Abdominal Trauma

Evaluation of Penetrating Abdominal Trauma

Penetrating abdominal injury

The abdomen extends from the nipples to the groin crease anteriorly, and the tips of the scapulae
to the gluteal skin crease inferiorly. Any penetrating injury to this area, or that may have
traversed this volume, should be considered as a potential abdominal injury, and evaluated as
such.

The incidence of penetrating injury will vary from hospital to hospital and region to region.
Some institutions will have a very low incidence of penetrating trauma, and yet it is vital that
penetrating injury is treated differently to blunt trauma. The mechanisms and physical
characteristics of injury are different, as are the relevance and accuracy of investigations and the
methods and timing of repair.

Priorities

Patients with significant penetrating abdominal injury tend to fall into 3 major categories:

Presentation Injury Type Management priority

Pulseless Major vascular injury
Emergency
laparotomy
Consider ED
thoracotomy

Haemodynamically Identify & control

unstable Vascular and/or solid haemorrhage
organ injury

AND/OR

Haemorrhage from other

sites

Haemodynamically Identify presence of

Normal Hollow viscus injury gastrointestinal,
Pancreas or renal diaphragmatic or
retroperitoneal injury
The appropriate investigations and management pathway vary with each of these clinical
presentations.

Pulseless

Patients who arrive without palpable pulses but with witnessed recent or current signs of life (eg.
pulseless electrical activity) need immediate laparotomy in the operating room. The ability to
transfer such a patient from the ambulance bay directly to the operating room and start the
laparotomy within 5 minutes of arrival is vital if this is to have any chance of success.

A second option is to perform a thoracotomy in the emergency department and cross-clamp the
aorta. This is a poor second choice option as it does not arrest haemorrhage, delays laparotomy,
and opens a second body cavity which will contribute to further heat and blood loss. This
manoeuver has a very low functional survivor yield, and yet remains the only hope for salvage in
this group of patients where immediate access to an operating room is not available.

ABDO TRAUMA

PENETRATING INJURY

Stab abdomen &

evisceration

PENETRATING
ABDO INJURY

PRIMARY SURVEY
AIRWAY
BREATHING
 CIRCULATION
DISABILITY
EXPOSURE

ADJUNCTS
CXR
DPL
FAST
NG CATHETER
URINARY CATHETER

SECONDARY

clamshell thoracotomy & laparotomy

Haemodynamically Unstable

Patients with penetrating trauma who are haemodynamically unstable require immediate
operation. 'Haemodynamically unstable' includes non-responders and transient-responders to
initial small-volume fluid bolus administration. Patients should be taken immediately to the
operating room, without further unnecessary investigations or interventions.

The only decision to be made in these patients is where is the bleeding and this which cavity to
expose first. Where there is a stab or gunshot wound obviously involving the abdomen, the
decision is simple, and the patient has a laparotomy.

If there is a question about the abdomen being the source of the bleeding, Diagnostic Peritoneal
Lavage (DPL) or FAST scan is used to determine the presence of free intra-peritoneal fluid. For
the DPL, a positive aspiration of frank blood, or lavage fluid with a high red cell count
(>100,000/ml) is required to confirm the presence of major intraperitoneal haemorrhage.

The decision to perform a laparotomy may be complicated if:

There are multiple stab wounds/gunshot wounds to multiple cavities.

 The wounds are at, or cross, junctional zones (eg. costal margin, groin or buttock
wounds).

There is evidence or the possibility of cardiac tamponade

The diagnosis of massive haemothorax may be made clinically, with a FAST scan, chest tube or
Chest X-ray, depending on the degree of shock present and the rapidity with which such tests can
be performed. Cardiac tamponade may be diagnosed with FAST or in the operating room with a
pericardial window.

It is more important to take the patient to the operating room and commence surgery than to
make a definitive diagnosis. If a thoracic injury is suspected during a laparotomy a hemithorax
can be explored through the diaphragm or a formal thoracotomy, and a tamponade explored
through a pericardial window and sternotomy.

There should be no delay in trying to resuscitate the patient prior to surgery.

gunshot flank

close range. unstable

liver injury

Haemodynamically Normal

Patients with clinical signs of peritonitis, or with evisceration of bowel should be taken
immediately to the operating room.

