PRESENTED BY:

Dr Louza Alnqodi, R3
outlines
Background
Clinical assessment of pt with blunt , penetrating
abdominal injuries
Diagnostic tools
Clinical approach
Conclusion.
R1
Which of the following does not cause a falsely
+ve DPL?

*Abdominal wall hematoma

*inadequate homeostasis
*pelvic #
*retroperitoneal injury
R1
Which of the following does not cause a falsely
+ve DPL?

*Abdominal wall hematoma

*inadequate haemostasis
*pelvic #
retroperitoneal injury
R2
Criteria for a +ve DPL include all of the following
except:

*initial aspiration of at least 50ml gross blood

*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
wound.
*presence of bile, bacteria or meat/vegetable fibers
R2
Criteria for a +ve DPL include all of the following
except:

initial aspiration of at least 50ml gross blood

*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
wound.
*presence of bile, bacteria or meat/vegetable fibers
R3
During the evaluation of a trauma patient, an
upright CXR showed gastric bubble shifted to the
rt .
No free air is present. What is the main concern?

*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
R3
During the evaluation of a trauma patient, an
upright CXR showed gastric bubble shifted to the
rt .
No free air is present. What is the main concern?

*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
R4
All of the following are clinical indicators' for
urgent laprotomy in pt presenting with
abdominal stab wounds except which one?

*bowel protrusion or evisceration

*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding
R4
All of the following are clinical indicators' for
urgent laprotomy in pt presenting with
abdominal stab wounds except which one?

*bowel protrusion or evisceration

*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding
R5
• A 25 yr old male presents with a stab wound to the
upper abdomen. Vital signs are stable. The abdomen
is not distended, soft, non-tender. Bowel sounds are
present. Upright CXR does not demonstrate a
Penumothorax or free air under diaphragm. What
should the next step be?
*evaluation of the peritoneal entry by local wound exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.
R5
• A 25 yr old male presents with a stab wound to the
upper abdomen. Vital signs are stable. The abdomen
is not distended, soft, non-tender. Bowel sounds are
present. Upright CXR does not demonstrate a
Penumothorax or free air under diaphragm. What
should the next step be?

*evaluation of the peritoneal entry by local wound exploration

*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.
anatomy
 Anterior abdomen
 flank
 Back
 intraperitoneal contents
 Retroperitoneal space contents
 Pelvic cavity contents
o Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal
ligaments and symphysis pubis.
o flank:
anterior and posterior axillary line ;sixth
intercostal to iliac crest
o Back:
posterior axillary line; tip of scapula to iliac crest
Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-
small bowel, sigmoid colon

 Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending
and descending colons

 Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia
mechanism
• Blunt trauma:

MVC
Seatbelt injury
fall from ht
crash injury
sport injury

 Penetrating injuries.
Blunt abdominal injuries carry a greater risk of
morbidity and mortality than peneterating
abdominal injuries.
associated with severe trauma to multiple
intraperitoneal organs and extra-abdominal
systems

 altered mental status, intoxication

Peritoneal signs are often subtle and may be

obscured by other painful injuries

Up to 20% of patients with hemoperitoneum have
benign abdominal exams on initial presentation.
Blunt injury
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%
 Splenic rupture is the most common visceral injury with
blunt abdominal trauma. Which of the following
statements regarding splenic rupture is FALSE?

 CT scan may confirm injury, but should not delay laparotomy in
unstable patients.
 Twenty percent of patients with left lower rib fractures have
associated splenic injury.
 Focused Assessment with Sonography for Trauma is useful if
performed by experienced users.
 Signs of peritonitis (involuntary guarding, rigidity, rebound) are
nearly always present.
 Splenic rupture is the most common visceral injury with
blunt abdominal trauma. Which of the following
statements regarding splenic rupture is FALSE?

 CT scan may confirm injury, but should not delay laparotomy in
unstable patients.
 Twenty percent of patients with left lower rib fractures have
associated splenic injury.
 Focused Assessment with Sonography for Trauma is useful if
performed by experienced users.
 Signs of peritonitis (involuntary guarding, rigidity, rebound) are
nearly always present.
Seatbelt injuries
Unrestrained front and rear seat passengers are at
unequivocally greater risk of intra-abdominal
injury than their restrained counterparts.

