ABDOMINAL TRAUMA

DR. MARIANA UNGUR

06/20/20 1
 INTRODUCTION

• Abdominal trauma can be very difficult to asses even in a hospital setting

• In the field, identifying which abdominal organ has been injured, is less important
than identifying that abdominal trauma itself has occurred.

• It is therefore of major importance to note abnormal signs associated with blood

loss and establish that abdominal injury is the probable cause, rather that being
concerned about, with for example, whether the source of the abdominal bleeding
originates from de spleen or liver

06/20/20 2
 ANATOMY REFFERENCES
• The abdomen can be arbitrarily divided into 4 areas. The first is the intrathoracic abdomen, which is the
portion of the upper abdomen that lies beneath the rib cage. Its contents include the diaphragm, liver,
spleen, and stomach. The rib cage makes this area inaccessible to palpation and complete examination.

• The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents include the urinary
bladder, urethra, rectum, small intestine, and, in females, ovaries, fallopian tubes, and uterus. Injury to
these structures may be extraperitoneal in nature and therefore difficult to diagnose.

• The third is the retroperitoneal abdomen, which contains the kidneys, ureters, pancreas, aorta, and vena
cava. Injuries to these structures are very difficult to diagnose on the basis of physical examination
findings. Evaluation of the structures in this region may require computed tomography (CT) scanning,
angiography, and intravenous pyelography (IVP).

• The fourth is the true abdomen, which contains the small and large intestines, the uterus (if gravid), and
the bladder (when distended). Perforation of these organs is associated with significant physical findings
and usually manifests with pain and tenderness from peritonitis. Plain x-ray films are helpful if free air is
present. Additionally, diagnostic peritoneal lavage (DPL) is a useful adjunct

06/20/20 3
 BOUNDARIES OF THE ABDOMEN

• Diaphragm
• Anterior abdominal wall
• Pelvic bones
• Vertebral column
• Muscles of the abdomen and flanks

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 ANTEROLATERAL ABDOMINAL WALL

06/20/20 5
 SURFACE ANATOMY OF ABDOMEN

• Quadrants
- Upper -right, left
- Lower -right, left
• Xiphoid
• Symphysispubis
• Umbilicus

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PERITONEAL
CAVITY

Also called the “true” abdominal cavity

•Quadrants:

Upper -right, left

Lower -right, left

•Contents--liver, spleen, stomach, small

intestine, colon, gallbladder, female
reproductive organs

06/20/20 7
PELVIC CAVITY

Surrounded by the pelvic bones

•Lower part of retroperitoneal space

•Contents:

- Rectum
- Bladder
- Urethra
- Iliac vessels
- In women, internal genitalia

06/20/20 8
RETROPERITONEAL
SPACE

Potential space behind the “true”

abdominal cavity
•Contents:
- Abdominal aorta
- Inferior vena cava
- Most of duodenum
- Pancreas
- Kidneys
- Ureters
- Ascending and descending colon

06/20/20 9
 SOLID & HOLLOW ORGANS

SOLID ORGANS HOLLOW ORGANS

• Liver • Stomach
• Spleen • Intestines
• Pancreas • Gallbladder
• Kidneys • Urinary bladder
• Adrenals • Uterus (female)
• Ovaries (female)
06/20/20 10
 MECHANISMS OF ABDOMINAL INJURY
• Emergency practitioners routinely encounter patients who suffer from abdominal
trauma, be it :
- blunt
- penetrating.

• These injuries are often confounded by altered mental status, distracting injuries, or
lack of historical information, and may present challenges in management.

• However, in the last several years new approaches to the diagnosis and management
of abdominal trauma, including bedside ultrasound, newer generation computed
tomography scans, laparoscopy, and the ability for selected nonoperative
management expedite identification of life threatening injury and offer new options
in treatment.

06/20/20 11
 BLUNT ABDOMINAL TRAUMA
• Historically, blunt abdominal trauma (BAT) is more frequently encountered in the
emergency department (ED) than penetrating abdominal trauma.

• Blunt abdominal trauma usually results from:

- Motor vehicle collisions

- Motorcycle collisions
- Pedestrian injuries
- Falls
- Assault
- Blast injuries

• The spleen is the most often injured organ and may be the only intra-abdominal
injury in over 60% of cases.
06/20/20 12
 ETIOLOGY
• Vehicular trauma is by far the leading cause of blunt abdominal trauma in the
civilian population.

