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The European Trauma Course Manual

Edition 4.0
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6.
Abdominal trauma
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QUnderstanding the differences between blunt and penetrating abdominal trauma

QThe principles of assessment and management of abdominal trauma

QRequesting the appropriate investigations in a patient with abdominal trauma

QThe role of surgery and interventional radiology in managing patients with abdominal trauma

Introduction localised blows to the renal angle (e.g. assault) or anterior

The commonest causes of death in trauma patients in
the first 48 hours after injury are traumatic brain injury
and major haemorrhage, the latter often the result
of trauma directly to the abdomen or indirectly at its
boundaries. Furthermore, the outcome from other
unrelated injuries is worsened in the presence of intra-
abdominal haemorrhage, by causing poor perfusion,
hypoxia, coagulopathy and immuno-suppression,
all of which contribute to multi-system organ failure.
Finally, perforation of hollow viscera with peritoneal
contamination results in sepsis which is a further
important contributor to late deaths after abdominal
trauma. Overall, abdominal injury is a contributing
factor in 20% of trauma deaths.
Mechanism of injury
Understanding the mechanism of injury can be useful
in order to predict the potential for abdominal injury
and an estimation of the direction and amount of
energy involved should be sought from the pre-
hospital care team.
The mechanism of injury is an important
marker of abdominal trauma.
Blunt abdominal trauma
In Europe, this is the commonest mechanism of injury
(>90% patients) and usually results from a road traffic
collision (RTC) or fall. The blunt force is typically
distributed over a wide area, with the exception of
abdomen (e.g. from bicycle handlebars). The resulting
abdominal damage is a consequence of deceleration
or compression forces on solid organs, particularly
the spleen, liver and kidneys and hollow viscera such
as bowel or bladder. Compression of an intestinal loop
that has partial proximal and distal obstruction due
to its folding can lead to a sudden rise in intraluminal
pressure and, occasionally perforation. This is called a
‘closed-loop phenomenon’ and typically occurs in the
small intestine. In addition, shear forces may tear the
mesentery in a fall, leading to bowel ischaemia.
Injuries to the chest and pelvis should suggest that a
significant, co-existing abdominal injury is likely, given
that much of the contents of the abdomen are within
either the bony chest or pelvis. Equally wherever there
is evidence of hypovolaemia, or its consequences,
abdominal injuries should be suspected and sought.
In cases of blunt injury to the trunk, the abdomen
must be considered injured until proven otherwise.
The clinical diagnosis of abdominal trauma is notoriously
difficult, as clinical examination of abdomen is unreliable.
Conventional single signs of peritoneal irritation such as
tenderness and guarding often cannot be elicited and
the situation is made more complex when coupled with
minimal external evidence of injury, painful distracting
injuries or a reduced level of consciousness. In contrast,
false positive examinations may result from injuries to
the chest or the pelvis as they can produce abdominal
signs. As a consequence, early imaging has become a
standard of care. The wide availability of sonography
has made its use an extension to the non-specific clinical
examination during the primary survey. Bearing these

