ABDOMINAL TRAUMA

PRESENTERS: DR. AMAN JAIN

DR. RAJAT UPADHYAY

MODERATOR: DR. USHA DALAL

 Introduction
 Initial Survey of an injured patient
 DCS
 Common modes/ mechanisms
 Specific points for abdominal trauma
 Investigations
 Organ systems
PRIMARY SURVEY

 Purpose: rapidly identify and manage impending or actual life threats to the patient.
 Priorities are the assessment and management of:

c Catastrophic haemorrhage
A Airway (and C-spine control)
B Breathing
C Circulation
D Disability
E Exposure / Environment
AIRWAY & CERVICAL SPINE

 Major threat to life : airway obstruction History or evidence or burn?

 Singeing of facial/ nasal hair

Look for  Facial/neck burns

 Facial fractures  Edema – neck/face

 Contaminants : blood, vomit, broken teeth  Hoarseness/ change in voice

 Epistaxis  Cough
 Soot in mouth/ nose/ saliva
 Assessment of neck
 Tracheal deviation
 Wounds
 Emphysema (subcutaneous)
 Laryngeal tenderness / crepitus
 Venous distension
 Esophageal injury (injury unlikely if able to swallow easily)
 Carotid haematoma/ bruitsesr/ swelling
 GCS
• C spine – stabilization - hard collar.
• Positioning of the head - neutral position
• Gentle suction of the airway to remove blood / vomitus / secretions
• Application of high flow oxygen
• Jaw thrust - avoiding head-tilt or chin lift
• Oropharyngeal / naso-pharygeal airway / Intubation – case to case basis
BREATHING

Life Threats
 Tension pneumothorax
 Open pneumothorax
 Massive haemothorax
ASSESSMENT and APPROPRIATE  Breath sounds or added sounds
MANAGEMENT
 Emphysema / crepitus
 Spontaneously breathing ?
 Clavicle / chest wall tenderness
 high flow oxygen – typically 10-15L O 2 via a non-rebreather
mask
 The work of breathing (recession, respiratory rate, accessory
muscle use)
 The effectiveness of breathing (oxygen saturation, symmetry and
degree of chest expansion)
 The effects of inadequate respiration (heart rate, mental state)
 Signs of injury (seat belt marks, bruising, wounds)
CIRCULATION

 Major threat: hypovolemic shock

 Look for
 Pulse Rate, skin colour, Capillary Refilling Time, Blood
Pressure
 Indirect signs - increased respiratory rate, decreased
mental state
Sites of potential bleeding
 External – assess by exposing wounds and look for ongoing bleeding - do not remove penetrating foreign bodies
 Intra-thoracic – assess for massive haemothorax (as per breathing above)
 Intra-abdominal – inspect for abdominal distension, bruising, and palpation for tenderness / guarding
 Intra-pelvic – gently assess the pelvis for stability by compressing the iliac crests ( pelvic binder )
 Long bone fractures – in particular assess the femurs as a site for major bleeding
 Retroperitoneal bleeding – this can be hard to identify – but maintain a high level of suspicion in those with signs of
haemorrhagic shock and no obvious signs of bleeding elsewhere or flank tenderness
 simultaneous resuscitation and appropriate management
 Establish intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital
fossa.
 Role of CVC
 As the IV is inserted, take blood for a blood sugar, cross-match, baseline investigations
 circulation inadequate? give a fluid bolus of 20 ml/kg of normal saline.
 Tamponade any continuing external haemorrhage.
 Circulation still unstable, repeat the fluid bolus using normal saline or a colloid solution.
 If a third bolus is necessary, consider using packed cells and arrange early surgical intervention
DISABILITY (MENTAL STATE)

 A = Alert
 V = responds to Voice
 P = responds to Pain
 U = Unresponsive
 GCS
EXPOSURE AND ENVIRONMENTAL CONTROL

 Remove clothing initially and look for any other obvious life threatening injury.
 Avoid hypothermia
 Limit exposure of the body
 Warm all ongoing fluids.
SECONDARY SURVEY

