• General Principles

o The abdomen is a diagnostic "black box."

o The goal in the ED is to determine the need for exploratory laparotomy rather than identifying specific
organ injuries.
o Physical examination is often unreliable due to factors like drugs, alcohol, head injuries, and spinal
cord injuries.
o Abdominal rigidity and hemodynamic compromise are clear indications for immediate surgical
exploration.
o Various diagnostic adjuncts help identify abdominal injuries.
o The approach differs for penetrating trauma vs. blunt trauma.
• Penetrating Abdominal Trauma
o Gunshot Wounds (GSWs)
 Laparotomy is warranted for gunshot or shotgun wounds that penetrate the peritoneal cavity.
 Standard approach: laparotomy for anterior truncal gunshot wounds between the fourth
intercostal space and the pubic symphysis if trajectory suggests peritoneal penetration.
 Increasing use of CT scans for nonoperative management of abdominal GSWs.
 Exceptions:
 Right upper quadrant (RUQ) penetrating trauma: if trajectory is confined to the liver
by CT, nonoperative observation may be reasonable.
 Obese patients: CT scan can delineate the track of a tangential wound and exclude
peritoneal violation.
 Laparoscopy can assess peritoneal penetration for tangential wounds but should not
be performed in unstable patients.
 Tangential high-energy GSWs may still cause transmitted hollow visceral injury due to
a blast effect.
 Gunshot wounds to the back or flank are difficult to evaluate due to retroperitoneal
organ involvement.
 Triple-contrast CT scan helps determine bullet trajectory and
peritoneal/retroperitoneal penetration.
o Stab Wounds
 Less likely than gunshot wounds to injure intra-abdominal organs.
 Anterior abdominal stab wounds (costal margin to inguinal ligament, between bilateral
midaxillary lines):
 Explored under local anesthesia in the ED to determine fascial penetration.
 If no peritoneal penetration, no further evaluation is needed, and the patient may be
discharged.
 If fascia is penetrated, further evaluation is required due to a 50% chance of requiring
laparotomy.
 Debate exists over the best diagnostic approach: serial examination, diagnostic
peritoneal lavage (DPL), or CT scanning.
 Recent evidence supports serial examination and laboratory evaluation.
 Right upper quadrant stab wounds:
 CT scan can assess trajectory and confinement to the liver for potential nonoperative
care.
 Flank and back stab wounds:
 Contrasted CT scan is used to assess for retroperitoneal injuries to the colon,
duodenum, and urinary tract.
o Thoracoabdominal Wounds
 May cause occult diaphragmatic injuries.
 Left lower chest wounds (gunshot or stab):
 Require diagnostic laparoscopy or DPL to exclude diaphragmatic injury.
 Right diaphragmatic injuries:
 Generally ignored unless a major liver injury is present, increasing the risk of a
biliopleural fistula.
 Diagnostic laparoscopy may be preferred over DPL in patients with a positive chest
radiograph (hemothorax or pneumothorax) or those who cannot tolerate DPL.
 DPL values for diaphragmatic injury differ from those for abdominal stab wounds:
  RBC count >10,000/μL is positive and warrants abdominal evaluation.
 RBC count between 1,000/μL and 10,000/μL suggests the need for laparoscopy or
thoracoscopy.
• Blunt Abdominal Trauma
o Initial evaluation with FAST (Focused Assessment with Sonography for Trauma)
 FAST has largely replaced DPL.
 FAST is not 100% sensitive.
 Hemodynamically unstable patients without a clear source of blood loss require diagnostic
peritoneal aspiration to rule out abdominal hemorrhage.
 FAST detects free intraperitoneal fluid (>250 mL) in:
 Morrison’s pouch
 Left upper quadrant
 Pelvis
 FAST does not reliably identify the source of hemorrhage or grade solid organ injuries.
o Management of Positive FAST Findings
 Patients with free fluid on FAST but no immediate laparotomy indications (hemodynamically
stable, no peritonitis) undergo CT for further evaluation.
 CT scan findings to note:
 Injury grading using the American Association for the Surgery of Trauma (AAST) scale.
 Contrast extravasation ("blush").
 Amount of intra-abdominal hemorrhage.
 Presence of pseudoaneurysms.
 CT is also used for patients with unreliable physical examinations.
o Limitations of CT Scanning
 Intestinal injuries are difficult to identify.
 Possible indicators of bowel injury:
 Thickened bowel wall
 Mesenteric “streaking”
 Free fluid without solid organ injury
 Free intraperitoneal air
o Monitoring and Further Evaluation
 Patients with free intra-abdominal fluid but no solid organ injury require close monitoring for
peritonitis.