• Auto-to-auto and auto-to-pedestrian collisions have been cited as causes in 50-75%

of cases.

• Other common etiologies include falls and industrial or recreational accidents.

• Rare causes of blunt abdominal injuries include iatrogenic trauma during

cardiopulmonary resuscitation, manual thrusts to clear an airway, and the Heimlich
maneuver

• The most commonly injured organs are the spleen, liver, retroperitoneum, small
bowel, kidneys, bladder, colorectum, diaphragm, and pancreas. Men tend to be
affected
06/20/20 slightly more often than women. 13
 HISTORY
• Initially, evaluation and resuscitation of a trauma patient occur simultaneously.

• In general, do not obtain a detailed history until life-threatening injuries have been
identified and therapy has been initiated.

• The initial assessment begins at the scene of the injury, with information provided
by the patient, family, bystanders, or paramedics, or police.

• Important factors relevant to the care of a patient with blunt abdominal trauma,
specifically those involving motor vehicles

06/20/20 14
 HISTORY
Important elements of the pertinent history include the
following:

• Allergies
• Medications
• Past medical and surgical history
• Time of last meal
• Immunization status
• Events leading to the incident
• Social history, including history of substance abuse
• Information from family and friends

06/20/20 15
 PHYSICAL EXAMINATION. PRIMARY SURVEY

• Resuscitation is performed concomitantly and continues as the physical examination

is completed.

• Priorities in resuscitation and diagnosis are established on the basis of

hemodynamic stability and the degree of injury.

• The goal of the primary survey, as directed by the Advanced Trauma Life Support
(ATLS) protocol, is to identify and expediently treat life-threatening injuries.

• The protocol includes the following:

- Airway, with cervical spine precautions

- Breathing
- Circulation
- Disability
06/20/20 16
- Exposure
 PHYSICAL EXAMANINATION.
SECONDARY SURVEY
• After an appropriate primary survey and initiation of resuscitation, attention should be focused on the secondary survey
of the abdomen.

• The secondary survey is the identification of all injuries via a head-to-toe examination.

• For life-threatening injuries that necessitate emergency surgery, a comprehensive secondary survey should be delayed
until the patient has been stabilized.

• The evaluation of a patient with blunt abdominal trauma must be accomplished with the entire patient in mind, with all
injuries prioritized accordingly. This implies that injuries involving the head, the respiratory system, or the
cardiovascular system may take precedence over an abdominal injury.

• In an unstable patient, the question of abdominal involvement must be expediently addressed. This is accomplished by
identifying free intra-abdominal fluid with diagnostic peritoneal lavage (DPL) or focused assessment with sonography
for trauma (FAST). The objective is rapid identification of those patients who need a laparotomy.

• The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate.
Associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult. Lower rib
fractures, pelvic fractures, and abdominal wall contusions may mimic the signs of peritonitis. 

• The greatest compromise of the physical examination occurs in the setting of neurologic dysfunction, which17
06/20/20 may be
caused by head injury or substance abuse.
 SIGNS AND SYMPTOMS
• The most reliable signs and symptoms in alert patients are pain, tenderness, gastrointestinal hemorrhage,
hypovolemia, and evidence of peritoneal irritation. However, large amounts of blood can accumulate in
the peritoneal and pelvic cavities without any significant or early changes in the physical examination
findings.

• Bradycardia may indicate the presence of free intraperitoneal blood in a patient with blunt abdominal
injuries.

• The respiratory pattern should be observed because abdominal breathing may indicate spinal cord injury

• The abdominal examination must be systematic. The abdomen is inspected for abrasions or ecchymosis.
Particular attention should be paid to injury patterns that predict the potential for intra-abdominal trauma
(eg, lap belt abrasions, steering wheel–shaped contusions). In most studies, lap belt marks have been
correlated with rupture of the small intestine and an increased incidence of other intra-abdominal injuries.

• Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign) indicates
retroperitoneal hemorrhage, but this is usually delayed for several hours to days.

• Visual inspection for abdominal distention, which may be due to pneumoperitoneum, gastric dilatation
secondary to assisted ventilation or swallowing of air, or ileus produced by peritoneal irritation, is
06/20/20
important. 18
 SIGNS AND SYMPTOMS

• Auscultation of bowel sounds in the thorax may indicate the presence of a diaphragmatic injury.
Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula.

• Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound tenderness, which
suggests peritoneal injury. Such signs appearing soon after an injury suggest leakage of intestinal content.
Peritonitis due to intra-abdominal hemorrhage may take several hours to develop.

• Fullness and doughy consistency on palpation may indicate intra-abdominal hemorrhage. Crepitation or
instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries associated with
lower rib injuries.

• Tenderness on percussion constitutes a peritoneal sign. Tenderness mandates further evaluation and
probably surgical consultation.

06/20/20 19
 SIGNS AND SYMPTOMS

• Rectal and bimanual vaginal pelvic examinations should be performed.  A rectal examination should be
done to search for evidence of bony penetration resulting from a pelvic fracture, and the stool should be
evaluated for gross or occult blood. The evaluation of rectal tone is important for determining the
patient’s neurologic status, and palpation of a high-riding prostate suggests urethral injury.

• The genitals and perineum should be examined for soft tissue injuries, bleeding, and hematoma. Pelvic
instability indicates the potential for lower urinary tract injury, as well as pelvic and retroperitoneal
hematoma. Open pelvic fractures are associated with a mortality rate exceeding 50%.

• A nasogastric tube should be placed routinely (in the absence of contraindications, eg, basilar skull
fracture) to decompress the stomach and to assess for the presence of blood. If the patient has evidence of
a maxillofacial injury, an orogastric tube is preferred.

• As the assessment continues, a Foley catheter is placed and a sample of urine is sent for analysis for
microscopic hematuria. If injury to the urethra or bladder is suggested because of an associated pelvic
fracture, then a retrograde urethrogram is performed before catheterization

06/20/20 20
 LABORATORY EVALUATION

• serum glucose
• complete blood count (CBC)
• serum chemistries
• serum amylase
• Urinalysis
• coagulation studies
• blood typing and cross-matching
• arterial blood gases (ABGs)
• blood ethanol
• urine drug screens
• a urine pregnancy test (for females of childbearing age).

06/20/20 21
 IMAGISTIC EVALUATION

• The chest radiograph may aid in the diagnosis of abdominal injuries such as
ruptured hemidiaphragm (eg, a nasogastric tube seen in the chest) or
pneumoperitoneum.

• The pelvic or chest radiograph can demonstrate fractures of the thoracolumbar

spine.

• The presence of transverse fractures of the vertebral bodies (ie, Chance fractures)
suggests a higher likelihood of blunt injuries to the bowel.

• In addition, free intraperitoneal air, or trapped retroperitoneal air from duodenal

perforation, may be seen.

06/20/20 22
 IMAGISTIC EVALUATION

• Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can
be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum. In
fact, in many medical centers, the FAST examination has virtually replaced DPL as the
procedure of choice in the evaluation of hemodynamically unstable trauma patients.

• The FAST examination is based on the assumption that all clinically significant abdominal
injuries are associated with hemoperitoneum. Hemodynamically stable patients with negative
FAST results require close observation, serial abdominal examinations, and a follow-up
FAST examination. However, strongly consider performing a CT scan, especially if the
patient is intoxicated or has other associated injuries.

• Hemodynamically unstable patients with negative FAST results are a diagnostic challenge.
Options include DPL, exploratory laparotomy, and, possibly, a CT scan after aggressive
resuscitation onsidered as a complementary measure to CT scanning, DPL, or exploration.

06/20/20 23
 COMPUTED TOMOGRAPHY

• Although expensive and potentially time-consuming, CT scanning often provides

the most detailed images of traumatic pathology and may assist in determination of
operative intervention.

• CT remains the criterion standard for the detection of solid organ injuries.

• In addition, a CT scan of the abdomen can reveal other associated injuries, notably
vertebral and pelvic fractures and injuries in the thoracic cavity.

• CT scanning, unlike DPL or FAST, has the capability to determine the source of
hemorrhage. In addition, many retroperitoneal injuries go unnoticed with DPL and
FAST examinations.

06/20/20 24
Blunt abdominal trauma. Right kidney injury with blood in perirenal space.
Injury resulted from high-speed motor vehicle collision

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Blunt abdominal trauma with splenic injury and hemoperitoneum.

