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ABDOMINAL INJURY

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INTRODUCTION
Detection of abdominal trauma
maybe difficult due to other coexisting injury.
It is vital to maintain high index of
suspicion of abdominal injury in
trauma patients.
To detect the existence of significant
intra-abdominal injury which needs
operative intervention.

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Anatomy
Internal

Peritoneal cavity

Retroperitoneal space

Pelvis

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Mechanism of Injury
Blunt trauma
Spleen, liver, and hollow viscus
Caused by compression, crushing,
shearing, decelaration (fixed organs)
Symptoms and signs: Skins
abrasion/brusising, seat belt imprints,
fracture of lower ribs, abdominal
tenderness/rigidity, distension, shock,
absent of bowel sounds, hematuria

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Mechanism of Injury
Penetrating trauma
Liver, small bowel, and colon
Caused by stab wounds and gunshot
wounds

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Assessment: History
Blunt

Speed
Time
Point of impact
Intrusion
Safety devices
Position
Ejection

Penetrating

Weapon
Distance

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Physical examination

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General examination : related to

haemodynamic instability
Abdominal findings:
Inspection for abd distention, contusion or
abrasion (lap belt ecchymosis), cullen sign and
grey turner sign (retroperitoneal haemorrhage.
Palpation : tenderness , rebound, rigidity,
guarding (haemoperitoneum)
Percussion: dullness/ shifting dullness
(intrabdominal collection)
Auscultation : all 4 quadrant.

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Classification of Hemorrhage

Class I IV
Not absolute
Only a clinical guide
Subsequent treatment
determined by patient
response

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Class I Hemorrhage

<750 mL BVL/ <15%

Respirations
14-20/min

Slightly
anxious

Urine
30 mL/hr
Crystalloids

Heart rate
<100/min

BP

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Class II Hemorrhage

750-1500 mL BVL/ 15-30%

Respirations
20-30/min

Mildly
anxious

Urine
20-30 mL/hr
Crystalloids, ? Blood

Heart rate
>100/min
Pulse
Pressure

BP

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Class III Hemorrhage

1500-2000 mL BVL/ 30-40%

Respirations
30-40/min

Confused,
anxious

Urine
5-15 mL/hr
Crystalloids, Blood

Heart rate
>120/min
Pulse
Pressure

BP

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Class IV Hemorrhage

2000 mL BVL/ >40%

Respirations
>35/min

Confused,
lethargic

Urine
negligible
Rapid fluids, Blood,
Operation

Heart rate
>140/min

BP

Pulse
Pressure

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MANAGEMENT

Initial Assessment
Primary survey
and
resuscitation of
vital functions
are done
simultaneously

a team
approach

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Primary Survey
A
B
C
D
E

Airway with c-spine protection

Breathing
Circulation
Disability / Neurologic status
Exposure / Environment

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Assessment and Management

Airway and Breathing

Oxygenate and ventilate

PaO2 >80 mmHg (10.6 kPa)
Circulation
Assess
Control
Treat

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Management: Vascular Access

2 large-caliber,
peripheral IVs
Central access
Femoral
Subclavian

Intraosseous
Obtain blood for
crossmatch

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Management: Fluid Therapy

Warmed crystalloid solution

Rapid fluid bolus
Adult:
2 liters Ringers
lactate
Child:
20 mL/kg
Ringers lactate

Monitor response to
initial therapy

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Reevaluate Organ Perfusion

Monitor
Vital signs
CNS status
Skin
perfusion
Urinary
output
Pulse
oximetry

Resuscitation

Protect and secure airway

Ventilate and oxygenate
Stop the bleeding !
Vigorous shock therapy
Protect from hypothermia

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BLOOD INVESTIGATION

GXM
FBC
COAGULATION
RENAL PROFILE
ABG

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IMAGING

Chest X RAY
Lateral cervical spine- X RAY
Pelvic- X RAY
ULTRASOUND (FAST SCAN)
CT SCAN

FAST (Focused Assessment With

Sonar For Trauma) SCAN
Good for identification of free fluid
Rapid and cost effective
Can be performed with equal
accuracy by surgeon
Does not evaluate retroperitoneal
injury

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Abdominal CT Scan
Blunt trauma
Haemodynamic instability
Normal and unreliable physical
examination
Retroperitoneal organ damage

Diagnostic Peritoneal
Lavage(DPL)

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Unstable patient
Placing a catheter into the
peritoneum
- immediate aspiration of frank blood
is positive
- if no frank blood, run 1 litre fluid
and the siphoned out positive
indicated by >100000 RBCs/ul, bile or
fecal matter

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EMERGENCY LAPAROTOMY
Haemodynamic instability
Involuntary guarding sign of
peritonitis
Abdominal distention
Evisceration of organs
Penetrating injury
Positive ix (DPL, CT)

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Indications for laparotomy

Blunt

+ DPL or
ultrasound, CT
scan
BP, suspected
visceral injury
Peritonitis

Penetrating

+ DPL or
ultrasound, CT
scan
Peritoneal /
retroperitoneal
injury
Evisceration

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Non operative approached

Base on ct scan diagnosis : mainly in
solid organ injury like liver, spleen
and kidney
Haemodinamically stable
Monitoring in ICU/HDS:
Reserved GXM
FBC
Vital sign
Clinical features

Diagnostic laparoscopy
Improved diagnostic accuracy compared
to:
FAST: poor specificity
DPL: poor specificity, invasive not informative
for retroperitoneal injury
CT: difficult to identified hollow viscus injury

Reduction of nontherapeutic laparotomy

rates
Reduction of long and short term morbidity
Not available in emergency

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Nasogastric intubation
Decompress stomach
Reduce risk of aspiration
Caution: base skull fracture,
maxillary fracture, need for
orogastric intubation.

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Bladder catheterisation
Decompress bladder
Output monitoring
Caution: urethral injury

Pelvic Fractures
Significant force
applied
Associated
injuries
Pelvic bleeding
Ends of bones
Pelvic muscles
Veins / arteries

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Pelvic Fractures
Mechanism

Classification

AP compression

Open

Lateral compression

Closed

Vertical shear

Pelvic Fractures
Assessment
Inspection
Palpate prostate
Pelvic ring
Leg-length discrepancy, external
rotation
Pain on palpation of bony pelvic
ring
AP x-ray

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Pelvic Fractures:
Management

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Resuscitate
Transfer as needed with PASG
Determine if intraperitoneal hemorrhage
Operation
Control hemorrhage

Fixation device

Possible angiography

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Genitourinary tract injuries

Associated with blunt
deceleration/penetrating abdominal
wounds that enter the
retroperitoneum or pelvis.
Haematuria+/-

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Genitourinary tract injuries

Clinical features:
contusion at back/ flank
Perineal haematomas and ant pelvic
fracture
Blood at the meatus/ inability to void

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Abdominal vascular injury

Mainly from penetrating injury
Arising within retroperitoneum or
mesentry
Warrant immediate laparotomy
Clinical features: lower limb
ischaemia, haematuria (renal
vascular injury)

Pancreatic injury
Isolated uncommon
Usually associated with duodenum,
liver , small bowel injury

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Summary
High index of suspicion to avoid missing
abdominal injury in trauma
The initial clinical evaluation may be
notoriously inconclusive or misleading due
to multiple injuries.
Various diagnostic modalities are available
to aid decision-making but these should
not replace meticulous clinical examination
and should not delay treatment.

Summary
Repeat clinical assessment is
essential for those selected for
conservative management.
The primary concern in trauma care
is not in the accurate diagnosis of a
specific type of injury but rather the
determination that an intraabdominal injury exists and surgical
intervention is necessary.

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