 If the patient has a significant closed head injury or cannot be serially examined, DPL is
performed to rule out bowel injury.
• Diagnostic Peritoneal Lavage (DPL) Process
o Performed using an infraumbilical approach.
o Steps:
1. Insert catheter.
2. Connect a 10-mL syringe and aspirate abdominal contents (diagnostic peritoneal
aspiration).
3. If >10 mL of blood is aspirated, the test is positive.
4. If <10 mL, infuse 1 liter of normal saline.
5. Withdraw effluent via siphoning.
6. Send for laboratory analysis.
o DPL laboratory evaluation (Table 7-6):
 RBC count
 WBC count
 Amylase
 Bilirubin
 Alkaline phosphatase
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GENERAL PRINCIPLES OF MANAGEMENT
 General Principles of Management
• Over the past 25 years, there has been a remarkable change in management practices and operative
approaches for injured patients.
 Nonoperative Management
• CT scanning has led to nonoperative management of solid organ injuries, replacing routine operative
exploration.
• Abdominal drains, once considered mandatory for parenchymal injuries and some anastomoses, have largely
disappeared.
• Fluid collections are now managed by percutaneous techniques instead of routine drainage.
 Operative Management
• Less radical resection techniques are now used:
o Splenorrhaphy instead of total splenectomy.
o Partial nephrectomy instead of total nephrectomy.
• Colonic injuries:
o Previously required colostomy.
o Now primarily repaired in virtually all cases.
• Anastomosis techniques:
o Shift from double-layer closure to continuous running single-layer closure, which is faster and
technically equivalent to multilayer techniques.
• Damage control surgery:
o Used in physiologically deranged patients.
o Limits initial operative time.
o Definitive repair is delayed until after resuscitation in the surgical intensive care unit (SICU).
 Advancements in Trauma Management
• Endovascular techniques:
o Stenting of arterial injuries and angioembolization are now routine adjuncts.
• Blunt cerebrovascular injuries (BCVI):
o Recognized as a significant preventable source of neurologic morbidity and mortality.
• Pelvic fracture management:
o Preperitoneal pelvic packing for unstable pelvic fractures.
o Early fracture immobilization with external fixators is a paradigm shift.
• Resuscitative endovascular balloon occlusion (REBOA):
o Recently added to the trauma armamentarium for life-threatening pelvic fracture bleeding.
 Hemostatic and Transfusion Strategies
• Massive transfusion protocols:
o Balance benefits of blood component therapy with immunologic risks.
• Viscoelastic hemostatic assays (TEG and ROTEM):
o Superior to traditional laboratory tests.
o Central to the evolving concept of goal-directed hemostasis.

Transfusion Practices
•  Injured patients with life-threatening hemorrhage develop acute coagulopathy of trauma (ACOT).
• Mechanism of inadequate clot formation involves:
o Activation of protein C, impairing Va and VIIa.
o Glycocalyx breakdown, releasing heparin sulfate.
o Immune activation, releasing DAMPs, DNA, histone, polyphosphate, and PMN elastase.
o Complement activation.
• Fibrinolysis is a key component of ACOT:
o Hyperfibrinolysis and fibrinolysis shutdown are both linked to increased mortality.
 Blood Component Therapy
• Fresh whole blood is not available in the United States since the early 1980s.
• Blood components used:
o Packed red blood cells (PRBCs).
o Fresh frozen plasma.
o Platelets.
 o Cryoprecipitate.
• Transfusion triggers for individual blood components remain debated.
o Critical care guidelines: PRBC transfusion at hemoglobin <7 g/dL.
o Acute resuscitation phase: Hemoglobin target of 10 g/dL to facilitate hemostasis via platelet
margination.
• Traditional thresholds for blood component replacement in coagulopathic patients:
o INR >1.5.
o PTT >1.5 normal.
o Platelet count <50,000/μL.
o Fibrinogen <100 mg/dL.
• TEG and ROTEM criteria have replaced traditional guidelines in many trauma centers.
• Goal: Limit transfusion of immunologically active blood components to reduce risks:
o Transfusion-associated lung injury.
o Secondary multiple organ failure.
 Massive Transfusion Protocols (MTP)
• Required for critically injured patients needing large blood component therapy.
• Goal:
o Restore blood volume.
o Reverse shock.
o Correct coagulopathy.
• Optimal transfusion ratio is unknown, but current evidence supports:
o 1:2 red cell:plasma ratio for patients at risk of massive transfusion (10 units of PRBCs in 6 hours).