Currently there are several possible options for the evaluation of penetrating abdominal trauma
in the haemodynamically normal trauma patient without signs of peritonitis. Many of these
patients will have some superficial tenderness around the wound site, but no signs of peritoneal
inflammation.

The goal of any algorithm for penetrating abdominal trauma should be to identify injuries
requiring surgical repair, and avoid unnecessary laparotomy with its associated morbidity.

Adjuncts the the initial evaluation of the trauma patient can provide clues to significant intra-
peritoneal injury:

Chest X-ray
An erect chest radiograph may identify sub-diaphragmatic air. This must be interpreted
with some caution in the absence of peritonitis, as air may be entrained into the peritoneal
cavity with a stab or gunshot wound. However it certainly signals peritoneal penetration
and warrants further investigation.

Nasogastric Tube
Blood drained from the stomach will identify gastric injury.

Urinary catheter
Macroscopic haematuria indicates a renal or bladder injury. Microscopic injury suggests
but is not pathognomonic of ureteric injury.

Rectal examination
Rectal blood indicates a rectal or signmoid penetration. Protoscopy & sigmoidoscopy
should be performed (see below)

Options for evaluation

Further evaluation requires the use of one or more of the following diagnostic modalities:

Serial Physical Examination (PE)

Local Wound Exploration (LWE)

Diagnostic Peritoneal Lavage (DPL)

Ultrasound (FAST)

CT Scan

Laparoscopy

Laparotomy

These different methods, each discussed below, are by no means equal. The decision on which
method, or combination of methods, to choose will depend primarily on hospital factors such as
trauma patient load, access to in-patient beds, availability of in-house surgical teams, access to
multislice CT scanners etc. Whichever decision tree is chosen should be accepted at a hospital-
wide level. The practice should not change from surgeon to surgeon and day to day. The
algorithm should be routinely audited for missed injuries, effectiveness and use of resources.

PE LWE DPL FAST CT Scan Laparoscop Laparotom

y y
Sensitivity (%)
(for therapeutic 95-97 71 87-100 46-85 97 50-100 -
intervention)
Specificity (%) 100 77 52-89 48-95 98 74-90 -
NPV (%) 92 79 78-100 60-98 98 100 -

Requires
awake,
+ - - - - - -
cooperative
patient
Invasive - + + - - + ++
Requires
+ +/- - - - + +
admission
Evaluates
retroperitoneu +/- - - - + - +
m
High clinical + - - - - +/- +/-
 workload
Complication
- + +/- - - + ++
rate

PE: Physical Exam; LWE: Local Wound Exploration; DPL: Diagnostic Peritoneal Lavage

Serial Physicial Examination

Serial physical examination has the best sensitivity and negative predictive value of all
modalities for the evaluation of penetrating abdominal trauma.

The patient is admitted for observation for 24 hours. During this time the patient is has frequent
(hourly), regluar checks of their haemodynamic status. The abdomen is examined routinely for
signs of developing peritonitis. Ideally the same surgeon should examine the patient each time. If
this is not possible, during a handover period both surgeons should examine the patient at the
same time so they agree on the current status of the abdomen and whether there has been any
progression in symptoms. The timing of examinations varies inthe literature, but should probably
start out more frequently and then decrease over time. A suggested sequence of examination
might be at 1, 4, 12 and 24 hours after the initial assessment. Some authors recommend
examination every four hours.

If the patient develops signs of haemodynamic instability or peritonitis during this period of
observation, a laparotomy is performed. If the patient is well the following day they start a
normal diet, and are discharged once diet is tolerated and they have completed the observation
period.

Patients who do not develop frank peritonitis, but who have persistent local symptoms of pain
and tenderness, with perhaps a fever or tachycardia at 24 hours should be evaluated by another
modality: CT Scan, laparoscopy or laparotomy.

The disadvantages of serial physicial exam are primarily the requirement to admit all patients
with a penetrating injury, and the requirement for frequent haemodynamic and physical
examinations. This usually requires the patient to be in a high dependency type setting, and
requires a body of in-house surgeons to perform the serial evaluations.