CHAPTER 6 ABDOMINAL TRAUMA | 87

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factors in mind, serial examination by the same clinician
may be of value in patients not requiring immediate
surgery or where imaging is delayed. When abdominal
injuries are suspected further investigations (mainly CT)
are usually required.
Penetrating abdominal trauma
Penetrating trauma in Europe is not common. When it
does occur it is important to remember that weapons do
not respect anatomical boundaries and external signs
can be minimal. The pattern of injuries can sometimes
be predicted from the entry site, but organs can be
damaged even though they apparently lie away from
the site of the entry as a result of the ricochet of a bullet
or sharpnel within the body, the posture of the patient
at the time of the attack, the use of a long-bladed
weapon or cavitation due to high energy transfer. A
further problem with the latter is that debris is sucked
into the temporary cavity created as it collapses. As a
result, extensive debridement will be required. For
these reasons the incidence of serious internal damage
increases with the degree of energy transfer.
Relationships of the peritoneal cavity
When considering what underlying structures could
be injured, it is helpful to recall the boundaries of the
abdomen (figure 6.1). The anterior abdominal area is
bordered by the anterior axillary lines laterally, the
nipple line above and the inguinal ligament below. The
posterior abdominal area is bordered by the posterior
axillary lines laterally and a horizontal line at the level
of the inferior scapulae angles above. The flanks are the
areas between the axillary lines. Inferiorly there is the
pelvic floor which is relatively fixed. In contrast the roof
of the abdominal cavity is formed by the diaphragm.
Therefore depending in the level of ventilation this
can lie between the nipple line and the costal margin.
Stab wounds in the anterior areas are more likely to
penetrate the peritoneum but those in the flank can
enter both thoracic and peritoneal cavities.
Figure 6.1 The boundaries of the abdomen. A-A: anterior axillary
line, B-B: internipple line, C-C: inguinal ligament, D-D: pelvic floor,
E-E: posterior axillary line, F-F: inferior scapular line
Assessment and management
Having accepted that clinical examination of the
abdomen in trauma is unreliable, it is not surprising
that it can become very insensitive in the presence of
88 | EUROPEAN TRAUMA COURSE
co-existing problems such as:
Qa reduced level of consciousness;
Qdistracting injuries elsewhere;
Qperitoneal irritation caused by blood or intestinal
contents leads to vagal stimulation that in turn
inhibits the reflex rise in heart rate expected in
hypovolaemia.
Further confounding factors are:
Qsolid organ injuries may present initially in a stable
haemodynamic state and subsequently deteriorate
due to rupture of a subcapsular haematoma;
Qsigns of hollow viscus rupture may take a few hours
to develop.
Up to 20% of initial abdominal examinations are
falsely negative contributing to the toll of undetected
or underestimation of abdominal injury. This rises
in younger patients who compensate well even
after significant blood loss; it is therefore essential
to maintain a high index of suspicion. Finally,
inexperience may lead to failure to consider injuries
to the boundaries of the abdomen which can result in
significant and life-threatening injuries namely:
Qtrans-diaphragmatic injury;
Qretro-peritoneal injury;
Qpelvic injury.
In abdominal trauma, a high index of
suspicion, an understanding of the
mechanism of injury, reassessment and
appropriate imaging are essential for a good
outcome.
The primary survey
Patients with abdominal trauma are assessed and
managed using the same system as described in
chapter 2. The circulation team must consider the
abdomen as a source of haemorrhage and ask the
following questions:
QIs the patient bleeding?
QIs the abdomen the likely site?
QHow can we achieve haemorrhage control?
Is the patient bleeding?
Initial signs may be subtle and it is important to have
a high index of suspicion and remain vigilant. LATE
indicators of circulatory compromise include poor
capillary refill, cold clammy skin, tachycardia, systolic
hypotension, anxiety or reduced level of consciousness
(chapter 5). Therefore once the symptoms and signs of
shock are identified, it is essential that resuscitation is
started and the next question quickly answered with:
Is the abdomen (or its boundaries) the likely
cause?
The abdomen must be considered as a cause of
haemorrhage if the mechanism of injury is appropriate or
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Focused Assessment with Sonography in Trauma (eFAST)

examination of the abdomen reveals the following clues:
Qabdominal bruises (seatbelt or tyre marks);
Qlacerations;
Qscrotal or labial haematoma;
Qflank haematoma;
Qtenderness;
Qguarding.
In addition:
Qshoulder-tip pain can be an indicator of subphrenic
irritation from intraperitoneal blood;
Qconsider the back of the patient; a log-roll should
be performed as soon as possible, particularly
A positive abdominal eFAST in a trauma patient is
characterized by finding a dark, anechoic strip in the
respective areas of the peritoneum, suggesting a
haemoperitoneum (figure 6.2). Unfortunately FAST does
not reliably determine the source of any fluid identified
and may miss visceral damage, especially in solid organs
without rupture of the capsule and retroperitoneal
injuries. Therefore it is useful as a ‘rule in’ rather than a
‘rule-out’ investigation for free intra abdominal fluid.
There are five views that are used in FAST:
Qsubxiphoid transverse view: assess for pericardial

when dealing with penetrating injuries. effusion and left lobe liver injuries
Qlongitudinal view of the right upper quadrant:

A rectal examination may be required to detect rectal assess for right liver injuries, right kidney injury,
or anal blood, displaced pelvic bony fragments, anal and Morison pouch
sphincter tone, perianal sensation and in males, the Qlongitudinal view of the left upper quadrant: assess

position of the prostate. This can be done supine or for splenic injury and left kidney injury
during the log roll. Vaginal examination is indicated in Qtransverse and longitudinal views of the suprapubic

the presence of perineal blood and when the source is region: assess the bladder and pouch of Douglas
unknown. Where there is frank blood loss per vagina,
examination should be deferred until the patient is
in the operating room. If examination of the rectum
and external genitalia does not suggest urethral
injury a catheter should be passed to measure urine
output, decompress bladder and detect haematuria. A
nasogastric tube helps decompress the stomach since
most patients will have some degree of gastroparesis
after trauma.