The three-point shoulder-lap belt is the most effective

restraining system and is associated with the
lowest incidence of abdominal injuries.

However, abdominal injuries are still ascribed to

shoulder-lap and lap-belt systems.
pathogensis
o compression of bowel between the belt and the
vertebral column.

o an acute short closed-loop obstruction occurs

along with perforation secondary to the sudden
generation of high intraluminal pressures.
Clinically, two symptom patterns emerge.

 ~1/4 of pt develop evidence of a hemoperitoneum secondary

to mesenteric lacerations.

 In the remainder, the intestinal injury most commonly

involves the jejunum contusion or perforation.

 Rare cases of acute abdominal aortic dissection with

incomplete or complete occlusion have also been described,
and injuries to the lumbar spine are not uncommon.
Mechanism

Stab wound
gunshot
Knives are not the sole implement used in
stabbings.

 Ice picks, pens, coat hangers, screwdrivers, and broken

bottles.

 most commonly in the upper quadrants, the left

more commonly than the right.
Stab wound
 multiple in 20% of cases
 involve the chest in up to 10% of cases.
 Most stab wounds do not cause an intraperitoneal
injury
 the incidence varies with the direction of entry into the
peritoneal cavity
 The liver, followed by the small bowel, is the organ
most often damaged by stab wounds.
Gunshot Wounds

handguns, rifles, and shotgun

the degree of injury depends .

 amount of kinetic energy imparted by the bullet to
the victim
 mass of the bullet and the square of its velocity
 Distance .
Missile velocities :
low (slower than 1100ft/sec)
medium (1100-2000ft/sec)
high (faster than 2000-2500ft/sec)
type I wounds: long range (>7 yards) , a
penetration of subcutaneous tissue and deep fascia
only.

Type II wounds: distance of 3 to 7 yards and may

create a large number of perforated structures.

Type III wounds occur at point-blank range (<3

yards) and involve a massive destruction of tissue
 multiple organ injuries are sustained, notably
perforations to bowel .

 greatest for small bowel, followed by the colon and

then the liver.
Missiles effects
Extensive tissue damage
 external contaminants tend to be dragged into the
wound.
 the closure of the tract immediately after the
bullet's passage may lead to an underestimation of
tissue damage.
high-velocity bullets can fragment internally
Small bowel injury is the most common injury
resulting from ___ abdominal trauma.

 penetrating
 blunt
Small bowel injury is the most common injury
resulting from ___ abdominal trauma.

 penetrating
 blunt
CLINICAL ASSESSMENT OF PT WITH
ABDOMINAL TRAUMA .
history
Primary goal is to identify that an injury exists, not
necessarily making an accurate diagnosis.

The patient's history may be unobtainable, elusive, or

temporarily abandoned while resuscitative measures are
carried out.
History from prehospital care team or transferring
hospital : the vital signs, physical assessment, prehospital
course, and response to therapy should be obtained

 Mechanism of injury is an important factor in developing a

high index of suspicion; thus a detailed history is helpful if
available.
Details about accident
Damage to car
Velocity
Steering wheel damage
Type of seatbelts used
Air bags deployed
 All patients involved in deceleration injuries and
bicycle injuries should be suspected of having
intraabdominal injury
In penetrating trauma:
# of shots or stabs
Type of weapon
Distance b/w firearm and victim
examination
 Overall, the accuracy of the physical
examination in patients with blunt abdominal
trauma is 55% to 65%.

 Although the presence of physical findings

makes intraperitoneal injury more likely, their
absence does not preclude serious pathology, and
none is exclusively diagnostic of a specific injury.
Hypotension in the acute stage results from
hemorrhage that is most often from a solid visceral
or vascular injury.
 hypotension with significant multiple blunt
trauma and is unexplained, one should assume the
presence of intraperitoneal hemorrhage until it is
excluded.
In conscious, alert pt, look for:
Abdo tenderness,90%
Peritoneal irritation
Penetrating: wounds (log roll pt)
Ecchymosis, Cullen and Gray-Turner signs
Rectal exam is important; assess for blood and
palpable bony fragments and position of the
prostate. High riding prostate suggests posterior
urethral tears.

