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?

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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