Good clinical acumen and a high index of suspicion will

point towards the likeliest source of haemorrhage and
investigations planned to assist with the confirmation.
However it is essential that management occurs
simultaneously with investigations.

How can haemorrhage be controlled? Figure 6.2 a Haematoperitoneum: Fluid (blood, hypoechoic) in
It is safest to consider intra-abdominal haemorrhage the lesser pelvis, with the uterus and full bladder, separated by the
as uncontrollable and requiring urgent surgical bladder wall (on the right in image) ‘swimming’ inside.
assessment. Haemodynamically unstable patients
will require immediate surgical intervention and as
a result, the primary survey may not be completed
due to need for surgery. In the meantime controlled
resuscitation should commence using blood
products and tranexamic acid according to the local
major haemorrhage protocol and prevention of
hypothermia. In those in whom there is no immediate
indication for laparotomy, but a high degree of
suspicion, early CT scanning should be carried out. This
can also act as a precursor to interventional radiology.
In more advanced trauma systems it is possible to
simultaneously resuscitate and perform a CT scan with
very early access to haemorrhage control surgery.

Investigations Figure 6.2 b Haematoperitoneum: Fluid (blood, hypoechoic)

In addition to routine blood tests, a number of other between kidney and liver, i.e. in the Morison’s pouch
investigations are available, so local expertise and
protocols must guide their use. The commonly used
ones in Europe are:

CHAPTER 6 ABDOMINAL TRAUMA | 89

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CT scanning
CT allows imaging of both the viscera and musculo-
skeletal structures, making it ideal for most abdominal
trauma. It has superseded many other investigations,
e.g. intravenous urography for renal trauma. However
it is less reliable for injuries to the diaphragm, bowel
or pancreas. Clinical suspicion regarding the need
for surgical intervention remains very important
in considering the CT findings and may overule
a negative CT result. The involvement of a senior
experienced surgeon is important in these situations.
Plain x-rays
A chest x-ray may have been taken in cases of doubt
about the presence or side of a pneumothorax. This
may also reveal lower rib fractures or evidence of
diaphragmatic injury (chapter 4) but subphrenic gas is
unlikely to be visible on a supine film. Plain abdominal
x-rays are rarely required, except to show the position
of a residual foreign body such as a bullet or shrapnel.
Diagnostic peritoneal lavage
Sonography and greater accessibility to early CT has led to
diagnostic peritoneal lavage virtually disappearing from
clinical practice. The only indication for its use is if other
imaging modalities are not available. Like sonography it
is sensitive for haemoperitoneum but has low specificity.
Immediate management
Some hypotensive patients will respond to fluid
resuscitation. However immediate intervention
should be the rule when the shocked patient has a
positive FAST scan or fails to have a sustained response
to appropriate treatment and the mechanism of
injury suggests an intraperitoneal haemorrhage. It is
crucial to understand that resuscitation may include
laparotomy and that correction of hypovolaemia may
not be possible before surgical control of bleeding
is achieved. Nevertheless, in severely compromised
patients, damage control resuscitation (chapter 5)
should be started before surgery commences; opening
the abdominal wall will cause significant hypotension
as the tamponade effect is lost.
Damage control surgery
This is the type of operative intervention commonly
carried out on shocked patients with abdominal
trauma. It consists of three phases:
Phase 1: Abbreviated laparotomy to control
haemorrhage and contamination
The entire focus is to identify and control life-
threatening haemorrhage. Vessels vital for survival
are repaired, expendable organs (e.g. spleen) are
removed, non-expendable organs are packed, gut
perforations are stapled, haemorrhage from other
areas is controlled with packs and haemostatic agents.
Finally, the abdomen is closed with a ‘Bogota Bag’
or left open (laparostomy) to avoid intra-abdominal
90 | EUROPEAN TRAUMA COURSE
compartment syndrome. Where facilities are available,
an endovascular approach by an interventional
radiologist can be used to identify any arterial
bleeding and control it by temporary or permanent
embolization. This can lead to either complete
haemostasis or reduce it sufficiently to allow a limited
surgical intervention.
Phase 2: Resuscitation in the Intensive Care Unit
This aims to optimize tissue oxygenation and
remove the ‘lethal triad’ by correcting any acidosis,
coagulopathy and hypothermia. In appropriate cases
interventional radiology should again be considered
as it can reduce blood loss before any further surgical
intervention.
Phase 3: Second look or definitive surgery
The objective at this stage is to carry out corrective and
restorative surgery in a patient who is normothermic,
not acidotic or coagulopathic and receiving adequate
nutrition. Where the abdomen is open, closure begins
but this may require more than one operation.
Interventional radiology
(angiography and embolisation)
It is increasingly recognized that many intra-abdominal
injuries causing haemorrhage can be managed with
angiography and embolisation, either alone or in
conjunction with surgery.
Advantages:
Qminimally invasive;
Qaccurate localisation of arterial bleed;
Qability to control bleeding by embolisation.
Disadvantages:
Qcompetences may not be present in all centres
receiving trauma;
Qcan take time (1–5 hours depending on complexity);
Qtechnically difficult in cases of obesity, hypotension,
degloving injury, atherosclerotic disease;
Qcomplications reported: haematoma, thrombosis,
subintimal dissection, pseudoaneurysm;
Qradiation dose;
Qadverse reaction to the contrast material.
A summary of the emergency management options
for intra-abdominal injuries is given in table 5.3.
Blood transfusion
The same system should be used as described in
chapter 5.
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Secondary survey Pitfalls