06/20/20 26
Blunt abdominal trauma. Normal Morrison,s pouch (ie, no free fluid).

06/20/20 27
 Blunt abdominal trauma. Free fluid in Morrison,s pouch

06/20/20 28
Blunt abdominal trauma with liver laceration.

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 DIAGNOSTIC LAPAROSCOPY

• Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for the

introduction of the laparoscope and creating other ports for retractors, clamps, and
other tools necessary for visualization of the repair.

• Diagnostic laparoscopy has been most useful in the evaluation of possible

diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on the
left side. In blunt trauma, it has no clear advantages over less invasive modalities
such as DPL and CT scanning; furthermore, complications can result from trocar
misplacement.

06/20/20 30
DIAGNOSTIC PERITONEAL LAVAGE

• DPL is used as a method of rapidly determining the presence of intraperitoneal blood.

• It is particularly useful if the history and abdominal examination of an unstable patient with
multisystem injuries are either unreliable (eg, because of head injury, alcohol, or drug
intoxication) or equivocal (eg, because of lower rib fractures, pelvic fractures, or confounding
clinical examination).

• DPL is also useful for patients in whom serial abdominal examinations cannot be performed
(eg, those in an angiographic suite or operating room during emergency orthopedic or
neurosurgical procedures)

• With the availability of fast, noninvasive, and better imaging modalities (eg, FAST, CT
scanning), the role of DPL is now limited to the evaluation of unstable trauma patients in
whom FAST results are negative or inconclusive. In some contexts, DPL may be
complemented with a CT scan if the patient has positive lavage results but stabilizes.

06/20/20 31
 DIAGNOSTIC PERITONEAL LAVAGE
is indicated for the following patients in the setting of
blunt trauma:

• Patients with a spinal cord injury

• Those with multiple injuries and unexplained shock
• Obtunded patients with a possible abdominal injury
• Intoxicated patients in whom abdominal injury is suggested
• Patients with potential intra-abdominal injury who will undergo
prolonged anesthesia for another procedure

06/20/20 32
 COMPLICATIONS OF DIAGNOSTIC
PERITONEAL LAVAGE
• Complications of DPL include bleeding from the incision and catheter insertion, infection (ie, wound,
peritoneal), and injury to intra-abdominal structures (eg, urinary bladder, small bowel, uterus).

• These complications may increase the possibility of false-positive studies. Additionally, infection of the
incision, peritonitis from the catheter placement, laceration of the urinary bladder, or injury to other intra-
abdominal organs can occur.

• Bleeding from the incision, dissection, or catheter insertion can cause false-positive results that may lead
to unnecessary laparotomy. Achieve appropriate hemostasis prior to entering the peritoneum and placing
the catheter.

• False-positive DPL results can occur if an infraumbilical approach is used in a patient with a pelvic
fracture. A pelvic x-ray film should be obtained prior to performing DPL if a pelvic fracture is suggested.
Before DPL is attempted, the urinary bladder and stomach should be decompressed

06/20/20 33
 PREHOSPITAL CARE

• Prehospital care focuses on:

- rapidly evaluating life-threatening problems
- initiating resuscitative measures
- initiating prompt transport to a definitive care site.

• The injured patient is at risk for progressive deterioration from continued bleeding
and requires rapid transport to a trauma center or the closest appropriate facility,
with appropriate stabilization procedures performed en route.

• Hence, securing the airway, placing large-bore intravenous (IV) lines, and
administering IV fluid must take place en route, unless transport is delayed.

06/20/20 34
 PREHOSPITAL CARE
• External hemorrhage rarely is associated with blunt abdominal trauma. If external bleeding is
present, control it with direct pressure

• If external bleeding is present, control it with direct pressure.

• Note any signs of inadequate systemic perfusion.

• Consider intraperitoneal hemorrhage whenever evidence of hemorrhagic shock is found in

the absence of external hemorrhage

• Acquire expeditious and complete spinal immobilization on patients with multisystem

injuries and on patients with a mechanism of injury that has potential for spinal cord trauma.

• In the rural setting, the pneumatic antishock garment may have a role for treating shock
resulting from a severe pelvic fracture.

• Promptly
06/20/20 notify the destination hospital so that that facility can activate its trauma team
35 and
prepare for the patient
 EMERGENCY DEPARTMENT CARE

• Upon the patient’s arrival in the emergency department (ED) or trauma center, a rapid
primary survey should be performed to identify immediate life-threatening problems.