 AMPLE history
 Allergies/ medications/ Past illness/ pregnancy/ last meal/ events

 Detailed Physical exam- head to toe

 Frequent assessment of vitals
 Diagnostic studies simultaneously
 X-rays/ fast exam/ lab work/ CT scan
STAGES OF DCS
 Prehospital ( ground zero)
 Abbreviated initial operation
 Resuscitation in the ICU
 Reoperation
 Closure of the abdominal wall
PHASES OF DCR
 Control of life-threatening
haemorrhage and contamination
 Correction of physiological
derangements
 Definitive management
 Initial evaluation – prehospital
 Early notification of trauma center – prompt mobilization of operative teams
 Damage control resuscitation and correction of physiological derangements – pre op
DCR combines three seemingly diverse
strategies—

• PERMISSIVE HYPOTENSION

• HEMOSTATIC RESUSCITATION

• DAMAGE CONTROL SURGERY

 HEMOSTATIC
RESUSCITATION
• Hemostatic resuscitation provides transfusions with plasma and
platelets in addition to red blood cells in an immediate and sustained
manner as part of the transfusion protocol for massively bleeding
patients.

• Rapid and proactive treatment of the coagulopathy associated with

major injury is now recognized as central to improve outcome.

• From a practical standpoint, requirement for >4 RBC units in 1 h with

ongoing need for transfusion or blood loss >150 ml/min with
hemodynamic instability and need for transfusion are reasonable
definitions.
• The target is to achieve a close ratio resuscitation with 1:1:1 of fresh
frozen plasma (FFP), platelets (Plts), and packed red blood cells
(PRBCs).

• The rationale behind early and sustained administration of FFP

involves the replacement of fibrinogen and clotting factors.

• A quantitative and qualitative platelet dysfunction has been shown to

play a role as well in the mechanism coagulation. Thus, platelet
replacement should be done simultaneously.
Who requires Massive Transfusion Protocol (MTP)?

ABC (Assessment of Blood Consumption) Score

• Trauma by penetrating mechanism

• Positive FAST.
• Arrival blood pressure <90 mmHg
• Arrival pulse >120 bpm.

A score of 2 or more is considered positive, i.e. patient to be taken for MTP.

The score is 75 % sensitive and 85 % specific.
ADJUNCTS

 CRYOPREICIPITATE
 Contains Fibrinogen, factor VIII, factor XIII and von Willebrand factor
 Fibrinogen deficiency develops earlier than other factors ( indication for transfusion – pl. fibrinogen < 1g/L)

 TRANEXAMIC ACID (TXA)

 Antifibrinolytic , interferes with plasminogen – fibrin binding
 Prevents clot breakdown – reduces blood loss
 Should be given within 3h of injury routinely ( if evidence of bleeding +)

 CALCIUM
 Important co factor for coagulation cascade
 Citrate - anticoagulant – chelates calcium - hypocalcemia
STAGES OF DCS

 Preshospital ( ground zero)

 Abbreviated initial operation
 Resuscitation in the ICU
 Reoperation
 Closure of the abdominal wall
WHEN SHOULD YOU BE PREPARED?

 Initial body temperature <35⁰C

 Arterial pH <7.2
 Base deficit <-15mmol/L in patients <55y age
 Serum lactate >5mmol/L
 INR >50% of normal (coagulopathy)
STAGES OF DCS

 Preshospital ( ground zero)

 Abbreviated initial operation
 Resuscitation in the ICU
 Reoperation
 Closure of the abdominal wall
 Correction of lethal triad ( metabolic failure/ physical exhaustion)
 DCR
STAGES OF DCS

 Pre hospital ( ground zero)

 Abbreviated initial operation
 Resuscitation in the ICU
 Reoperation
 Closure of the abdominal wall
 12-72 hours after the original damage operation

 Goals at Reoperation
 Removal of packs
 Comprehensive examination – missed injuries
 Re establish intestinal continuity / create stoma
 Insertion of drains and feeding access
STAGES OF DCS