Once the patient is haemodynamically normal and the
primary survey completed, the abdomen must be re-
evaluated as part of secondary survey as described in
chapter 2.
Patients in whom there is a high index of suspicion
of intra-abdominal trauma, but no specific focus
found, should undergo serial physical examination,
repeated blood tests and abdominal sonography.
Diaphragmatic, pancreatic, duodenal and small bowel
trauma may all be missed during the initial assessment
and may require further CT examination or surgical
exploration.
If the secondary survey reveals the signs of
an acute abdomen, urgent surgical referral is
required.
Local wound exploration
A stab wound may be explored in the operating room
to determine whether there is a peritoneal breach.
Penetration of the transversalis fascia or inability to find
the end of the tract constitutes a positive exploration
and the need for further diagnostic evaluation. If all
such patients are subjected to laparotomy, up to half
will not show any significant injury. Laproscopy may
be useful in looking for peritoneal breach and reduce
the need for laparotomy. Wounds in the posterior
abdomen and flank are particularly difficult to explore
due to the thickness of the muscles. Be very cautious
when dealing with penetrating trauma between the
nipple and the costal margins because these could
have entered the thorax, abdomen or both depending
upon the position of the diaphragm at the time of
impact. These require exploration by a surgeon and, if
there is doubt, double contrast CT may help.
The greatest risk is the underestimation of the
severity of abdominal injury and the over-reliance
upon clinical examinations. This is particularly
true when the latter is complicated by a reduced
level of consciousness, distracting injuries or good
physiological compensation. Both blunt and
penetrating diaphragmatic injuries are diagnosed,
as are hollow viscous and retroperitoneal trauma.
Potential pregnancy must be considered on any
presentation of injury in women of child-bearing age.
Summary
Abdominal trauma can vary immensely in
magnitude. The presence of significant injury
may not always be obvious on presentation and
the clinical signs can add to the confusion. The
trauma team must therefore be suspicious of
abdominal trauma in all patients with multiple
injuries and must have a clear understanding
of the mechanism of injury. It is best to assume
that abdominal trauma exists unless proven
otherwise. All the investigations available to
establish a diagnosis have their roles and must be
used liberally according to the index of suspicion.
These cognitive abilities will be integrated with
the practical skills during the course workshops.
Q All ultrasound images courtesy of Dr. Dieter von
Ow, Kantonsspital St. Gallen, Switzerland. First
published in EUROPEAN HOSPITAL Vol. 25, Issue
5/16, www.healthcare-in-europe.com.