• Emergency transfusions:
o Type O-negative RBCs given when cross-matching is unavailable (takes up to 45 minutes).
o AB plasma is the universal donor, but A plasma is a safe alternative.
• Blood typing and cross-matching are essential to prevent life-threatening intravascular hemolytic
transfusion reactions.
• Trauma centers and blood banks must be capable of transfusing >50 blood component units per procedure
when necessary.
• Preemptive massive transfusion protocols allow coordination between:
o Surgeons.
o Anesthesiologists.
o Blood bankers.
 Post-Injury Coagulopathy and the Lethal Triad
• Shock-induced coagulopathy is exacerbated by:
o Core hypothermia.
o Metabolic acidosis.
• This is termed the "bloody vicious cycle", now known as the "lethal triad".
• Pathophysiology of the lethal triad:
o Inhibition of temperature-dependent enzyme-activated coagulation cascades.
o Platelet dysfunction.
o Endothelial abnormalities.
o Fibrinolytic activity changes.
• Coagulopathy may be insidious:
o Surgeons must recognize subtle signs, such as excessive bleeding from skin edges.
• Point-of-care viscoelastic assays (TEG and ROTEM):
o Provide comprehensive assessment of clot capacity and fibrinolysis.
o Results available in 15 minutes.
• Traditional laboratory coagulation tests:
o INR, PTT, fibrinogen levels, and platelet count take at least 45 minutes.
• Damage control surgery limits operative time and allows physiologic restoration in the SICU, improving
survival.
Prophylactic Measures
Preoperative and Intraoperative Care
• Preoperative Antibiotics
o All injured patients undergoing an operation should receive preoperative antibiotics.
o The type of antibiotic is determined by the anticipated source of contamination in the abdomen or
other operative region.
o Additional doses should be administered during the procedure based on blood loss and the half-life
of the antibiotic.
o Extended postoperative antibiotic therapy is administered only for contaminated open fractures.
o Tetanus prophylaxis is administered to all patients according to published guidelines.
Venous Thromboembolism (VTE) Prevention
• Trauma patients are at risk for venous thromboembolism (VTE) and its associated morbidity and mortality.
• Pulmonary embolism (PE) can occur much earlier in the patient’s hospital course than previously believed.
• High-risk patients for VTE:
o Patients with multiple fractures of the pelvis and lower extremities.
o Patients with traumatic brain injury (TBI) or spinal cord injury.
o Patients requiring ligation of large veins in the abdomen and lower extremities.
o Morbidly obese patients.
o Patients over 55 years of age.
• VTE Prophylaxis:
o Low molecular weight heparin (LMWH) is initiated as soon as bleeding has been controlled and
intracranial pathology is stable.
o High-risk patients should receive antiplatelet therapy in addition to LMWH.
o Removable inferior vena cava (IVC) filters should be considered if there are prolonged
contraindications to LMWH administration.
o Pulsatile compression stockings (sequential compression devices) are routinely used unless
contraindicated by a fractured lower extremity or vascular injury.
Thermal Protection in Trauma Patients
• Hypothermia Risks in Trauma Patients:
o Hemorrhagic shock impairs perfusion and metabolic activity, reducing heat production and body
temperature.
o Removing clothing causes additional heat loss.
o Cold PRBCs or room temperature crystalloid infusion further exacerbates hypothermia.
o Patients may arrive in the OR with temperatures below 34°C (93.2°F).
• Effects of Hypothermia:
o Aggravates coagulopathy.
o Provokes myocardial irritability.
• Hypothermia Prevention:
o In the ED:
 Maintain a comfortable ambient temperature.
 Cover patients with warm blankets.
 Administer warmed IV fluids and blood products.
o In the OR:
 Use a Bair Hugger® warmer (upper body or lower body blanket).
 Administer heated inhalation via ventilatory circuit.
o For severe hypothermia (temperature <30°C [86°F]), arteriovenous rewarming should be
considered.
Emergent Abdominal Exploration
• Incision Choice:
o In adults: Midline incision (versatile).
o In children under age 6: Transverse incision may be advantageous.
• Incision Technique:
o Scalpel is preferred over an electrosurgical unit for speed.
o Incisional abdominal wall bleeding should be ignored until intra-abdominal hemorrhage is
controlled.
• Hemorrhage Control:
 o Evacuation of liquid and clotted blood with multiple laparotomy pads to identify major bleeding
sources.
o Blunt Trauma:
 Palpate spleen and liver first and pack if fractured.
 Inspect infracolic mesentery for zone I vascular injury.
o Penetrating Trauma:
 Follow trajectory of the penetrating device to locate bleeding sources.
