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Abdominal and Pelvic Trauma

TLS Hospital Miri 2017


Challenging component of the initial assessment of

injured pt
The assessment of circulation during the primary survey
includes early evaluation of the possibility of occult
haemorrhage in the abdomen and pelvis in any pt who
has sustained blunt trauma
Unrecognized abd injury continues to be a cause of
preventable death after truncal trauma.
External anatomy of the Abdomen
External anatomy of the Abdomen
Internal Anatomy of the Abdomen

Internally divided into three regions:

Peritoneal space
Retroperitoneal space
Abdominal Organs
and Vital Vessels
Mechanism of Injury

Why is the mechanism of

injury important?

predicting injury patterns
Blunt Trauma
Direct blow
Contact with lower rim of the
steering wheel
Door intruding into the passenger
Shearing injuries
Restraint device e.g lap-type seat
belt or shoulder harness
component is worn improperly
Deceleration injuries

Air-bag deployment does not

preclude abd injury
Penetrating Trauma

Stab wounds & low

velocity gunshot wounds
cause tissue damage by
lacerating and cutting
High velocity gunshot
wounds transfer more
kinetic energy to
abdominal viscera
Explosive devices cause
injuries through several
mechanisms including

Physical Examination
Adjuncts to Physical Examination
Evaluation of Blunt Trauma
Evaluation of Penetrating Trauma
History - MVA

Type of collision
Vehicle intrusion into the passenger compartment
Types of restraint sued
Deployment of air bags
Patients position in the vehicle
Status of other passengers
Prehospital treatment and vital signs
History Penetrating trauma

Time of injury
Distance from assailant
No of stab or gunshot wounds
Amount of external bleeding at the scene
History Explosive device

Likelihood of visceral high P injuries increased if the

esplosion occurred in an enclosed spaced with
decreasing distance of the pt from the explosion.
Physical Examination

Followed by

Assessment of pelvic stability

Rectal exam
Vaginal Exam
Gluteal Exam

DOCUMENTATION - +ve or -ve

Adjuncts to Physical Examination

Gastric tube
Urinary catheter
Other studies
Other studies

Focused Assessment Sonography in Trauma (FAST)
Diagnostic Peritoneal Lavage (DPL)
Contrast studies
DPL RBC Criteria (per mm3 )
Evaluation of Blunt Trauma

If there is early or obvious evidence that the patient will

be transferred to another facility, time consuming tests
such as contrast urologic and GI studies, DPL and CT
should not be performed
Evaluation of Penetrating trauma

Penetrating Wounds
Thoracoabdominal Lower Chest Wounds
Local Wound Exploration & Serial Physical Examinations
DPL in Anterior Abdominal Stab Wounds

Serial Physical Examination

Double or Triple Contrast CT in Flank and Back Injuries
Indications for Laparotomy (in adults)

Blunt trauma + hypotension with a +ve FAST or clinical

evidence of intraperitoneal bleeding
Blunt trauma + +ve DPL
Penetrating + hypotension
Gunshot wounds traversing the peritoneal cavity or
visceral/vascular retroperitoneum
Bleeding from the stomach, rectum or GU tract from
penetrating trauma

Free air, retroperitoneal air, or rupture of the

hemidiaphragm after blunt trauma
Ruptured GI tract, intraperitoneal bladder injury, renal
pedicle injury or severe visceral parenchymal injury after
blunt or penetrating trauma as demonstrated on CT
Spesific Diagnoses

Diaphragm injuries
Duodenal injuries
Pancreatic injuries
GU injuries
Small bowel injuries
Solid Organ injuries
Pelvic Fractures & Associated Injuries

Indicates major forces were applied to the patient

Significant a/w injuries to intraperitoneal and
retroperitoneal visceral and vascular structures
Hypotension may or may not be related to the pelvic #
itself when blunt trauma is the mechanism of injury
Potential sources of blood loss

# bone surfaces
Pelvic venous plexus
Pelvic arterial injury
Extrapelvic sources

The pelvis SHOULD BE temporarily stabilized or closed

using an avaialable commercial compression device or
sheet to decrease bleeding
Mechanism of Injury/Classification

AP compression
Lateral compression
Vertical shear
Complex (combination) pattern

Flank, scrotum, Perianal region
Blood at the urethral meatus
High-riding prostate gland
Mechanical instability

Leg-length discrepancy or rotational deformity (usu

external) without a # of that extremity
Because the unstable pelvis is able to rotate externally,
the pelvis can be closed by pushing on the iliac crest at
the level of the ASIS

Simple techniques

Sheet wrapped
Commercially available pelvic splints
Other pelvis-stabilizing devices