• The first priority is reassessment of the airway. Protection of the cervical spine with in-line
immobilization is absolutely mandatory. If intubation is indicated, attempt nasotracheal (ie, if
no contraindications) or endotracheal intubation. If possible, perform and record a brief
neurologic examination prior to neuromuscular blockade and intubation. If intubation is
unsuccessful, perform cricothyroidotomy.

• After an airway has been established, adequate ventilatory exchange is assessed by

auscultation of both lung fields. Patients who display apnea or hypoventilation require
respiratory support, as do those patients with tachypnea. Provide all patients with
supplemental oxygen from a device capable of delivering a high fraction of inspired oxygen
(FIO2) (eg, a nonrebreather mask)

06/20/20 36
 EMERGENCY DEPARTMENT CARE
• Clinical diagnosis of a tension pneumothorax is treated with needle decompression followed by chest
thoracostomy tube placement. Other mechanical factors that can interfere with ventilation include sucking
chest wounds, a hemothorax, and pulmonary contusion. Treat these aggressively and expediently.

• The next priority in the primary survey is an assessment of the circulatory status of the patient.
Circulatory collapse in a patient with blunt abdominal trauma is usually caused by hypovolemia from
hemorrhage. Identification of hypovolemia and signs of shock necessitate vigorous resuscitation and
attempts to identify the source of blood loss.

• Effective volume resuscitation is accomplished by controlling external hemorrhage and infusing warmed
crystalloid solution via 2 large-bore (eg, 18-gauge) peripheral IV lines. Use central lines for patients in
whom percutaneous peripheral access cannot be established. Administer a rapid bolus of crystalloid.

• Hemodynamic instability despite the administration of 2 L of fluid to adult patients indicates ongoing
blood loss and is an indication for immediate blood transfusion. Administer type O, Rh-negative blood if
cross-matched or type-specific blood is not available.

• The primary survey is completed with a brief neurologic assessment of the patient using elements of the
Glasgow Coma Scale. The patient is undressed and draped in clean, dry, warm sheets.
06/20/20 37
 EMERGENCY DEPARTMENT CARE
• After the primary survey and initial resuscitation have begun, complete the secondary survey, as
described earlier .Perform a thorough head-to-toe examination, paying attention to evidence of the
mechanism of injury and potentially injured areas. Before the placement of a nasogastric tube and Foley
catheter, perform appropriate head, neck, pelvic, perineum, and rectal examinations. “Log-roll” the
patient to examine the back and palpate the entire spinal column.

• On the basis of the injury mechanism and the findings from physical examination, obtain initial trauma
radiographic studies. In general, trauma suite views include lateral cervical spine, anterior portable chest,
and pelvis radiographs.

• In-line spinal immobilization must be continued until spinal fractures have been ruled out. Additional
radiographs are indicated for other findings in the secondary survey.

• Bedside ultrasonography using a trauma examination protocol (eg, FAST) can be used to determine the
presence of intraperitoneal hemorrhage.If findings are negative or equivocal, DPL may be performed in
hemodynamically unstable patients.

• Depending on patient stability, injury mechanism, and likelihood of intra-abdominal injury, further
investigation may be warranted for patients who are hemodynamically stable after the initial assessment
and resuscitation and who have negative or equivocal FAST or DPL results. Further investigation
06/20/20 contrast-enhanced CT scans of the abdomen and pelvis or serial examinations
includes 38 and
ultrasonography.
 APPROACH CONSIDERATIONS
• Indications for laparotomy in a patient with blunt abdominal injury include the following:
- Signs of peritonitis
- Uncontrolled shock or hemorrhage
- Clinical deterioration during observation
- Hemoperitoneum findings after focused assessment with sonography for trauma (FAST)
or diagnostic peritoneal lavage (DPL) examinations
- Finally, surgical intervention is indicated in patients with evidence of peritonitis based
on physical examination findings.

• Operative treatment is not indicated in every patient with positive FAST scan results. Hemodynamically
stable patients with positive FAST findings may require a computed tomography (CT) scan to better
define the nature and extent of their injuries. Operating on every patient with positive FAST scan findings
may result in an unacceptably high laparotomy rate.