 Pre hospital ( ground zero)

 Abbreviated initial operation
 Resuscitation in the ICU
 Reoperation
 Closure of the abdominal wall
FORMAL CLOSURE VS OPEN ABDOMEN

 Cardiovascular/respiratory and renal status

 Continuing need to complete organ
repairs/Gastrointestinal reconstruction
 Midgut distension
 Distance separating the two sides of the Linea alba

 Abdominal compartment syndrome

ABDOMINAL TRAUMA SPECIFIC

 History – Noteworthy aspects

 Fatality at the scene
 Vehicle type and velocity
 Whether the vehicle rolled over
 Patient's location within the vehicle
 Extent of intrusion into the passenger compartment
 Extent of damage to the vehicle; steering wheel deformity
 Whether seatbelts were used (unrestrained victims are at higher risk of injury)
 whether air bags deployed
MECHANISM OF INJURY

 BLUNT TRAUMA
 Motor vehicles accidents
 Fall
 Assault
 PENETRATING TRAUMA
 Gunshot wounds
 Stab wounds
 Shrapnel wounds
THE MOST COMMONLY INJURED ORGANS

 Overall - Spleen
 Blunt trauma - Spleen > Liver > Intestines
 Penetrating trauma - Liver > Small intestines > diaphragm
 Gunshot wound - Small intestines > colon > Liver
 Seat belt syndrome - Mesentery
 Deceleration injury - Duodenojejunal flexure
PER ABDOMINAL EXAMINATION

 Wide range of presentations

normal vital signs and minor complaints ---------obtunded patient in severe shock
 absence of abdominal pain or tenderness does NOT rule out the presence of significant intra-
abdominal injury.
 Seatbelt sign
 Hypotension
 Abdominal distension
 Abdominal guarding
 Rebound tenderness (uncommon)
 Concomitant femur fracture (may indicate BAT among pedestrians stuck by automobiles)
 Pain not corresponding to physical signs – rule out retroperitoneal injuries
Reference point : ASIS
 In alert patients free of distracting injuries
 abdominal pain
 abdominal tenderness

 Referred pain
 splenic injury - left shoulder (Kehr's sign)
 liver injury - right shoulder

 Abdominal tenderness is present in up to 90 % of cases.

 Hypotension following Blunt Abominal Trauma (BAT)
 most often results from hemorrhage from a solid abdominal organ or intra-abdominal vascular injury.
 Although we must look for extra-abdominal sources of bleeding (eg, scalp laceration, thoracic injury, or
long bone fracture)
 An extra-abdominal source of hemorrhage never obviates the need to evaluate the peritoneal cavity
 Head injury alone cannot explain shock except in rare cases of profound intracranial trauma or in infants
who may have significant intracranial bleeding or cephalohematoma
 Abdominal wall ecchymosis - The "seatbelt sign“
 intra-abdominal injury in up to one-third of patients

 Abdominal distention - ileus, pneumoperitoneum, or gastric dilation - indicate significant injury.

 Do not wait – actively look and investigate

 Decreased bowel sounds - chemical peritonitis - hemorrhage / ruptured hollow viscus

 Bowel sounds heard in the chest - diaphragmatic rupture
INVESTIGATIONS

 Hematocrit <30 %
 A normal hematocrit is dangerously reassuring
 Must still look for intra abdominal bleeding

 Leukocyte count – nonspecific

 Pancreatic enzymes
 If elevated – may be suggestive of pancreatic injury – confirmatory studies are needed
 If normal – cannot exclude
 Threshold 109 U/L for SGOT and 97 U/L for SGPT
 84 percent sensitivity
 98 percent negative predictive
 Cut off : BD less than -6
 associated with intra-abdominal hemorrhage and the need for laparotomy and blood transfusion
 sensitivity and specificity of 88.2% and 95.2%
 Urinalysis – Gross hematuria suggests serious renal injury and mandates further investigation

 Additional tests
 women of childbearing age with BAT – UPT
 patient taking anticoagulant or antiplatelet medications- coagulation studies
RADIOLOGY