Local Wound Exploration

Local wound exploration (LWE) requires a formal evaluation of a stab wound under local
anaesthesia. This procedure is usually performed in the operating room, but is performed in the
emergency department by some institutions. The wound is extended under local anaesthesia and
the track followed through tissue layers.

Penetration of the anterior fascia is considered a positive LWE, as penetration of the peritoneum
is difficult to identify. A positive LWE leads to either laparotomy or another diagnostic test such
as DPL or laparoscopy.
When LWE is used alone to determine laparotomy, there will be a high non-therapeutic
laparotomy rate. Even if the peritoneam is penetrated were used as a cut-off, many of these
patients will have no intra-peritoneal injury, or an injury that does not require surgical
intervention - most commonly omental laceration, mesenteric laceration or liver tears that have
stopped bleeding.

Diagnostic Peritoneal Lavage

Diagnostic Peritoneal Lavage (DPL) involves passing a small catheter into the peritoneal cavity,
usually at the umbilicus or just inferior to this. If blood can be aspirated through this catheter,
this is referred to as a positive 'tap' or aspiration (DPA). If no blood can be aspirated a litre of
warm crystalloid solution is run into the peritoneal cavity and then allowed to drain out. This
lavage fluid is then sent to the laboratory for analysis of red cell count, white cell count and any
bowel contents (faecal or food matter).

It is important to realise that the role of DPL in the haemodynamically stable patient is diffierent
from that in the unstable patient. In the unstable patient the problem is one of major
haemorrhage, and identifying the site of haemorrhage. DPL is used as an alternative to the FAST
scan to identify intra-peritoneal haemorrhage (more often in blunt trauma). In the unstable
patient one is searching for a lot of blood, so a positive DPL in this setting requires either a
positive aspiration (DPA) or a high red-cell count (>100,000/ml).

The situation in penetrating abdominal trauma is very different. A haemodynamically unstable

patient with an abdominal stab wound needs no further investigations and will proceed to
laparotomy, as discussed above. So the role of DPL in the haemodynmically normal patient with
penetrating abdominal injury is to identify hollow viscus injury (stomach, small bowel, colon) or
diaphragmatic injury.

If faecal or food matter is seen on microscopy this is diagnostic. However this is rarely the case -
and a decision to proceed to laparotomy is usually based on the red cell count. By necessity this
must be lower than that looking for gross haemorrhage, so the threshold for the red cell count is
set somewhere between 5000/ml and 20,000/ml. The lower the threshold, the more sensitive the
test, but the higher the non-therapeutic laparotomy rate. Contamination from the insertion site of
the DPL can lead to false positive results. Some units also use a white cell count >500/ml as a
positive result - this value is probably too low and 3000/ml isprobably a better threshold for
gastrointestinal tract injury.

The primary disadvantages of DPL are that it is invasive, does not evaluate the retroperitoneum,
and has a signficiant false positive rate.

FAST

The role of FAST in penetrating trauma has not been fully evaluated. While FAST is sensitive for
pericardial fluid, it appears to have a high false negative rate for intra-abdominal injury. This
may improve if serial FAST scans are performed. Ultrasound as yet cannot detect the small
amounts of fluid which may be associated with a hollow viscus injury.
 A positive FAST indicates peritoneal penetration, but is poor at discriminating for injuries
requiring intervention

A negative FAST does not exclude significant abdominal injury.

It is therefore impossible to recommend FAST as the only investigation for the assessment of
penetrating intra-abdominal injury. It MAY have a role in combination with other investigations.

CT Scan

As the technology has improved, CT scanning is finding more and more of a role in the
evaluation of penetrating abdominal injury. Most studies recommend a multidectector
(multislice) scanner with triple-contrast protocol (intravenous, oral and rectal), although it is not
clear how important the GI contrast is for the detection of bowel injury. Of all the diagnostic
modalities listed, CT gives the best assessment of retroperitoneal structures.

The CT features of penetrating bowel injury are:

Signs of peritoneal violation

o Free intra-peritoneal air

o Free intra-peritoneal fluid

o Wound track extending through peritoneum

Signs of bowel injury

o Wound track extending to bowel wall

o Bowel wall defect

o Bowel wall thickening

o Intra-luminal contrast leak

o (not free intra-peritoneal air - may have been entrained through peritoneal wall)

Other signs of intra-peritoneal injury

o Intravenous contrast extravasation

o Diaphragmatic tear (especially on re-formats)

The use of CT for penetrating intra-abdominal injury remains in its infancy, and not all CT
scanners have the resolution or software capabilities necessary to achieve the sensitivity and
specificity rates quoted in the literature. Interpretation of the scans is also difficult and requires
multiple passes on different 'window' settings by a trained and experienced trauma radiologist.

