Abdominal

Trauma
Abdominal Trauma
Penetrating Abdominal Trauma
◦ Stabbing 3x more common than firearm wounds
◦ GSW cause 90% of the deaths
◦ Most commonly injured organs: small intestine > colon > liver

Blunt Abdominal Trauma

◦ Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple organs/systems)
◦ Most commonly injured organs: spleen > liver, intestine is the
most likely hollow viscus.
◦ Most common causes: MVA (50 - 75% of cases) > blows to
abdomen (15%) > falls (6 - 9%)
 Pathophysiology of
Penetrating Abdominal Trauma
injury
Stab Wounds
◦ Knives, ice picks, pens, coat
hangers, broken bottles
◦ Liver, small bowel, spleen

Gunshot wounds
◦ small bowel, colon and liver
◦ Often multiple organ injuries,
bowel perforations
Pathophysiology of injury
Pathophysiology of injury
Blunt Abdominal Trauma
Rupture or burst injury of a hollow organ by sudden rises in
intra-abdominal pressures
Crushing effect
Acceleration and deceleration forces → shear injury
Seat belt injuries
◦ “seat belt sign” = highly correlated with intraperitoneal
injury
Physical Exam
Generally unreliable due to distracting injury, AMS,
spinal cord injury
Look for signs of intraperitoneal injury
◦ abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
◦ entrance and exit wounds to determine path of injury.
◦ Distention - pneumoperitoneum, gastric dilation, or ileus
◦ Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
◦ Abdominal contusions – eg lap belts
◦ ↓bowel sounds suggests intraperitoneal injuries
◦ DRE: blood or subcutaneous emphysema
Diagnostic studies
Lab tests: not very helpful
May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox
screen
Imaging
Plain films:
◦ fractures – nearby visceral damage
◦ free intraperitoneal air
◦ Foreign bodies and missiles
CT Imaging
◦ Accurate for solid visceral lesions and intraperitoneal hemorrhage
◦ guide nonoperative management of solid organ damage
◦ IV not oral contrast
◦ Disadvantages : insensitive for injury of the pancreas, diaphragm,
small bowel, and mesentery
Imaging
Angiography
◦ To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma in an unstable pt
◦ Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma
 FAST
Focused assessment with sonography for trauma (FAST)
◦ To diagnose free intraperitoneal blood after blunt trauma
◦ 4 areas:
◦ Perihepatic & hepato-renal space (Morrison’s pouch)
◦ Perisplenic
◦ Pelvis (Pouch of Douglas/rectovesical pouch)
◦ Pericardium (subxiphoid)

◦ sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid

Extended FAST (E-FAST):

◦ Add thoracic windows to look for pneumothorax.
◦ Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

Trauma.org
Morrison’s pouch (hepato-renal space)
FAST

trauma.org
 FAST
Perisplenic view

trauma.org Rosen’s Emergency Medicine, 7th ed. 2009

Retrovesicle (Pouch of Douglas)
FAST

Pericardium (subxiphoid)

trauma.org
 FAST
Advantages:
◦ Portable, fast (<5 min),
◦ No radiation or contrast
◦ Less expensive

Disadvantages
◦ Not as good for solid parenchymal damage, retroperitoneum, or
diaphragmatic defects.
◦ Limited by obesity, substantial bowel gas, and subcut air.
◦ Can’t distinguish blood from ascites.
◦ high (31%) false-negative rate in detecting hemoperitoneum in
the presence of pelvic fracture
Diagnostic Peritoneal Lavage
Largely replaced by FAST and CT
In blunt trauma, used to triage pt who is HD
unstable and has multiple injuries with an
equivocal FAST examination
In stab wounds, for immediate dx of
hemoperitoneum, determination of intraperitoneal
organ injury, and detection of isolated diaphragm
injury
In GSW, not used much
Diagnostic Peritoneal Lavage
1. attempt to aspirate free peritoneal blood
◦ >10 mL positive for intraperitoneal injury

2. insert lavage catheter by seldinger, semiopen, or

open
3. lavage peritoneal cavity with saline
Positive test:
◦ In blunt trauma, or stab wound to anterior, flank, or back:
RBC count > 100,000/mm3
◦ In lower chest stab wounds or GSW: RBC count > 5,000-
10,000/mm3
Local Wound Exploration
To determine the depth of penetration in stab
wounds
◦ If peritoneum is violated, must do more diagnostics

Prep, extend wound, carefully examine (No blind

probing)
Indicated for anterior abdominal stab wounds, less
clear for other areas
 Laparoscopy
Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
◦ esp for diaphragm injury: Sens 87.5%, specificity 100%

Can repair organs via the laparoscope

◦ diaphragm, solid viscera, stomach, small bowel.

