Abdominal

Trauma
PPP MOHD SHAHRIL BIN OTHMAN
POST BASIC ED KPPS
HPSF

Abdominal Trauma
Introduction
The most critical component of initial
assessment in injured patient
Should be done during the primary
survey (part of assessment of
circulation).
Unrecognized abdominal injuries
continue to be a cause of preventable
deaths after truncal trauma.

Abdominal Trauma
Challenges in ED:
1.Identification and assessment
-Missed or delayed diagnoses
2.Diagnostic modalities
-timely use of diagnostic procedures
tremendously alter morbidity and
mortality
3.Transportation of critically ill
intrabdominal trauma

Abdominal Trauma
classification
1) Blunt Abdominal Trauma
-Supreme challenge to the emergency
personnels clinical acumen.
-Historical data may be incomplete, absent, or
presumptive.
-The symptoms and signs can be unreliable
and obfuscated by head injury, alcohol, or
other toxins.
2) Penetrating Abdominal Trauma

Abdominal Trauma
Assessment

Clues to abdominal trauma:

Mechanism of injury
-High energy impact
Shock out of proportion to external injury
Associated chest & pelvis trauma
Persistent tachycardia
Blood in the urine, rectum, vagina, or nasogastric tube all suggest
hollow viscus injury and intraperitoneal penetration.

Abdominal Trauma
Blunt Abdominal Trauma

Pathophysiology
1) Sudden and pronounced rises in intraabdominal pressures
created by outward forces can cause rupture or burst injury of a
hollow organ.
-Lap-belt restraints injury.
1) Compression of abdominal viscera between the applied force
to the anterior wall and the posterior thoracic cage or vertebral
column produces a crushing effect.
-Solid visceral are especially vulnerable to this injury,

2) Sharp shearing forces affecting both hollow and solid viscera

-cause organs and vascular pedicles to tear, especially at
relatively fixed points of attachment.

Abdominal Trauma
Critical pathway in Emergency Department
History
-High index of suspicion
Proper Triage
Primary survey
Secondary survey
Diagnostic evaluation
Therapeutic and definitive care
Referral and tranportation of critically ill intrabdominal
injury patient

Penetrating Abdominal Trauma

Special scenarios.

PAL

AAL

6th ICS

1. Stab wound to flank

Problems:
Retroperitoneal colon
injury
Renal / ureteric injury

Inguinal lig

Stab wound to flankcont

Investigation of potential colon injury:

There is no good radiological investigation for this injury.

Serial physical examination is the most important.

Consider CT scan with rectal contrast.
Investigation of renal injury:
Absence of haematuria does not exclude an injury to the urinary
tract.

In the presence of haematuria proceed to CT scan with

intravenous contrast.

Penetrating Abdominal Trauma

Special scenarios.

2. Stab at Costal Margin

If shocked - use FAST
to exclude
haemopericardium
Haemothorax/pneum
othorax and free fluid
in abdomen implies a
diaphragmatic injury.
.

Costal
Margin

Penetrating Abdominal Trauma

Special scenarios.

3. Tangential Gunshot Wounds

-In general, most gunshot wounds will require laparotomy.
However, if:
Haemodynamically normal
No clinical signs
Possible tangential gunshot wound track
Consider CT scan exclude/confirm peritoneal
penetration.

Abdominal Trauma
Blunt abdominal trauma in pregnancy
Injuries
Retroperitoneal hemorrhage
Abruptio placenta
DIC
Uterine Rupture
Seatbelts 3 Points Restraints
1/3 improperly or dont use
belts
Unbelted is at 2.3X to give
birth <48 hrs & 4.1X fetal death

Abdominal Trauma
Penetrating abdominal trauma in pregnancy

GSWs
Gravid uterus alter injury
pattern to the mother.
If missile enter upper
abdomen; increased
probability of harm (upto
100%).
If enters below uterine fundus
visceral injury less likely (0%)

Abdominal Trauma

Immediate Laparotomy if:

Blunt abdominal trauma with recurrent
hypotension despite adequate resuscitation
Early or subsequent peritonitis
(clinical examination)
Evisceration
Bleeding from stomach,rectum,GU tract from
penetrating trauma
Hypotension with penetrating abdominal trauma

Abdominal Trauma
Diagnostic strategies

Diagnostic peritoneal lavage

ATLS standards list the indications as those situations in which:

abdominal examination is equivocal (fractures of the

lumbar spine, rib fractures),
unreliable (head injury, substance abuse), or
impractical (planned prolonged surgical procedure for
head injury).
Absolute contraindication is an existing indication for laparotomy.
Relative contraindications include morbid obesity, advanced
cirrhosis, coagulopathy, and possibly advanced pregnancy.

Diagnostic peritoneal lavage

Positive DPL if:

Gross blood on initial aspiration
>100,000 RBC's/mm3 on
lavage fluid
>500 WBC's/mm3 on lavage
fluid aspiration contain food or
vegetable fibers.

Diagnostic peritoneal lavage

Weaknesses:
Significant retroperitoneal injuries may be undetected with
DPL.
DPL leaves fluid in the abdomen, making subsequent CT or
ultrasound less reliable.
Clinical physical examination may be unreliable after DPL.
Injuries sometimes occur during DPL and may mandate
laparotomy in patients who would otherwise not require
surgery.

Abdominal Trauma
Diagnostic strategies

The FAST examination

rapid,
bedside,
ultrasound examination performed to
identify intra-peritoneal haemorrhage or
pericardial tamponade.
FAST examines four areas for free fluid:
1)
2)
3)
4)

Perihepatic & hepato-renal space

Perisplenic
Pelvis
Pericardium

The FAST examination

Studies,
FAST has a sensitivity
between 73% and 88%,
a specificity between
98% and 100% and is
96% to 98% accurate.

Abdominal Trauma
Diagnostic strategies

CT scan with
contrast
-Provides excellent
imaging of solid
organs (liver, spleen,
kidneys) and
retroperitoneum.

Summary
Always start with primary survey
ABCDE

Volume resuscitate aggressively

IV Crystalloid, blood if needed

Unstable patients dont go to CT

Summary
Recognize common injury patterns
Solid organ injuries high risk blood loss
Seatbelt injuries Chance Fracture and bowel
perforation
Bowel and pancreas injuries

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):S42130.
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
MTLS.

TQ