 Must be stabilized before most radiographic studies can be performed

 Pay careful attention to potential spinal cord injuries and guard against further injury (during
positioning and transfer)
 A clinician familiar with trauma care must accompany any patient who has the potential to
deteriorate
 CT scanners adjacent to the emergency department
 Chest Xray - in the resuscitation room - as part of the primary survey.
 X-ray pelvis - done where there are risk factors for pelvic injury
 high speed / rollover or lateral impact motor vehicle accidents
 Pedestrian vs car
 Cyclist vs car
 Abnormal pelvis examination
 Significant lower limb injury (eg femur fracture)
CHEST X-RAY FINDINGS S/O ABDOMINAL TRAUMA

 Lower rib fractures

CHEST X-RAY FINDINGS S/O ABDOMINAL TRAUMA

 Diaphragmatic hernia  Free air under the diaphragm

ULTRASONOGARPHY - EFAST

 Requires around 200ml of free fluid to

be detected
 Sensitivity – 90%
 Specificity – 95%
Limitations of ultrasound in the setting of BAT include:
 Injury to solid parenchyma, the retroperitoneum, or the diaphragm is not well seen.
 False negatives
 Uncooperative patients
 Obesity
 bowel gas
 subcutaneous air
 Blood cannot be distinguished from ascites or urine.
 Insensitive for detecting bowel injury
 Less sensitive than plain radiograph for detecting pneumothorax in the context of blunt trauma
CECT ABDOMEN

Indications and pre-requisites

 Positive clinical findings

 High index of suspicion
 Positive FAST scan
 Hemodynamically stable
Advantages
 Noninvasive
 Better defines organ injury and potential for nonoperative management of splenic and liver
injuries
 Detects the source and amount of hemoperitoneum
 Active bleeding often detectable
 Retroperitoneum and vertebral column can be assessed
 Additional imaging can be performed when needed (eg, head, cervical spine, chest, pelvis)
 Patients with negative imaging are at low risk for clinically significant injuries
Disadvantages
 Despite improvements in image resolution, MDCT

remains an insensitive test for mesenteric, bowel

and pancreatic duct injuries
 Upto 20% patients with blunt bowel or mesenteric injury were missed in this study, recognized later on repeat CT
or in the OR
 IV contrast is needed; oral contrast is not needed as it rarely adds to diagnostic accuracy and may delay
imaging
 Relatively high cost
 Can be unobtainable or delay critical care for unstable patients
 Radiation exposure
Angiography
 Unstable patients with BAT and a pelvic fracture may benefit from angiography
 Selective embolization – spleen, pelvic vessels
 Time consuming
 Interventional radiology may not be available 24x7

A matter of debate
The order and timing of angiographic embolization versus laparotomy with preperitoneal packing
CLINICAL SCENARIOS
HEMODYNAMICALLY UNSTABLE PATIENT

 Perform eFAST
 Positive – initial resuscitation - emergency laparatomy
 limited (eg, poor image quality) - the surgeon must decide whether suspicion for intra-abdominal injury is
sufficiently high to warrant emergency laparotomy.
 We suggest CT to evaluate for intra-abdominal (as well as extra-abdominal injuries) in patients who can be resuscitated
adequately to undergo scanning.
 If this cannot be accomplished, an adequate FAST exam cannot be done, and clinicians choose to perform a DPT or
DPL, most experts agree that the aspiration of 10 mL of gross blood confirms the presence of a significant intra-
abdominal wound that warrants emergency laparotomy.
 In unstable patients with no evidence of intra-abdominal injury (negative FAST exam, negative
abdominal CT), clinicians must search for alternative sites of hemorrhage or other non-
hemorrhagic causes of shock.
HEMODYNAMICALLY STABLE PATIENT