Disadvantages:
◦ poor sensitivity for hollow visceral injury, retroperitoneum
◦ Complications from trocar misplacement.
◦ If diaphragm injury, PTX during insufflation
 Management
General trauma principles:
◦ airway management, 2 large bore IVs, cover penetrating
wounds and eviscerations with sterile dressings
Prophylactic antibiotics: decrease risk of intra-
abdominal sepsis due to intestinal perf/spillage
◦ (eg zosyn 3.375 g IV)

In general, leave foreign bodies in and remove in the OR

Management of penetrating abdominal
trauma
Management of penetrating abdominal
trauma
Mandatory laparotomy
vs
Selective nonoperative management

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Mandatory laparotomy
◦ standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
◦ Now thought unnecessary in 70% of abdominal stab
wounds
◦ Increased complication rates, length of stay, costs
◦ Immediate laparotomy indicated for shock, evisceration,
and peritonitis

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Selective management used to reduce unnecessary
laparotomies
Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
Strategy depends on abdominal region:
◦ Thoracoabdomen
◦ Nipple line to costal margin
◦ Anterior abdomen
◦ Xiphoid to pubis
◦ Flank and back
◦ Posterior to anterior axillary line
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Thoracoabdomen
Big concern is diaphragmatic injury
◦ 7% of thoracoabdominal wounds

Diagnostic evaluation:
◦ CXR (hemothorax or pneumothorax)
◦ Diagnostic peritoneal lavage
◦ FAST
◦ Thoracoscopy

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Thoracoabdomen

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Anterior abdomen
◦ Only 50-70% of anterior stab wounds enter the abdomen
◦ of these, only 50-70% cause injury requiring OR
◦ 1. is immediate lap indicated ?
◦ 2. Has peritoneal cavity been violated?
◦ 3. Is laparotomy required?

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of PAT
Anterior abdomen

Rosen’s Emergency Medicine 7 th ed

 Management of penetrating abdominal
trauma
Back/Flank
◦ Risk of retroperitoneal injury
◦ Intraperitoneal organ injury 15-
40%
◦ Difficulty evaluating
retroperitoneal organs with
exam and FAST
◦ In stable pts, CT scan is reliable
for excluding significant injury:

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal penetration have
injury requiring operative management
Most centers proceed to lap if peritoneal entry is
suspected
Expectant management rarely done

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosen’s Emergency Medicine 2009
 Management of PAT
Gunshot wounds
assess peritoneal entry
by missile path, LWE, CT,
US, laparoscopy (all
limited)

Rosen’s Emergency Medicine, 7 th ed. 2009

Management of Blunt abdominal trauma

ashwinearl.blogspot.com
Management of Blunt abdominal trauma
Exam less reliable
Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring surgical
repair
◦ FAST, CT, DPL
◦ In HD stable pts, CT is preferred

Rosen’s Emergency Medicine, 7 th ed. 2009

 Management of Blunt abdominal trauma
Clinical Indications for Laparotomy after Blunt Trauma
MANIFESTATION PITFALL

Unstable vital signs with strongly

indicated abdominal injury Alternative sources, shock

Unequivocal peritoneal irritation Unreliable

Insensitive; may be due to

cardiopulmonary source or invasive
Pneumoperitoneum
procedures (diagnostic peritoneal
lavage, laparoscopy)

Evidence of diaphragmatic injury Nonspecific

Significant gastrointestinal bleeding Uncommon, unknown accuracy

Rosen’s Emergency Medicine, 7 th ed. 2009

 Damage Control
Patients with major exsanguinating injuries may not
survive complex procedures
Control hemorrhage and contamination with
abbreviated laparotomy followed by resuscitation
prior to definitive repair

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
 Damage Control
0. initial resuscitation
1. Control of hemorrhage and contamination
◦ Control injured vasculature, bleeding solid organs
◦ Abdominal packing

2. back to the ICU for resuscitation

◦ Correction of hypothermia, acidosis, coagulopathy

3. Definitive repair of injuries

4. Definitive closure of the abdomen

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
 Damage Control

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
ntrol

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
 Damage Control
Resuscitation in the ICU
IVF (crystalloid, not colloid)
Transfusion
◦ ?1:1:1 PRBC/plt/FFP

Recombinant activated factor VII

◦ Increased thromboembolic complications

Rewarming if hypothermic
Correction of metabolic abnormalities
Low tidal volume ventilation recommended (4-6 ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
 Damage
Open Control
abdominal wounds and definitive closure
40-70% can’t have primary closure after definitive repair.
Temporary closure methods

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
 Abdominal Compartment Syndrome
Common problem with abdominal trauma
Definition: elevated intraabdominal pressure (IAP)
of ≥20 mm Hg, with single or multiple organ system
failure
◦ ± APP below 50 mm Hg

Primary ACS: associated with injury/disease in

abdomen
Secondary (“medical”) ACS: due to problems
outside the abdomen (eg sepsis, capillary leak)

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
 Abdominal Compartment Syndrome

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

 Abdominal Compartment Syndrome
Effects of elevated IAP
◦ Renal dysfunction
◦ Decreased cardiac output
◦ Increased airway pressures and decreased
compliance
◦ Visceral hypoperfusion

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
 Abdominal Compartment Syndrome
Management
◦ Surgical abdominal decompression
◦ Nonsurgical: paracentesis, NGT, sedation
◦ Staged approach to abdominal repair
◦ Temporary abdominal closure

Bailey J. Crit Care 2000, 4:23–29 Sugrue M. Curr Opin Crit Care 2005; 11:333-338
Conclusions
Watch out for implements and missiles violating the
abdomen
Laparotomy is mandatory if shock, evisceration, or
peritonitis
Diagnostic studies used to determine need for laparotomy
in PAT and BAT
FAST is noninvasive, quick and accurate way to evaluate for
intraperitoneal blood
Damage Control is a principle of staged operative
management with control and resuscitation prior to
definitive repair
Abdominal compartment syndrome is a common problem
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):S421-30.
Marx: Rosen’s 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, 4:23–29