERITONEAL SPACE: Contains the abdominal aorta, inferior vena cava, kidneys and
ureters, duodenum and panceas. Injuries are difficult to assess due to absent peritoneal signs and
injuries are not detected by DPL.

WHY TO KNOW ABDOMINAL ANATOMY:

1. Structures in the peritoneal cavity( stomach, small bowels, sigmoid colon, spleen and liver), injury to
these organs can be detected by signs of petitonitis, can be detected by DPL and FAST, and by free intra-
abdominal air usually under diaphragm.
2. Structures in the retro-peritoneal cavity( duodenum, ascending and descending colon, kidneys, ureters,
aorta, inferior vena cava) injuries in these structures will not show signs of peritonitis, and can not be
detected by FASTor DPL, but by contrast CT scans or other specific tests.

1
3. In penetrating injuries 3 areas (Lower chest or thoracoabdominal area, anterior abdominal area and
flank and back area) have different diagnostic approaches.

MECHANISM OF INJURY

A. Blunt trauma. Direct blow such as steering wheel or a door intruding into the passenger compartment or
falls from a height cause compression or crushing injury to abdominal solid or hollow organs leading to
hemorrhage or leakage of hollow viscera contents leading to peritonitis. Deceleration injury: Differential
movement of fixed and non-fixed parts of the body would lead to injury to: liver, spleen, heart, kidneys,
aortic arch.
 Most commonly affected organs: Spleen, liver, small bowel, retroperitoneal structures
B. Penetrating injuries:

1. Stab wounds and low velocity gunshot injuries cause lacerations in their tract.
Stab wounds affect adjacent abdominal structures.
 Most commonly affect: Liver, small bowels, diaphragm and colon and abdominal vascular
structures.
2. High velocity gunshot (high kinetic energy): they have the following effects;
A. Direct laceration in their trajectory tract.
B. By the effect of temporary cavitation causing damage lateral to their tract.
C. They may tumble or fragment causing further injuries.
D. Also they have possibility of ricochet off boney structures causing secondary missiles.

 Gun shot injuries affect mostly the small bowel, colon, liver and abdominal vascular
structures.

ASSESSMENT

 In hypotensive patients the aim is to determine if abdominal injury is the cause of the
hypotension.
 In stable patients without signs of peritonitis, detailed assessment is needed to determine the
specific abdominal injury.

A. History
1. RTA: speed, type of collision, vehicle intrusion into passenger compartment, types of
restrains, air bags, runover, ejection.
2. Penetrating injuries: type of weapon, distance.
3. Prehospital condition and management given.

B. Examination
1. Inspection, auscultation, percussion and palpation.
2. Look for signs of peritonitis.
3. Assess pelvic stability.
4. Penile, perineal and rectal and vaginal examination.
5. Evaluation of penetrating wounds:

Penetrating injuries
a. Any patient with penetrating injury (stab or gunshot) who is hemodynemically unstable with signs
of peritonitis or distended abdomen need laparotomy.
b. Most gunshot injuries (90%) have significant intraperitoneal injuries, so most cases need
laparotomy.
2
 c. About 30% of stab wounds DO NOT penetrate the petitoneum, so selective management is needed,
we assess by: local wound exploration, serial physical examinations and DPL.

C. Intubation:

a. Gastric tube: The aim of it is therapeutic (Relieve acute gastric dilatation, decompress the stomach
before DPL, and remove gastric contents to decrease aspiration), the other aim is diagnostic as blood
from stomach may indicate upper gastrointestinal injury.
b. Urinary catheter: The aims are: Relieves retention, decompress the bladder before DPL, and for
monitoring of urinary output as an indication for tissue perfusion.

D. Blood and urine samples:

**Blood type and cross-matching, electrolytes, amylase, CBC, toxicity samples and Pregnancy test
**Urine routine, drug levels, pregnancy tests.

E. X-ray studies.:
All trauma patients should have cervical spine, chest, and pelvic x-rays in the initial assessment.
Other diagnostic studies are performed in stable patients for specific diagnosis.
Abdominal x-rays, urethrography, cystography, CT scans, gastrointestinal studies and angiography.

Diagnostic studies in blunt trauma.

Blunt abdominal injury with hypotension and clinical evidence of intra-abdominal bleeding should
undergo laparotomy.

1. Diagnostic peritoneal lavage: Rapid, Invasive, Sensitive but not specific for intra-abdominal bleeding.
Not good for retroperitoneal injuries. Can be performed in the primary survey.
2. FAST (Focused Assessment Sonography in Trauma): Rapid, Bed side, Non-invasive, Accurate (as
DPL and CT scan) in detection of intra-abdominal blood. Not specific, not good for retroperitoneal
injuries. Can be performed in the primary survey.
3. CT scans: It is time consuming so it should be performed only in stable patients. It needs contrast to
visualize internal organs. It diagnoses specific injuries and their extent. Can diagnose retropetoneal and
pelvic injuries that CAN NOT be detected by physical examination, DPL or FAST.

Diagnostic studies in penetrating trauma.

1. Penetrating trauma+ hemodynemically unstable patient = Laparotomy.

2. Gunshot wound in anterior abdomen = laparotomy.
3. Stab wounds with hypotension, peritonitis, evisceration of omentum or small bowel or free air
under diaphragm. These need emergency laparotomy.

Stab wounds in stable patients: 3 states are evaluated as follows:

1. Lower chest wounds: diaphragm, upper abdominal structures.

a. Serial physical examination
b. Serial chest x-rays
c. Thoracoscopy
d. Laparoscopy
e. CT scan for right thoracoabdominal injuries to diagnose liver injury.
f. Note that we can not do local wound exploration as in anterior abdominal stab wounds
3
 2. Anterior abdominal stab wounds:
a. Local wound exploration.
b. serial physical examination
c. DPL
d. Laparoscopy.

3. Flank or back penetrating injuries. The thick muscles protect the internal organs. Injuries usually
are retroperitoneal. In stable patients the following studies are helpful in diagnosis:
a. Serial physical examination.
b. Double or triple contrast CT scans.

INDICATIONS FOR LAPAROTOMY IN ADULTS

A. Blunt abdominal injury with hypotension and clinical evidence of intra-abdominal bleeding.
B. Blunt abdominal injury with positive DPL or FAST.
C. Penetrating abdominal trauma with hypotension.
D. Gunshot wounds traversing peritoneal or retroperitoneal cavities.
E. Penetrating trauma with evisceration.
F. Penetrating trauma with bleeding from stomach, rectum or genitor-urinary tract.
G. Peritonitis
H. Free peritoneal or retroperitoneal air. or rupture of diaphragm
I. Contrast CT scan: ruptured gastrointestinal tract, bladder injury, renal pedicle injury.