Definitive care
Definitive care is provided after complete resuscitation
of the patient. It will be based upon the response to
treatment, the results of all the investigations, the
extent of all the abdominal injuries identified and the
surgical resources available. Most haemodynamically
stable patients with solid organ injury from blunt
and penetrating trauma may be managed without
operation. This is only possible if there is high
quality CT available to accurately assess and stage
the injuries. Once a non-operative approach is
decided upon, observation of vital parameters in a
ward with continuous monitoring and assessment
by an experienced team is mandatory. Frequent
measurement of the haemoglobin and haematocrit
is necessary as well as repeated imaging. Surgical
intervention must be possible at any time.

CHAPTER 6 ABDOMINAL TRAUMA | 91

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6b.
Trauma in pregnancy or as a result of domestic violence
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QUnderstanding the anatomical and physiological changes associated with pregnancy
QHow these changes affect the management of the pregnant trauma patient
QHow to recognise injuries due to domestic violence
Introduction
Trauma in pregnancy is not common, but it is the most
frequent cause of non-obstetric death. It also presents
the resuscitation team with a number of logistical
problems; two patients are involved, both of whom
require resuscitation, the anatomical and physiological
changes induced by pregnancy influence the patterns of
injuries seen and the patient’s response to those injuries
and therapeutic interventions. Domestic violence is
unfortunately remarkably common, under-diagnosed,
and without effective intervention, is often fatal.
Anatomical implications
on the mechanism of injury
For the first 12 weeks of pregnancy, the gravid uterus
is relatively safe within the bony pelvis. During the
second trimester it ascends, but its thick, muscular
walls, the contained amniotic fluid, and the relatively
small size of the fetus, all help to diminish the direct
consequences of trauma. As the third trimester
progresses and the uterus continues to enlarge, its
wall thins, affording progressively less mechanical
protection to the fetus. At the same time, the bowel
and diaphragm are elevated to within the boundaries
of the thorax, making the uterus the most vulnerable
intra-abdominal organ. As the woman approaches
term, descent of the fetal head into the pelvis may
be associated with a slight decrease in fundal height.
However engagement of the fetal head means that
maternal pelvic fractures may be associated with
serious intracranial injury to the fetus, with or without
fetal skull fracture.
CHAPTER 6B TRAUMA IN PREGNANCY OR THE RESULT OF DOMESTIC VIOLENCE | 93
Although the uterus has elastic properties, these are
not shared by the placenta. Thus, shear forces applied
to the utero-placental interface can result in cleavage.
This explains the incidence of placental abruption
(abruptio placentae) in otherwise minor trauma.
This possibility must always be considered in the
management of the pregnant patient.
When faced with a patient with penetrating injuries
the clinician should remember that in late pregnancy,
lower thoracic and upper abdominal injuries may
result in complex combinations of gastrointestinal
involvement. On the other hand, the uterus is quite
effective in protecting the mother, both in terms of
its size (increasing the probability that it will be the
‘target’) and its capacity to absorb energy. Maternal
outcome, therefore, tends to be favourable after
penetrating injury. The fetus, on the other hand, tends
not to fare as well. For example, gunshot wounds
involving the uterus are associated with a 7-10%
maternal mortality, but with a fetal death rate of
around 70%.
Pre-hospital care
This follows the procedures described in chapter 2.
Local triage protocols should ensure that pregnant
trauma victims are transported to centres where
obstetric and, for near-term pregnancies, neonatal
facilities are available. The ability to adequately
monitor the fetus is crucial for decision-making
during clinical management. It is also important that
the pre-hospital team warn the receiving hospital so
that appropriate obstetric personnel can be available
when the patient arrives.
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Primary survey and resuscitation
The same system as described in chapter 2 is used
but requires some adaptations to take account of the
anatomical and physiological changes induced by
pregnancy. However, the priorities remain the same.
The important changes are summarised below.
Airway and cervical spine control
The risk of inhalation of gastric contents is a constant
threat in pregnancy, particularly from the second
trimester onwards. Therefore early consideration should
be given to preventing its occurrence by securing the
airway with a cuffed tracheal tube. However, there is
an increased incidence of difficult and failed intubation