• Resuscitative thoracotomy is not recommended in patients with blunt thoracoabdominal trauma who have
pulseless electrical activity upon arrival in the emergency department (ED). The survival rate in this
situation is virtually 0%. These patients may be allowed a thoracotomy in the ED only if they have signs
of life upon arrival.
06/20/20 39
 NONOPERATIVE MANAGEMENT
• Nonoperative management (NOM) strategies based on CT scan diagnosis and the hemodynamic stability
of the patient are now being used in adults for the treatment of solid organ injuries, primarily those to the
liver and spleen. In blunt abdominal trauma, including severe solid organ injuries, selective nonoperative
management has become the standard of care.

• Angiography is a valuable modality in nonoperative management of abdominal solid organ injuries from
blunt trauma in adults. It is used aggressively for nonoperative control of hemorrhage, thereby obviating
nontherapeutic cost-inefficient laparotomies.

• Splenic artery embolotherapy (SAE), although not standard of care, is another nonoperative management
modality for adult blunt splenic injury.

• The trend toward simply observing hemodynamically stable patients with injuries involving the spleen,
liver, or kidneys is becoming more popular. If the decision has been made to observe the patient, closely
monitor vital signs and frequently repeat the physical examination.

• An increased temperature or respiratory rate can indicate a perforated viscus or the formation of an
abscess. Pulse and blood pressure can also change with sepsis or intra-abdominal bleeding.

• 06/20/20examination findings reflecting peritonitis are an indication for surgical intervention.

Physical 40
 SURGICAL MANAGEMENT

06/20/20 41
 RESUSCITATIVE THORACOTOMY

• Resuscitative thoracotomy in the ED is only occasionally life-saving. It is an aggressive, desperate

measure intended to save a patient whose death is thought to be imminent or otherwise inevitable.
Survival with good neurologic recovery is more likely for patients with penetrating trauma than for
patients with blunt trauma. Thoracotomy may have a role in selected patients with penetrating injuries to
the neck, chest, or extremities and those with signs of life within 5 minutes of arrival in the ED.

• A resuscitative thoracotomy is seldom of benefit for patients with cardiac arrest secondary to blunt
or head injury or for those without vital signs at the scene of the accident. Patients with blunt
thoracoabdominal trauma with pulseless electrical activity upon arrival in the ED have a survival rate of
virtually 0% and are poor candidates for resuscitative thoracotomy. Patients with blunt trauma may be
allowed a thoracotomy in the ED only if they have signs of life upon arrival.

• In a patient with hemoperitoneum from blunt thoracoabdominal trauma, the goals of a resuscitative
thoracotomy in the ED are:
(1) to cross-clamp the aorta, diverting available blood to the coronaries and cerebral vessels during
resuscitation
(2) to evacuate pericardial tamponade
(3) to directly control thoracic hemorrhage and
06/20/20
(4) to open the chest for cardiac massage. 42
 LAPAROTOMY AND DEFINITIVE REPAIR

• Indications for laparotomy in a patient with blunt abdominal injury include signs of peritonitis,
uncontrolled shock or hemorrhage, clinical deterioration during observation, and hemoperitoneum
findings after FAST or DPL examinations

• When laparotomy is indicated, broad-spectrum antibiotics are given. A midline incision is usually
preferred. When the abdomen is opened, hemorrhage control is accomplished by removing blood and
clots, packing all 4 quadrants, and clamping vascular structures. Obvious hollow viscus injuries (HVIs)
are sutured.

• After intra-abdominal injuries have been repaired and hemorrhage has been controlled by packing, a
thorough exploration of the abdomen is then performed to evaluate the entire contents of the abdomen.

• After intraperitoneal injuries are controlled, the retroperitoneum and pelvis must be inspected. Do not
explore pelvic hematomas. Use external fixation of pelvic fractures to reduce or stop blood loss in this
region. Explore large or expanding midline retroperitoneal hematomas, with the anticipation of damage to
the large vascular structures, pancreas, or duodenum. Do not explore small or stable perinephric
hematomas.

06/20/20 43
LAPAROTOMY AND DEFINITIVE REPAIR

• After the source of bleeding has been stopped, further stabilizing the patient with
fluid resuscitation and appropriate warming is important. After such measures are
complete, perform a thorough exploratory laparotomy with appropriate repair of all
injured structures.