 Clinician’s assessment of their risk for significant intra-abdominal injury

 The approach selected will vary depending upon many factors, including patient age and
comorbidities, mechanism of injury, examination findings, and hospital resources.
 Low-risk patients and observation
 For patients deemed low-risk by clinical presentation, vital signs, and laboratory tests (no anemia, no
elevated transaminase concentrations [if obtained], and no hematuria)
 a nine-hour period of observation that includes serial vital signs and abdominal examinations is generally
sufficient to identify patients with occult intra-abdominal injury
 Serial ultrasound examinations may be done
HEMODYNAMICALLY STABLE PATIENT

 One or more concerning laboratory findings

 A low-risk clinical presentation + laboratory findings associated with intra-abdominal injury
(hematocrit<30%, elevated SGOT/SGPT, microscopic hematuria)
 Perform CECT abdomen
 Negative - a nine-hour period of observation that includes serial vital signs and abdominal examinations is generally
sufficient to identify patients with injuries that CT may have missed (eg, bowel injury).
 Persistent pain or tenderness despite a negative CT- indication for admission
HEMODYNAMICALLY STABLE PATIENT

 One or more concerning findings in presentation or examination - Perform CECT abdomen

 Negative CT imaging - at low risk for clinically significant intraabdominal injuries,
 Persistent pain or tenderness despite a negative CT should be admitted
 High risk examination findings include the following: hypotension, peritoneal signs (eg, abdominal
guarding, rebound tenderness), abdominal distension, and seatbelt sign.
 Repeated clinical examination
 Role of repeat CECT in case of persistence of symptoms and signs
 Role of DPL ,DPT, EL.
EXPLORATORY LAPAROTOMY

Indications
 Unexplained signs of blood loss or hypotension in a patient who cannot be stabilized and in
whom intra-abdominal injury is strongly suspected
 Clear and persistent signs of peritoneal irritation
 Radiologic evidence of pneumoperitoneum consistent with a viscus rupture
 Evidence of a diaphragmatic rupture
 Persistent, significant gastrointestinal bleeding seen in nasogastric drainage or vomitus
SPECIAL CONSIDERATIONS

Pelvic fracture
 evidence of ongoing bleeding (i.e., hemodynamic instability), the presence or absence of
hemoperitoneum determines management.
 USG/DPT
 positive – emergency laparotomy
 Negative – might active suggest retroperitoneal haemorrhage

 Important exception - intraperitoneal fluid detected by US does not represent hemorrhage. Major
pelvic fracture can be associated with intraperitoneal bladder rupture.
 Careful examination of the perineum and rectum
 Place a pelvic stabilization device (prefabricated pelvic binder, or a bed sheet tied tightly around
the pelvis) on any potentially unstable pelvic fracture that may be contributing to hemodynamic
instability
 Multiple system injury
 Eg - intraperitoneal hemorrhage in a patient with apparent closed head injury and suspected
blunt aortic disruption.
 Traditionally, laparotomy to control intraperitoneal hemorrhage takes precedence over operative
management of head or chest trauma.
 In general, a patient with known hemoperitoneum who cannot be stabilized must first undergo
laparotomy for life-saving hemostasis before other injuries are addressed.
 The necessity and timing of neurosurgical intervention is directed by the patient’s neurologic
examination (GCS, presence of lateralizing neurologic signs), and CT imaging results.
 Pregnant patient — Trauma remains the most common non-obstetric cause of maternal death
during pregnancy, and has been reported to complicate 6 to 7 percent of pregnancies.
 Initial evaluation and management of the pregnant trauma patient is directed at determining the
extent of maternal injury and directing resuscitation towards the mother’s survival.
Geriatric patient
 Patterns of trauma in older adults are similar to those of adults in general
 However, the signs and symptoms of abdominal injury are often attenuated in adults > 60 years
 Must maintain a high index of suspicion for injuries in this population.
Patient transfer
 A trauma patient at a small rural hospital may need a laparotomy for hemorrhage control before
being transferred to a trauma center for definitive care
 Referral to hospitals with dedicated neurosurgery/ hepatobiliary/ interventional radiology units
Only after stabilization
 Consultation with the trauma center should begin as soon as it is apparent the patient has
sustained injuries beyond the management capacity of the hospital.