in this group of patients. Due to the reduction in the
volume of the functional residual capacity (the reserve
from which oxygen is drawn during apnoea) and the
increase in oxygen consumption, careful attention must
be paid to ensure adequate pre-oxygenation before the
use of hypnotics and neuromuscular blocking drugs to
facilitate tracheal intubation. This intervention therefore
is best performed by those with appropriate training.
Alternative airway devices must also be available to
allow the safe management of the airway in cases of
difficult or failed intubation. However these devices
do not guarantee protection against aspiration and
should be replaced with a tracheal tube as soon as
skilled assistance is available.
Breathing and ventilation
Maternal hyperventilation is normal as a result of
an increase in tidal volume and results in a PaCO2
value of 4.0-4.5kPa (30-34mmHg). However, the
pregnant patient will desaturate and become hypoxic
significantly more rapidly than an age-matched,
non-pregnant woman. Supplemental oxygen must
therefore be provided to ALL pregnant trauma patients.
Circulation and control of haemorrhage
Maternal cardiovascular adaptation to pregnancy is
extensive, and complicates management of the victim
of trauma. Heart rate increases gradually throughout
pregnancy, reaching a maximum during the third
trimester, at 10-15 beats/min over baseline. Blood
pressure decreases by 5-15mmHg during the second
trimester, with a return to normal values by term. The
blood volume increases by 40-50%, with the increase
in plasma volume exceeding that of red cell mass. This
causes the ‘physiologic anaemia of pregnancy’ and in
late pregnancy a haematocrit of 30-35% is normal.
As trauma patients are cared for supine, aortocaval
compression will occur in any visibly pregnant
woman. This will result in reduced venous return to
the mother compromising her cardiac output and
blood flow to the fetus. It is therefore essential that
manual displacement of the uterus or left lateral tilt of
15 degrees is used to prevent this.
94 | EUROPEAN TRAUMA COURSE
As in any other young trauma patient, the pregnant
female will compensate for blood loss and only develop
signs of hypovolaemia after the loss of a significant
volume. As her blood pressure falls, this will trigger
placental vasoconstriction and a fall in fetal oxygenation.
Furthermore, uterine vessels are exquisitely sensitive to
catecholamines which cause profound vasoconstriction.
For these reasons, hypovolaemia in the mother will gravely
compromise the fetus. The presence of physiological
changes in the mother should alert the trauma team to
the potential for compromise of the fetus.
In Rhesus negative women with obvious uterine
bleeding, an early prophylactic dose of anti-D
immunoglobulin should be given.
In addition to the usual causes of shock, uterine rupture
must also be considered. Symptoms and signs suggestive
of this condition are abdominal tenderness, guarding,
rigidity, an abnormal fetal lie and the easy palpation of
fetal parts. Fetal survival in these cases is rare.
Disability (neurological assessment)
It should be remembered that the trauma may have
been secondary to a seizure as a result of hypertensive
disease of pregnancy and a reduced level of
consciousness after a seizure could be confused with
the presence of a head injury. Dipstick analysis of urine
should be performed as soon as a specimen can be
obtained. The concomitant presence of proteinuria,
hypertension and peripheral oedema usually allow
the diagnosis to be made, but skilled obstetric help
will be indispensable under these circumstances.
Exposure
As with all trauma patients, a full examination must be
carried out taking care to avoid hypothermia. Bleeding
from the urogenital tract may first be seen at this point.
Investigations
The indications and relative advantages of sonography
and CT scanning are the same in the pregnant patient
as in other patients (chapter 2).
Secondary survey
After initial evaluation and resuscitation, the systematic
secondary survey is undertaken using the principles
described in chapter 2. In addition, obstetric consultation
must be obtained as a priority along with assessment of
fetal heart sounds. The latter can be done using Doppler
as early as 10 weeks gestation and cardiotocographic
monitoring can be instituted between 20-24 weeks
gestation. The normal fetal heart rate is 120-160 beats/
min; tachycardia or bradycardia, recurrent decelerations,
lack of accelerations, or the loss of beat-to-beat heart
rate variability are markers of possible fetal distress.
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Careful examination of the patient’s abdomen
is essential. Signs of peritoneal irritation may be
difficult to elicit because of thinning of the abdominal
wall musculature, and stretching of the peritoneal
membrane itself. Areas of tenderness and guarding are
important to note. Fetal movements may be palpated, as
well as the presence or absence of uterine contractions.
The height of the uterus is also useful to corroborate