• Severe Hypotension (SBP <70 mmHg):
o Apply digital pressure or clamp on the aorta at the diaphragmatic hiatus.
o After hemorrhage localization:
 Direct digital occlusion for vascular injury.
 Laparotomy pad packing for solid organ injury.
• Specific Hemorrhage Control Techniques:
o Liver Bleeding:
 If patient is hemodynamically unstable, use Pringle maneuver (clamp hepatic pedicle with a
vascular clamp or Rummel tourniquet).
o Splenic Bleeding:
 Clamp the splenic hilum if hilar bleeding is present.
 To mobilize the spleen:
 Rotate medially to expose the lateral peritoneum.
 Incise peritoneum and endoabdominal fascia for blunt dissection from
retroperitoneum.
• Exposure of Intra-Abdominal Vasculature:
o Proximal aorta control at the diaphragmatic hiatus.
o If supraceliac aortic injury, consider:
 Transecting the left crus of the diaphragm.
 Extending the laparotomy via a left thoracotomy.
o Alternative: Transfemoral REBOA into zone I for contained hematomas.
• Vascular Injury Approach:
o Supracolic vascular injuries (aorta, celiac axis, proximal SMA, left renal arteries):
 Left medial visceral rotation.
o Fullen zone I SMA injuries (posterior to pancreas):
 Left medial visceral rotation.
o Fullen zone II SMA injuries (pancreatic edge to middle colic branch):
 Access via lesser sac at the base of the transverse mesocolon.
 May divide pancreas for access.
o Fullen zones III & IV SMA injuries:
 Direct mesentery approach.
o Inferior vena cava (IVC) injuries:
 Right medial visceral rotation.
 Proximal control just above the iliac bifurcation using a sponge stick.
 Satinsky clamp for anterior caval wounds.
• Iliac Vessel Injuries:
o Proximal aortic control stops arterial bleeding but not venous hemorrhage.
o Tamponade with digital pressure or laparotomy pads helps prevent exsanguination.
o Sponge sticks placed on either side of the injury improve hemostasis.
o Complete pelvic vascular isolation may be required for severe bleeding.
o Right common iliac artery may require division for exposure of venous injuries.
o Artery must be repaired after venous injury treatment to prevent limb ischemia.
Identification of Enteric Contamination
• After hemorrhage control:
o Inspect small and large bowel for injury.
o Unroof associated hematomas to rule out adjacent bowel injury.
o Inspect stomach (anterior and posterior) via lesser sac opening.
o Evaluate duodenal injuries with a wide Kocher maneuver.
o Palpate pancreas (including posterior surface) to exclude injury.
Postoperative Considerations
• Damage Control vs. Primary Repair:
o Decision based on patient’s intraoperative physiologic status.
• Enteral Access Considerations:
o Multisystem trauma patients may require gastrostomy or jejunostomy tube.
• Abdominal Closure:
o Irrigate with warm saline before closure.
o Midline fascia closed with running heavy absorbable suture.
o Skin closure based on intra-abdominal contamination.

Abdominal Injuries
Liver and Extrahepatic Biliary Tract
1. Susceptibility to Injury
• The liver is highly susceptible to blunt trauma due to its large size.
• Frequently involved in upper torso penetrating wounds.
2. Nonoperative Management
• Pursued in hemodynamically stable patients without peritonitis or other indications for laparotomy.
• Criteria for SICU Admission:
o Patients with >Grade II injuries.
o Frequent hemodynamic monitoring, hemoglobin determination, and abdominal examination.
• Absolute Contraindication:
o Hemodynamic instability from intraperitoneal hemorrhage.
• Predictors of Complications or Failure:
o High injury grade, large hemoperitoneum, contrast extravasation, or pseudoaneurysms.
• Adjuncts to Nonoperative Management:
o Angioembolization and ERCP.
o Indication for hepatic hemorrhage control via angiography:
 Transfusion of 4 units of RBCs in 6 hours or 6 units in 24 hours.
3. Operative Management
• Indications: 15% of patients require emergent laparotomy.
• Primary Goal: Arrest hemorrhage.
• Initial Control Measures:
o Perihepatic packing and manual compression.
o Opposition of liver laceration edges for local pressure control.
o Strategic pad placement for bleeding control (10-15 pads for extensive right lobar injury).
o Left lobe packing less effective due to inadequate compression support.
o Pringle Maneuver: Immediate application to control major hemorrhage.
 Intermittent release helps attenuate hepatic cellular loss.
• Persistent Bleeding Despite Packing:
o Consider injuries to hepatic artery, portal vein, or retrohepatic vasculature.
o Pringle maneuver helps identify bleeding source:
 Stops bleeding from hepatic artery/portal vein.
