Abdominal Trauma
Anatomy
4 regions
Intra-thoracic Intra-abdominal cavity Pelvis Retro-peritoneum
Frequency of Organ Injury
Spleen Liver Mesentery Urological Pancreas Small bowel Colon Duodenum
46% 33% 10% 9% 9% 8% 7% 5%
Clues from the history
Rapid deceleration Use of lap belt History of ejection Fall from great height 10% of admissions to trauma centers
Abdominal Trauma
Unrecognized injury : Cause of preventable death Exam compromised by Alcohol, illicit drugs Injury to brain, spinal cord Injury to ribs, spine, pelvis
Anatomy
External
Anterior abdomen Flank Back
Anatomy
Abdominal Evaluation
Blunt trauma
Penetrating trauma
Mechanism of injury
Blunt
Spleen, liver, and hollow viscus Compression Crushing Shearing Deceleration (fixed organs)
Mechanism of injury
Penetrating
Liver, small bowel, and colon Laceration / low energy Kinetic energy / high energy
Assessment : History
Blunt
Penetrating
Speed Point of impact Intrusion Safety devices Position Ejection
Weapon Distance
Mechanism of injury?
Mechanism of injury?
Mechanism of injury?
16
17
Assessment : Physical Exam
Inspection Percussion Palpation Auscultation
Assessment : Physical Exam
Local wound exploration by surgeon Pain over bony pelvis Genitourinary, perineal, rectal,vaginal and gluteal
Adjuncts : Intubation
Gastric Tube
Relieves dilatation Decompresses stomach before DPL
Caution
Basilar skull / facial fractures May induce vomiting / aspiration
Adjuncts : Intubation
Urinary Catheter
Monitors urinary output Decompresses bladder before DPL Diagnostic
Caution
Urethral injury
Adjuncts : X-ray Studies
Routine
Blunt : AP chest, pelvis Penetrating : AP chest, abdomen with markers (if hemodynamically normal) Urethrogram Cystogram
Contrast
GI IVP
Special Studies in Blunt Trauma
DPL Time Transport Sensitivity Specificity Eligibility Rapid No High Low All patients Rapid No High? Intermediate All patients US* CT Delayed Required High High Hemodynamically normal
*operator dependent
Associated with Fractures
left lower six ribs 20% spleen right lower six ribs 10% liver upper lumbar vertebra pancreas + duodenum transverse process kidney pelvis bladder urethra rectum vascular
Reliability of Clinical Evaluation
Low sensitivity Unreliable in 34 - 45% patients Why?
Reliability of Clinical Evaluation
Low sensitivity Unreliable in 34 - 45% patients Why? head injury spinal injury alcohol drug use
Investigative Techniques
Laparotomy Diagnostic Peritoneal Lavage Computer Tomography Ultrasound Scanning Laparoscopy
Immediate Laparotomy
Abdominal distension + hypotension Peritonitis Abdominal visceral injury
rectal bleeding and pelvic fracture ruptured diaphragm peritoneal air on CXR
Indications for Investigation
When abdominal examination is
Unreliable (altered mental state) Equivocal Unexplained hypotension or shock
DPL - Contraindications
Absolute
Patient needs laparotomy
Relative
Multiple previous operations Pregnancy (Third trimester)
DPL - Methods
Open Semi-closed Closed In common
Co-operative patient Sterile precautions Warm isotonic fluid (1L) Empty bladder NG tube preferred Roll + syphon
DPL - Choice of Method
Open
Abdominal distension Previous surgery pregnancy portal hypertension coagulopathy
gross obesity Pelvic # pregnancy prev incision
Closed
High
Diagnostic Peritoneal Lavage Methods
DPL - Positive Results
Gross blood >10 ml Red cells >100,000 /mm3 White cells >500 /mm3 (?) Amylase > 175u/dl gross GI contents bacteria on gram stain
DPL - Equivocal Results
Red cells 50,000 - 100, 000 /mm3 White cells 100 - 500 /mm3 Found in 2 - 6 % DPL Serious intra-abdominal injury in 86% Repeat lavage ?
DPL - advantages
Simple Fast Economical Reliable
accuracy false positive false negative
97.3 - 99.1 % 0.2 - 1.4 % 1.2 - 1.3 %
DPL - disadvantages
Oversensitive Lacks specificity Fails to investigate Complication rate
Source Amount Continuation Retroperitoneum
6-25% non-therapeutic laparotomy rate
1 - 1.7 %
Computed Tomography
CT - contraindications
Absolute
Patient needs laparotomy Unstable patient
CT - advantages
Non-invasive Reliable - Accuracy 91 - 98.3 % - Sensitivity 60 - 85 % - Specificity 100 % Delineate specific organ injury Haemoperitoneum > 100ml Assesses the retroperitoneum
CT - disadvantages
Need for transfer to scanner Need cooperative patient Complications related to contrast Ionizing radiation Cost + Time + Personnel Usefulness in hollow viscus injury ?
CT organ specific injury
Splenic injury
CT organ specific injury
Liver laceration
CT organ specific injury
Liver laceration & blood collection
CT organ specific injury
Pancreatic Transection
FAST
Focused abdominal sonography for trauma
To identify if the abdomen is the source of haemorrhage in unstable trauma patients ? - FLUID To evaluate those with no major risk factors for abdominal trauma
FAST - Results
Reliability
accuracy sensitivity specificity
86 - 97 % 88 - 91.7 % 94.7 - 99 %
Can detect 70 ml fluid
USG- Advantages
Safe (Non-invasive) Cheap Rapid Can be performed in resuscitation area Can be used to follow-up injuries being managed conservatively
USG - Disadvantages
Training required Interobserver variation Difficulties - subcutaneous emphysema - gas distension - morbid obesity Cannot determine type of fluid Inadequate detection of visceral perforation Accuracy improves on repeated scanning
FAST
Laparoscopy - Advantages
Can be used as adjunct to CT and allows direct visualization of injury allows assessment of whether there is ongoing bleeding
Laparoscopy - Disadvantages
Unsuitable for unstable patients Performed in operating room Difficulty to examine entire bowel length Difficulty to examine retroperitoneum Tedious Significant learning curve Requires presence of surgeon with expertise
Choice of investigation
DPL / CT Scan / USG (FAST) ? Unstable patient
to assess for blood and need for laparotomy
Stable patient
to define site of injury may permit non-operative Tx
Unstable patient
Requires experience
Blunt Abdominal Trauma
FAST
DPL
Laparotomy FAST
CT
CT
CT
Penetrating Injury
Gun shot? Evisceration? Rigid silent abdomen? Free gas on radiography? No Explore wound under local anesthesia
Is peritoneum intact? Yes Positive
DPL
Negative
No
Yes
Laparotomy
Admit, observe
Debride suture Consider discharge
Summary
FAST: bed side, sensitive, operator dependent DPL: bed side, oversensitive CT: specific, only on hemodynamically stable patients
Summary
Blunt abdominal trauma
Clinical examination may be unreliable Role of DPL, FAST, CT
Penetrating injury
Decision may be unequivocal in subtle clinical cases Role of wound exploration