estimates of gestational age with the gestational age in
weeks being approximately equal to the height (in cm)
above the pubic symphysis (figure 6b.1).
The obstetrician who will care for the patient should
perform a vaginal examination. In addition to
assessment of fetal position, the presence of vaginal
bleeding, amniotic fluid and any dilatation and/or
effacement of the cervix are important elements to
evaluate. Vaginal bleeding is present in up to 70%
of cases of placental abruption. Additional signs are
uterine tenderness, contractions, and uterine irritability
(contractions induced by palpation of the uterus).
There is some controversy as to the optimal duration
of electronic fetal monitoring in the pregnant patient
after trauma. If the initial assessment reveals more
than six contractions per hour, abdominal or uterine
tenderness, ruptured membranes, hypotension
or vaginal bleeding, monitoring must continue
for at least 24 hours. Without any of these signs or
symptoms, and with normal abdominal sonography
and no abnormalities on monitoring, an otherwise
normal patient can be discharged after four hours.
Conversely signs of placental abruption and fetal
distress in a patient with a viable fetus should prompt
immediate operative delivery.
Figure 6b.1 Diagram of fundal height with gestation in weeks
CHAPTER 6B TRAUMA IN PREGNANCY OR THE RESULT OF DOMESTIC VIOLENCE | 95
Feto-maternal haemorrhage
This occurs when there is blood transfer loss from the
fetus to the maternal circulation and occurs in 8-30% of
pregnant trauma cases. This results in the risk of a Rh-
negative mother being sensitised by her Rh-positive
fetus. To avoid this complication, a prophylactic dose
(300 micrograms) of anti-D immunoglobulin should
be given to all pregnant Rh negative women, within
72 hours of the injury. The only possible exception
being those with trauma limited to sites far from the
abdomen.
Peri-mortem caesarean section
Data in trauma are lacking. In the context of ‘medical’
cardiac arrests, it is relatively well documented that if
resuscitation is not effective after 5 minutes, delivery
of the fetus if over 20 weeks, is the only management
that will allow adequate CPR in the mother and
possible restoration of her circulation. A decision to
perform a peri-mortem caesarian section must be
made in close collaboration with the obstetrician.
Domestic violence
The incidence of domestic violence is enormous. A
Swiss survey of 1500 women showed an incidence
of 20%, and a similar study in the UK concluded
that 25% of women were victims of some form of
domestic violence. Other data reveal that up to one
third of women are beaten, coerced into having sexual
intercourse or otherwise abused in their lifetimes.
Diagnosis and management
Given the incidence of this problem, trauma team
members will meet with it in their day-to-day practice.
However the associated shame and guilt means that
under-diagnosis is the rule rather than the exception.
For this reason, a high clinical index of suspicion is
necessary. Presence of the following suggests a non-
accidental origin of the injuries:
Qinjuries inconsistent with the explanation given of
their cause;
Qfrequent attendance at the Emergency
Department;
Qself-blame for the cause of the injuries;
Qdelayed presentation;
Qlow self-esteem, features of depression and self
harm;
Qa partner insisting being present at all times;
Qsubstance abuse;
Qinappropriate concern about the injuries.
Although it is important to identify victims of domestic
violence when they present, this is secondary to their
immediate care. Clearly after the patient’s injuries
have been dealt with, a member of the team should
be tasked with screening for evidence of violence and
ensuring referral to the appropriate local authorities
according to local protocols.
Personal copy of smorteanu@gmail.com [51773]

Summary
The anatomical and physiological changes that
occur in pregnancy are sufficient to require
members of the trauma team to have an
understanding of how to adapt the primary
survey and resuscitation in this group of patients
to maximise the chances for the outcome of both
the mother and child after major trauma. There
should be early involvement of obstetricians in
all pregnant trauma patients and neonatologists
or paediatricians where a viable pregnancy is
involved.

Having worked through this chapter you are now

ready to apply the following knowledge in the
abdominal trauma:
Qthe differences in presentation and
management between blunt and penetrating
abdominal trauma;
Qthe principles of assessment and management

of abdominal trauma;
Qwhat investigations to request in a patient with

abdominal trauma;
Qthe role of surgery and interventional radiology

in managing patients with abdominal trauma;

Qthe anatomical and physiological changes

associated with pregnancy;

Qhow these changes impact on management of

the pregnant trauma patient.

These cognitive abilities will be integrated with

the practical skills during the course workshops.

96 | EUROPEAN TRAUMA COURSE