Laparoscopy

Laparoscopy is also a technology somewhat in its infancy, and remains very user dependent. A
full trauma laparoscopy for the evaluation of penetrating injury requires general anaesthesia and
complete examination of intra-peritoneal contents, including visualisation of the whole small
bowel and intra-peritoneal colon. In most studies laparoscopy has a significant false negative,
primarily from missed bowel injuries. Laparoscopy is also limited in the evaluation of
retroperitoneal injury.

Laparoscopy is the diagnostic method of choice for the diagnosis of suspected diaphragmatic
injury. Many diaphragmatic lacerations can alse be repaired via the laparoscope.

Laparoscopy may also have a role in patients who have localised tenderness or develop a white
cell count or fever without generalised peritonitis after a period of clinical observation.
Laparoscopy may be useful to confirm that a wound is tangential and does not enter the
peritoneal cavity - although many of the methods above have advantages over laparoscopy for
this indication.

Laparotomy

Exploratory laparotomy for all penetrating abdominal wounds still has a role in resource-limited
environments, or occasionally in cases of multi-cavitary injuries. For most situations however the
non-therapeutic laparotomy rate will be unacceptable high. With the incidence of complications
with a negative laparotomy at of 12%-41%, with hospital stays of 4-8 days, , it is difficult to
support such a strategy where adjunctive methods such as CT or DPL are available and serial
physicial examination has such a low missed injury rate.

Recommended approaches

Which diagnostic tree a hospital chooses for the evaluation of penetrating injury will be
dependent on numerous factors, including trauma patient load, surgical team availability and
coverage, the availability of multidetector CT scanners and trauma radiologists, and access to the
operating room and critical care beds.

Many different systems are used around the world. The following recommendations are in order
of preference and are by no means the only possibilities. Each choice is associated with the
caveats listed above.

1. Serial physical examination

 2. Multidetector CT

3. Local Wound Exploration AND either:

o Diagnostic Peritoneal Lavage OR

o Laparoscopy

gunshot epigastrium
blood in NG tube

stomach injury

Special Situations

Wounds to thoracoabdominal junction zone

Thoracoabdominal injuries need to be evluated for diaphragmatic injury. Where there is evidence
of thoracic and abdominal injury there must, by definition, be an injury to the diaphragm. For
example, if there is a right pneumothorax and a liver laceration, the diaphragm must also be torn.
 R haemothorax from + liver injury
R lower chest stab = diaphragm injury

If the evidence for this is less clear, but diaphragm injury is still suspected, the options are
ultrasound, MRI, CT or laparoscopy/thoracoscopy. All radiological studies may miss small
diaphragmatic tears, and so laparoscopy / thoracoscopy remains the investigation of choice.
Laparoscopy is preferred for left sided injuries, thoracoscopy or laparoscopy for right sided
injuries. Diaphragmatic lacerations may also be repaired through a laparoscopic or laparoscope-
assisted approach.

Flank or back wound

Flank or back wounds may be associated with injuries to retroperitoneal organs such as the
colon, kidney and lumbar vessels - or more rarely the pancreas, aorta and inferior vena cava. Of
these, the colon is the injury most often missed. Where colon injury is a possibility, the duration
of serial physical examination is extended to 72 ours, watching for fever or a rise in the white
cell count. An alternative is to perform a triple-contrast CT scan. Where the wound track extends
up to the colon, or there is evidence of abnormal bowel wall thickening, laparotomy is indicated.

Wound to buttock or perineum

The most dangerous missed injury here is the occult rectal injury. Any penetrating injury to the
gluteal region carries the risk of rectal injury. Digital rectal examination is inadequate and full
proctoscopy and sigmoidoscopy should be performed, looking for the presence of blood and/or a
mucosal tear.

gunshot flank
necrotizing fasciitis
from gluteal stab &
missed rectal injury

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