 Urethral disruption should be considered when

blood is noted at the meatus.

Vaginal exam for bleeding – may suggest bony

fragments causing laceration. Implications of
bleeding during pregnancy should be considered.
The major findings with injury of the solid
abdominal organs are those of hemorrhagic
shock. Signs with solid organ injury include all of
the following EXCEPT:

 abdominal pain and tenderness

 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may result from
confined hemorrhage)
The major findings with injury of the solid
abdominal organs are those of hemorrhagic
shock. Signs with solid organ injury include all of
the following EXCEPT:

 abdominal pain and tenderness

 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may result from
confined hemorrhage)
DIAGNOSTIC STRATEGIES

Hct: can be a delayed sign, should do serial.

WBC:  in stress, peritoneal irritation
Pancreatic enzymes: if normal, does NOT r/o
pancreatic injury
 amylase: EtOH, narcotics
amylase & lipase: ischemia 2 hypotension
both non-specific & non-sensitive for pancreatic
injuries
Are abdo x-rays useful in trauma?

Although plain abdominal films can

demonstrate numerous findings, their place in
acute trauma is limited. Because of spinal
precautions, hemodynamic instability, time
consuming or patient discomfort.
 Smaller diaphragmatic injuries are often missed, with
herniation occurring late as the negative
intrathoracic pressure gradually draws the mobile
abdominal organs into the chest. Early radiographic
findings may be absent or subtle and include all of the
following EXCEPT :

  pleural effusion 
  appearance of the nasogastric tube in the chest 
  appearance of bowel loops in the chest 
  elevation of the diaphragm
  blurring of the diaphragm 
 Smaller diaphragmatic injuries are often missed, with
herniation occurring late as the negative
intrathoracic pressure gradually draws the mobile
abdominal organs into the chest. Early radiographic
findings may be absent or subtle and include all of the
following EXCEPT :

  pleural effusion 
  appearance of the nasogastric tube in the chest 
  appearance of bowel loops in the chest 
  elevation of the diaphragm
  blurring of the diaphragm 
Imaging
CT
 Able to define organ injury
 Good for retroperitoneal &
vertebral column
 Non-invasive
 Not Operator dependant
 Not great for hollow viscus
 Stable patient
 Cost $$$
 Complications: IV or oral
contrast
US
 Good for solid organs
 Portable
 Fast
 100 cc detection blood
 Mediastinum evaluation
 No radiation
 No contrast need
 Not see well: solid
parenchymal,
retroperitoneal, diaphragm
 Problem if: obesity, gas
 Less sensitive than DPL for
hemoperitoneal
 Operator dependant
20 y/o female patient involved in a low velocity MVA. Upon initial exam no
abnormalities noted, no complains.
The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT
Scan which showed Liver Laceration Grade III. This patient was treated non-
operatively.
Preferred Site of Diagnostic Peritoneal Lavage

Standard adult :Infraumbilical midline C or SO

 Standard pediatric: Infraumbilical midline C or SO
2ed &3ed trimester pregnancy :Suprauterine FO
 Midline scarring :Left lower quadrant FO
 Pelvic fracture: Supraumbilical FO
DPL RBC Criteria (per mm3 )
Indeterminate Positive
20–100,000 100,000 Blunt
Stab wound
  20,000–100,000 100,000   Anterior abdomen
20,000–100,00 100,000  Flank

20,000–100,000 100,000   Back

1000-5000 5000 Low chest

1000-5000 5000 Gunshot wound
List causes false negative DPL?
Catheter preperitoneal space
Fluid in compartment 2 adhesions
Diaphragmatic tear, so fluid goes into thoracic cavity
 
-sole absolute contraindication to DPL is the
established need for laparotomy.

