Abdominal Trauma

Cheryl Pirozzi, MD
Fellows Conference 5/4/11

Abdominal Trauma
Penetrating Abdominal Trauma
Stabbing 3x more common than firearm wounds
GSW cause 90% of the deaths
Most commonly injured organs: small intestine > colon >
liver

Blunt Abdominal Trauma

Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple
organs/systems)
Most commonly injured organs: spleen > liver, intestine is
the most likely hollow viscus.
Most common causes: MVA (50 - 75% of cases) > blows to
abdomen (15%) > falls (6 - 9%)
Rosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injury
Penetrating Abdominal
Trauma
Stab Wounds
Knives, ice picks, pens,
coat hangers, broken
bottles
Liver, small bowel, spleen

Gunshot wounds
small bowel, colon and
liver
Often multiple organ
injuries, bowel
perforations

Rosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Rosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injury
Blunt Abdominal Trauma
Rupture or burst injury of a hollow organ by
sudden rises in intra-abdominal pressures
Crushing effect
Acceleration and deceleration forces shear
injury
Seat belt injuries
seat belt sign = highly correlated with
intraperitoneal injury

Rosens Emergency Medicine, 7th ed. 2009

Physical Exam
Generally unreliable due to distracting injury, AMS,
spinal cord injury
Look for signs of intraperitoneal injury
abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
entrance and exit wounds to determine path of injury.
Distention - pneumoperitoneum, gastric dilation, or ileus
Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
Abdominal contusions eg lap belts
bowel sounds suggests intraperitoneal injuries
DRE: blood or subcutaneous emphysema

Rosens Emergency Medicine, 7th ed. 2009

Diagnostic studies
Lab tests: not very helpful
May have Hct, WBC, lactate, LFTs,
lipase, tox screen

Rosens Emergency Medicine, 7th ed. 2009

Imaging
Plain films:
fractures nearby visceral damage
free intraperitoneal air
Foreign bodies and missiles

Rosens Emergency Medicine, 7th ed. 2009

Imaging
CT
Accurate for solid visceral lesions and intraperitoneal
hemorrhage
guide nonoperative management of solid organ
damage
IV not oral contrast
Disadvantages : insensitive for injury of the
pancreas, diaphragm, small bowel, and mesentery

Rosens Emergency Medicine, 7th ed. 2009

Imaging
Angiography
To embolize bleeding vessels or solid visceral
hemorrhage from blunt trauma in an unstable
pt
Rarely for diagnosing intraperitoneal and
retroperitoneal hemorrhage after penetrating
abdominal trauma

Rosens Emergency Medicine, 7th ed. 2009

FAST
Focused assessment with sonography for trauma
(FAST)
To diagnose free intraperitoneal blood after blunt trauma
4 areas:
Perihepatic & hepato-renal space (Morrisons pouch)
Perisplenic
Pelvis (Pouch of Douglas/rectovesical pouch)
Pericardium (subxiphoid)
sensitivity 60 to 95% for detecting 100mL - 500mL of fluid

Extended FAST (E-FAST):

Add thoracic windows to look for pneumothorax.
Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

Rosens Emergency Medicine, 7th ed. 2009

Trauma.org

FAST

Morrisons pouch (hepato-renal space)

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

FAST
Perisplenic view

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

FAST

Retrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)

Rosens Emergency Medicine, 7th ed. 2009

trauma.org

FAST
Advantages:
Portable, fast (<5 min),
No radiation or contrast
Less expensive

Disadvantages
Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
Limited by obesity, substantial bowel gas, and subcut air.
Cant distinguish blood from ascites.
high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture

Rosens Emergency Medicine, 7th ed. 2009

Diagnostic Peritoneal Lavage

Largely replaced by FAST and CT
In blunt trauma, used to triage pt who is
HD unstable and has multiple injuries with
an equivocal FAST examination
In stab wounds, for immediate dx of
hemoperitoneum, determination of
intraperitoneal organ injury, and detection
of isolated diaphragm injury
In GSW, not used much
Rosens Emergency Medicine, 7th ed. 2009

Diagnostic Peritoneal Lavage

1. attempt to aspirate free peritoneal blood
>10 mL positive for intraperitoneal injury

2. insert lavage catheter by seldinger,

semiopen, or open
3. lavage peritoneal cavity with saline
Positive test:
In blunt trauma, or stab wound to anterior,
flank, or back: RBC count > 100,000/mm3
In lower chest stab wounds or GSW: RBC count
> 5,000-10,000/mm3
Rosens Emergency Medicine, 7th ed. 2009

Local Wound Exploration

To determine the depth of penetration in
stab wounds
If peritoneum is violated, must do more
diagnostics

Prep, extend wound, carefully examine (No

blind probing)
Indicated for anterior abdominal stab
wounds, less clear for other areas

Rosens Emergency Medicine, 7th ed. 2009

Laparoscopy
Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
esp for diaphragm injury: Sens 87.5%, specificity
100%

Can repair organs via the laparoscope

diaphragm, solid viscera, stomach, small bowel.