• Patients who had gross enteric contamination of the peritoneal cavity are given
appropriate antibiotics for 5-7 days.

• If a pelvic hematoma was found and the patient continues to lose blood after
external fixation of a pelvic fracture, arteriography with embolization can be used to
stop the small percentage of arterial bleeding found in pelvic fractures.

• In adults, splenic artery embolization has been shown to improve nonoperative

splenic salvage rates
06/20/20 44
 CONSULTATIONS

• The best outcomes from trauma are obtained by involving consultants

who possess specific expertise and training in managing trauma
patients.

• Consider evaluation by a trauma surgeon for all patients with

evidence of blunt abdominal trauma. Clearly, hemodynamic
instability or the identification of significant abnormalities during
physical examination or a diagnostic procedure necessitates the
involvement of a trauma surgeon.

06/20/20 45
Specific physical examination findings that call for timely surgical
evaluation are as follows:

• History of blunt abdominal trauma, shock, or abnormal vital signs (eg, tachycardia, hypotension)

• Evidence of shock without obvious external blood loss

• Evidence of peritonitis (eg, marked tenderness, involuntary guarding, percussion tenderness)

• Findings consistent with potential intra-abdominal injury (eg, lap belt signs, lower rib fractures, lumbar
spine fractures)

• Altered levels of consciousness or sensation, whether due to drugs, alcohol, or head/spinal injury

• Patients who require other prolonged operative intervention (eg, orthopedic procedures)

• Specific findings on diagnostic studies that call for timely surgical evaluation include evidence of free
fluid or solid organ injury on sonograms or CT scans.

• Although a trend toward nonoperative management of hepatic, splenic, and renal injuries in patients who
are hemodynamically normal has occurred, a trained trauma surgeon must oversee this care.
06/20/20 46
Other specific findings that indicate timely trauma surgeon
involvement are as follows:
 

• Positive findings on DPL

• Evidence of extravasated contrast or extraluminal air on an upper gastrointestinal

series (eg, duodenal rupture), plain abdominal radiography, or cystography

• Serious pelvic fractures

• Evidence of bladder rupture on contrast cystogram or gross hematuria

• Elevated findings on liver function studies

06/20/20 47
PENETRATING ABDOMINAL TRAUMA

• Stab wounds are encountered three times more often than gunshot wounds, but have
a lower mortality because of their lower velocity and less invasive tract. As a result
of their greater force and extensive missile tract, gunshot wounds account for up to
90% of the mortality associated with penetrating abdominal trauma.

• Injury to the bowel (small, then large) is most often found, followed by hepatic
injury, regardless of type of penetrating injury

06/20/20 48
 INITIAL ASSEMENT OF PENETRATING
TRAUMA

• Energy imparted to body:

 Low velocity: Knife, ice pick

 Medium velocity: Gunshot wounds, shotgun wounds
 High velocity: High-power hunting rifles, military weapons

• Ballistics

• Trajectory

06/20/20 49
• Distance
 SOLID ORGAN INJURY

06/20/20 50
 LIVER TRAUMA
• Largest organ in the abdominal cavity

• Located in the right upper quadrant of abdomen

• Commonly injured from trauma to the:

- Eighth through twelfth ribs on right side of body
- Upper central part of abdomen

• Suspect liver injury in any patient with:

- Steering wheel injury
- Lap belt injury
- History of epigastric trauma

• After injury, blood and bile escape into peritoneal cavity

06/20/20 - Produces signs and symptoms of shock and peritoneal irritation, respectively
51
 LIVER INJURY GRADING

Grade Injury Type/Description

I Hematoma: subcapsular, <10% surface area.
Laceration: capsular tear, <1cm parenchymal depth.

II Hematoma: subcapsular, 10-50% surface area, intraparenchymal <10cm in diameter.

Laceration: capsular tear, 1-3cm parenchymal depth, <10cm in length.

III Hematoma: subcapsular, >50% surface area, intraparenchymal hematoma > 10cm or
expanding .
Laceration: 3 cm parenchymal depth

IV Laceration: parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud

segments.

V Laceration: parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud

segments within a single lobe.
Vascular: juxtahepatic venous injuries (major hepatic veins, retrohepatic vena cava.)