 Does not stop bleeding from hepatic veins/retrohepatic vena cava.
4. Management of Specific Vascular Injuries
• Portal Triad Vasculature Injuries:
o Ligation from the celiac axis to the common hepatic artery at gastroduodenal branch is tolerated.
o Proper hepatic artery should be repaired.
o Right or left hepatic artery and, in urgent cases, portal vein may be selectively ligated.
o Lobar necrosis may necessitate delayed resection.
o Right hepatic artery ligation requires cholecystectomy.
o Repair Techniques:
 Stab wounds: Primary end-to-end repair.
 Destructive injuries: Temporary shunting followed by RSVG.
 Blunt avulsions: Directed packing or Fogarty catheters.
 Proximal portal triad injuries: Pancreatic transection for access.
• Retrohepatic Vena Cava or Hepatic Vein Injuries:
o If Controlled by Packing: Leave undisturbed, monitor in SICU.
 o Persistent Bleeding:
 Direct repair with/without hepatic vascular isolation.
 Three Techniques for Hepatic Vascular Isolation:
1. Suprahepatic/infrahepatic clamping of vena cava with stapled resection.
2. Temporary shunting of retrohepatic vena cava.
3. Venovenous bypass.
o Hepatic vein stenting via interventional radiology may be considered.
5. Techniques for Hepatic Parenchymal Hemorrhage Control
• Minor Lacerations: Manual compression.
• Topical Hemostatic Agents:
o Electrocautery, argon beam coagulator, microcrystalline collagen, thrombin-soaked gelatin foam
sponge, fibrin glue, BioGlue.
• Suturing Techniques:
o Liver sutures (blunt-tipped 0 chromic sutures) for hemostasis.
o Running sutures for shallow lacerations.
o Horizontal mattress sutures for deeper lacerations.
o Avoid excessive tension to prevent hepatic necrosis.
• Alternative Approaches:
o Hepatic lobar arterial ligation for recalcitrant hemorrhage.
o Omentum use to fill large defects and provide macrophage support.
o Intraparenchymal tamponade with Foley catheter or balloon occlusion.
o Hepatotomy with bleeder ligation.
o Angioembolization: Considered early in treatment.
6. Liver Transplantation for Trauma
• Considered in extraordinary cases with extensive hepatic injury or necrosis.
• Requires exclusion of other severe injuries (e.g., CNS injuries).
• Donor availability is a limiting factor.
7. Gallbladder and Extrahepatic Biliary Duct Injuries
• Gallbladder Injuries: Require cholecystectomy.
• Extrahepatic Bile Duct Injuries:
o Small lacerations: T-tube insertion or lateral suturing with 6-0 monofilament absorbable suture.
o Transections/tissue loss: Roux-en-Y choledochojejunostomy.
o Anastomosis secured with single-layer interrupted 5-0 monofilament suture.
o Hepatic duct injuries: Often impossible to repair emergently.
 Approaches: External drainage with delayed repair or ERC stenting.
 Ligation possible if the opposite lobe is intact.
8. Postoperative Management
• Perihepatic Packing Removal:
o Typically 24 hours post-injury.
o Earlier if ongoing hemorrhage.
o Signs of rebleeding: Falling hemoglobin, blood clot accumulation, bloody drain output, hemodynamic
instability.
o Post-op hemorrhage reevaluated in OR after coagulopathy correction.
o Angioembolization is an option for complex injuries.
• Expected Transaminase Elevation:
o Due to prolonged Pringle maneuver, typically resolves.
o Hepatic artery ligation may cause frank hepatic necrosis.
• Liver Fever:
o Common in first 5 days post-injury.
o Intermittent fevers should be evaluated for infectious complications.
9. Complications
• Hemorrhage and Hepatic Necrosis.
• Bilomas:
o Loculated bile collections, infected or sterile.
o If infected: Treat as abscess via percutaneous drainage.
o Large collections should be drained.
• Biliary Ascites:
 o Major bile duct disruption.
o Often requires reoperation and wide drainage.
• Pseudoaneurysms and Biliary Fistulas:
o Arterial pseudoaneurysms can rupture:
 Into bile duct (hemobilia: RUQ pain, GI bleeding, jaundice).
 Into portal vein (portal hypertension with esophageal varices).
 Best treated with hepatic arteriography and embolization.
o Biliovenous fistulas cause rapid bilirubin elevation.
 Treated with ERCP and sphincterotomy.
o Pleurobiliary/Bronchobiliary Fistulas:
 Result from diaphragm injury.
 Require operative closure; occasionally resolve with endoscopic sphincterotomy and stenting.