Relative contraindications:
- prior abdominal surgery
- Infections
- Coagulopathy
- obesity
- second- or third-trimester pregnancy.
CLINICAL APPROCHES TO PT WITH:
o BLUNT ABDOMINAL TRAUMA
o STAB WOUND
o GUNSHOT
o ABDOMINAL WITH PELVIC TRAUMA.
Clinical Indications for Laparotomy after
Blunt Trauma
Pitfall Manifestation
Alternate sources shock Unstable vital signs with
strongly suspected
abdominal injury
Unreliable Unequivocal peritoneal
irritation
Insensitive; may be due to Pneumoperitoneum
cardiopulmonary source or
invasive procedures (diagnostic
peritoneal lavage, laparoscopy)
Nonspecific Evidence of
diaphragmatic injury
Uncommon, unknown Significant
accuracy gastrointestinal bleeding
Approach to abdominal stab
wound.

Step I: Clinical Indications for Laparotomy.

Step II: Peritoneal Violation.
Step III: Injury Requiring Laparotomy.
Clinical Indications for Laparotomy Following
Penetrating Trauma
Pitfall Premise Manifestation
Thorax or mediastinum, Major solid visceral or Hemodynamic
causal or contributory vascular injury instability
Unreliable, especially Intraperitoneal injury Peritoneal signs
immediately post-injury
No injury in one fourth Additional bowel, other Evisceration
to one third of stab injury
wound cases
Rare clinical, Diaphragm Diaphragmatic injury
radiographic findings
Uncommon, unknown Proximal gut Gastrointestinal
accuracy hemorrhage
Comorbid disease or Vascular impalement Implement in situ
pregnancy creates high
operative risk
Insensitive; may be Hollow viscus Intraperitoneal air
caused by perforation
intraperitoneal entry
Peritoneal Violation.
1.    Evisceration
2.    Intraperitoneal air
3.    Local wound exploration
4.    Ultrasonography
5.    Laparoscopy
Stab wound to right lower quadrant with caecal
evisceration.  No colon injury at laparotomy.
Eviscerated omentum is easily mistaken for
subcutaneous fat, so care must be taken in the
examination of open abdominal injuries. Which of the
following statements regarding abdominal
evisceration treatment is FALSE?

 Cover eviscerated organs with moist gauze or petrolatum

gauze (to prevent desiccation) for replacement at
laparotomy.
 Return all eviscerated organs to the peritoneal cavity. 
 Only organs with vascular compromise should be promptly
returned to the abdominal cavity.
Eviscerated omentum is easily mistaken for
subcutaneous fat, so care must be taken in the
examination of open abdominal injuries. Which of the
following statements regarding abdominal
evisceration treatment is FALSE?

 Cover eviscerated organs with moist gauze or petrolatum

gauze (to prevent desiccation) for replacement at
laparotomy.
 Return all eviscerated organs to the peritoneal cavity. 
 Only organs with vascular compromise should be promptly
returned to the abdominal cavity.
 In the abdominal stab wound victim without clear indications for
exploration (obvious peritoneal penetration, unexplained hypotension,
or signs of peritoneal irritation), local wound exploration with local
anesthesia should be performed; laparotomy should be performed if the
__ is penetrated.

  rectus abdominis muscle 

  posterior rectus sheath 
  transversalis fascia.
25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar
entered at the level of the epigastrium and exited through the left posterior thoracic wall.

Abdominal stab wound, with hepatic

.lesion grade II
Implements in situ
 implements in situ of the torso in the operating room.
 to ensure expeditious control of hemorrhage
 the implement reside within a vascular space or highly vascularized
organ.

 exceptions to this practice exist:

 situations in which emergency department resuscitation is impeded
by the presence of the implement
 the patient is at high risk of significant morbidity from nontherapeutic
laparotomy because of severe comorbid conditions or pregnancy.
?# What is your approach to pelvic •
conculsion
The accuracy of physical examination is limited in cases of
blunt and penetrating trauma. It is less reliable by
distracting injury, altered sensorium (e.g., head trauma,
alcohol or drug intoxication, mental retardation), and
spinal cord injury.

The choice of diagnostic studies for abdominal trauma is

based on clinical need first and foremost, as well as study
availability and the trustworthiness of that study in a
respective center
Ultrasonography and peritoneal aspiration are rapid
methods of determining or excluding the presence of
hemoperitoneum in the critically ill blunt or penetrating
trauma patient.

Clinical indications for laparotomy are more dependable in

and more frequently applicable to cases of penetrating
trauma than cases of blunt trauma.
THANK YOU