VI Laceration: parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud

segments within a single lobe.
Vascular: juxtahepatic venous injuries (major hepatic veins, retrohepatic vena cava.)

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 GRADE IV LIVER LACERATION
(BLUNT TRAUMA)

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GRADE IV LIVER LACERATION - OMENTAL
PATCH REPAIR

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 PENETRATING LIVER TRAUMA
Gunshot to right lobe of liver, grade II injury
Gunshot to right lobe of liver, grade II injury. 
Entrance wound. Exit wound.

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 LIVER TRAUMA
Gunshot in the flank of abdomen Grade III liver injury from gunshot to the flank

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 LIVER TRAUMA
Gunshot to the right upper quadrant.  through
& through grade IV liver injury seen at Gunshot liver, laparotomy and view after pack removal
laparotomy.

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Balloon tamponade of a transhepatic liver gunshot wound.  damage control procedure.  the
balloon is constucted of a penrose drain sutured to a foley catheter.  a Senstaken-Blakemore
tube is an alternative.  Image at time of re-look laparotomy

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GRADE V LIVER INJURY FROM GUNSHOT

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ABDOMINAL STAB WOUND, WITH HEPATIC
LESION GRADE II.

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 LIVER INJURY TO SEGMENT 3 WITH
TRAUMATIC BILE LEAK

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SEGMENTAL RESECTION OF BILE LEAK WITH
LIGASURE

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 LIVER INJURY POST RESECTION OF
SEGMENT III

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 SPLEEN
• Lies in upper left quadrant of abdomen

• Rich blood supply

• Slightly protected by organs surrounding it medially and anteriorlyand by lower portion of rib
cage
- Most commonly injured organ from blunt trauma
- Associated intraabdominal injuries common

• Suspect splenic injury in:

- Motor vehicle crashes
- Falls or sport injuries in which there was an impact to lower left chest, flank, or upper left
abdomen

• Kehr’s sign
- Left upper quadrant pain with radiation to left shoulder
- Common complaint associated with splenic injury
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 SPLEEN INJURY GRADING

Grade Injury Type/Description

I Localised capsular disruption or haematoma

II Single/multiple lacs not involving hilum

III Laceration including hilum

IV Avulsion/fragmentation

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BLUNT SPLENIC RUPTURE FOLLOWING ROAD
TRAFFIC ACCIDENT

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 GRADE IV SPLEEN RUPTURE FROM
BLUNT TRAUMA

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 PANCREAS

• Solid organ that lies in the peritoneal space

• Blunt injury usually occurs from a crushing injury of the pancreas

between the spine and a steering wheel, handlebar, or blunt weapon

• Most pancreatic injuries are due to penetrating trauma

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DISTAL PANCREATECTOMY FOR GRADE
III PANCREATIC INJURY

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 PANCREAS AND DUODENUM TRAUMA

Grade V blunt pancreas & duodenum Grade V blunt pancreas & duodenum injury -
injury superior mesenteric vein repair

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GUNSHOT TO PANCREATIC HEAD. GRADE V

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 GRADE III PANCREAS INJURY
LAPAROTOMY

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 HOLLOW ORGAN INJURY

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 STOMACH

• Not commonly injured after blunt trauma because of its protected

location in abdomen

• Penetrating trauma may cause gastric transectionor laceration

• Patients exhibit signs of peritonitis rapidly from leakage of gastric

contents

• Diagnosis confirmed during surgery unless nasogastric drainage

returns blood
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ANTERIOR STOMACH INJURY REPAIRED BY
PRIMARY SUTURE.

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GUNSHOT WOUND TO STOMACH

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DUODENAL INJURY WITH COMPLETED PYLORIC
EXCLUSION

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COLON AND SMALL INTESTINE INJURIES

• Injury is usually the result of penetrating trauma

• Large and small intestine may also be injured by compression forces

-High-speed motor vehicle crashes
-Deceleration injuries associated with wearing personal
restraints

• Bacterial contamination common problem with these injuries

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 PENETRATING JEJUNAL INJURY WITH
EVISCERATION

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SEGMENTAL RESECTION OF JEJUNUM WITH
PRIMARY ANASTOMOSIS

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 THROUGH AND THROUGH GUNSHOT
WOUND TO SIGMOID COLON

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COLON INJURY FROM AIR GUN PELLET IN
A 5 YEAR OLD

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