Disadvantages:
poor sensitivity for hollow visceral injury,
retroperitoneum
Complications from trocar misplacement.
If diaphragm injury, PTX during insufflation

Rosens Emergency Medicine, 7th ed. 2009

Management
General trauma principles:
airway management, 2 large bore IVs, cover
penetrating wounds and eviscerations with
sterile dressings

Prophylactic antibiotics: decrease risk of

intra-abdominal sepsis due to intestinal
perf/spillage
(eg zosyn 3.375 g IV)

In general, leave foreign bodies in and

remove in the OR
Rosens Emergency Medicine, 7th ed. 2009

Management of penetrating
abdominal trauma

forsurenot.com

Management of penetrating
abdominal trauma
Mandatory laparotomy
vs
Selective nonoperative management

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating
abdominal trauma
Mandatory laparotomy
standard of care for abdominal stab wounds
until 1960s, for GSWs until recently
Now thought unnecessary in 70% of abdominal
stab wounds
Increased complication rates, length of stay,
costs
Immediate laparotomy indicated for shock,
evisceration, and peritonitis

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating
abdominal trauma
Selective management used to reduce
unnecessary laparotomies
Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
Strategy depends on abdominal region:
Thoracoabdomen
Nipple line to costal margin

Anterior abdomen
Xiphoid to pubis

Flank and back

Posterior to anterior axillary line
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating
abdominal trauma
Thoracoabdomen
Big concern is diaphragmatic injury
7% of thoracoabdominal wounds

Diagnostic evaluation:

CXR (hemothorax or pneumothorax)

Diagnostic peritoneal lavage
FAST
Thoracoscopy

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Thoracoabdomen

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating
abdominal trauma
Anterior abdomen
Only 50-70% of anterior stab wounds enter the
abdomen
of these, only 50-70% cause injury requiring
OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of PAT
Anterior abdomen

Rosens Emergency Medicine 7th ed

Management of penetrating
abdominal trauma
Back/Flank
Risk of retroperitoneal
injury
Intraperitoneal organ
injury 15-40%
Difficulty evaluating
retroperitoneal organs
with exam and FAST
In stable pts, CT scan
is reliable for excluding
significant injury:

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating
abdominal trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal
penetration have injury requiring operative
management
Most centers proceed to lap if peritoneal
entry is suspected
Expectant management rarely done

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosens Emergency Medicine 2009

Management of PAT
Gunshot wounds
assess peritoneal
entry by missile
path, LWE, CT,
US, laparoscopy
(all limited)

Rosens Emergency Medicine, 7th ed. 2009

Management of Blunt abdominal

trauma

ashwinearl.blogspot.com

Management of Blunt abdominal

trauma
Exam less reliable
Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring
surgical repair
FAST, CT, DPL
In HD stable pts, CT is preferred

Rosens Emergency Medicine, 7th ed. 2009

Management of Blunt abdominal

trauma
Clinical Indications for Laparotomy after
MANIFESTATION
PITFALL
Blunt
Trauma
Unstable vital signs with strongly
Alternative sources, shock
indicated abdominal injury
Unequivocal peritoneal irritation Unreliable

Pneumoperitoneum

Insensitive; may be due to

cardiopulmonary source or
invasive procedures (diagnostic
peritoneal lavage, laparoscopy)

Evidence of diaphragmatic injury Nonspecific

Significant gastrointestinal
bleeding

Uncommon, unknown accuracy

Rosens Emergency Medicine, 7th ed. 2009

Damage Control
Patients with major exsanguinating injuries
may not survive complex procedures
Control hemorrhage and contamination
with abbreviated laparotomy followed by
resuscitation prior to definitive repair

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control
0. initial resuscitation
1. Control of hemorrhage and contamination
Control injured vasculature, bleeding solid organs
Abdominal packing

2. back to the ICU for resuscitation

Correction of hypothermia, acidosis, coagulopathy

3. Definitive repair of injuries

4. Definitive closure of the abdomen

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control
Resuscitation in the ICU
IVF (crystalloid, not colloid)
Transfusion
?1:1:1 PRBC/plt/FFP

Recombinant activated factor VII

Increased thromboembolic complications

Rewarming if hypothermic
Correction of metabolic abnormalities
Low tidal volume ventilation recommended (4-6
ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control
Open abdominal wounds and definitive
closure
40-70% cant have primary closure after definitive
repair.
Temporary closure methods

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Abdominal Compartment
Syndrome
Common problem with abdominal trauma
Definition: elevated intraabdominal
pressure (IAP) of 20 mm Hg, with single or
multiple organ system failure
APP below 50 mm Hg

Primary ACS: associated with injury/disease

in abdomen
Secondary (medical) ACS: due to
problems outside the abdomen (eg sepsis,
capillary leak)
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment
Syndrome

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:2329

Abdominal Compartment
Syndrome
Effects of elevated
IAP
Renal dysfunction
Decreased cardiac
output
Increased airway
pressures and
decreased compliance
Visceral
hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment
Syndrome
Management
Surgical abdominal decompression
Nonsurgical: paracentesis, NGT, sedation
Staged approach to abdominal repair
Temporary abdominal closure

Bailey J. Crit Care 2000, 4:2329

Sugrue M. Curr Opin Crit Care 2005; 11:333-338

Conclusions
Watch out for implements and missiles violating the
abdomen
Laparotomy is mandatory if shock, evisceration, or
peritonitis
Diagnostic studies used to determine need for laparotomy
in PAT and BAT
FAST is noninvasive, quick and accurate way to evaluate
for intraperitoneal blood
Damage Control is a principle of staged operative
management with control and resuscitation prior to
definitive repair
Abdominal compartment syndrome is a common problem
in abdominal trauma

References
Biffl WL, Moore EE. Management guidelines for
penetrating abdominal trauma. Curr Opin Crit Care
2010;16:609-617
Waibel BH, Rotondo MF. Damage control in trauma
and abdominal sepsis. Crit Care Med. 2010 Sep;38(9
Suppl):S421-30.
Marx: Rosens Emergency Medicine, 7th ed. 2009
Mosby
Sugrue M. Abdominal compartment syndrome. Curr
Opin Crit Care 2005; 11:333-338
Bailey J, Shapiro M. Abdominal compartment
syndrome. Crit Care 2000, 4:2329