Introduction

Divided into two types :

Blunt
Crushing injury
Hit by car
Penetrating
Dog bites
Projectile: Gunshot
Stab or Impale

Patient can suffer both

eg; patient who involved in motor vehicle crashes

may be impaled on objects at the same time

Rapid, life-threatening bleeding can be

hidden in the abdomen

 Contusion of abdominal organs

Fracture of solid organs
Laceration or perforation of

abdominal organs
Avulsion of blood vessels
Hemoabdomen
Peritonitis
Septic
Hernia

Blunt Trauma
Most common mechanism of injury seen in US
Diffuse injury pattern
Biomechanics involve;

Compression
Crushing
Shearing
Stretching forces

Falls from height will produce a unique

pattern of injury.
The severity depends on the distance, surface

Marks of impact sustained by the

front-seat passenger in a car
crash

Penetrating Trauma
Stabs wound
Directly injure tissue as the blade passes through the

body
Any stab wound in the lower chest, pelvis, flank or
back has caused abdominal injury until proven
otherwise

Gunshot wound
Bullets designed to break apart once enter the body
Bullets may injure directly;
Secondary missiles, such as bone or bullet fragments or;
From energy transmitted from the bullet

Entrance and exit wound can approximate the

missile trajectory

Surface Anatomy of the

Abdomen
Quadrants
Upperright, left
Lowerright, left

Xiphoid

Right Upper Quadrant

Liver
Gall Bladder
Right Kidney
Ascending Colon
Transverse Colon

Symphysis pubis
Umbilicus

Right Lower Quadrant

Ascending Colon
Appendix
Right Ovary
(female)
Right Fallopian
Tube (female)

Left Upper Quadrant

Spleen
Stomach
Pancreas
Left Kidney
Transverse Colon
Descending
Colon

Left Lower Quadrant

Descending
Colon
Sigmoid colon
Left Ovary
(female)
Left Fallopian
Tube (female)

Abdominal Anatomy
Periumbilical area
Located around (peri) the navel

(umbilicus)
Small bowel lies in all quadrants in
periumbilical area

Suprapubic area
Located just above pubic bone
Urinary bladder, uterus lie in this area

Abdominal Cavity
Peritoneum = abdominal cavity lining
Divides abdomen into two spaces
Peritoneal cavity
Retroperitoneal space

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Abdominal Anatomy
Peritoneal

Retroperitoneal

Spleen
Liver

Pancreas
Kidney

Stomach
Gall bladder

Ureter
Inferior vena cava
Abdominal aorta

Bowel

Urinary bladder
Reproductive

organs

Disease, injury of retroperitoneal

organs often causes back pain
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Abdominal Anatomy
Organs can be classified as:
Hollow
Solid
Major vascular

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Diagnosing Abdominal
Injury

Solid Visceral Injury

Liver
Spleen
Kidney
Pancreas

When solid organs

are injured, they
bleed heavily and
cause shock
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 Usually produce symptoms by blood loss

Highly non specific
Young patient may lose 50 to 60% vol of

blood loss but asymptomatic (for many hours

or days)
Hypotension, tachycardia, skin changes, or
mental confusion with blood loss
Abdominal tenderness, distension, and/or
tympany may not be present until patient
has nearly exsanguinated into their abdomen
Thus, assuming that a stable patient does not
have an intraabdominal injury is hazardous

Gastrointestinal
Injuries
Blood loss + peritoneal

contamination
Gastric injuries produce symptoms
by chemical irritation when acidic
contents are spilled into the
abdominal cavity
Inflammation may take 6 to 8 hours
to develop

Retroperitoneal Injuries
Symptoms may be subtle or completely

absent initially
Duodenal injuries

Rupture due to rapid increase in intraluminal

pressure when both pylorus and the proximal

small bowel develop spasm
Rupture usually contained within the
retroperitoneum (abd pain, fever, tenderness)

Pancreatic
After decelerating injury
Very little hemorrhage
Leakage of enzymes digests structures in

retroperitoneal space, causes volume loss,

shock

Who needs evaluation?

1. Presence of abd pain, tenderness or distension
2. Mechanism of injury and prehospital death

suggest potential for injury

3. Lower chest or pelvic injury
4. High speed collision
5. MVA with fatalities
6. Unprotected injuries (i.e. motorcycle crashes)
7. Inability to tolerate a delayed diagnosis (e.g the
elderly, with comorbids)
8. Presence of distracting injuries (e.g long bone
fractures)
9. Decreased level of consciousness
10. Pain-masking drugs (eg; ethanol, opiates)

Physical examination
Is the patient shocked
Unexplained hypotension
Skin bruising immediately after injury
Abdominal distension
Increasing abdominal tenderness, guarding

and rigidity
Lateral lower rib fracture
Pelvic fractures
Are there associated injuries : eg. head, rib,
cervical spine etc.

Plain radiographs
Plain xray have an extremely limited use in
patients with blunt abdominal trauma
Chest and Plain Abdominal X-Rays (erect and
supine)

Free air under diaphragm

Diaphragmatic rupture
Rib and pelvic fractures

Screening evaluation
Both DPL and FAST can screen for hemoperitoneum after blunt
trauma

F.A.S.T

Diagnostic peritoneal lavage

Rapid, safe and inexpensive
~1% of major complication
Positive DPL : aspiration of

10 mL of free flowing blood

Only 25 mL of blood must

accumulate in the abd for

DPL to be positive
In general, positive if:
> 100,000 RBC/mm3
>500 WBC/mm3
Gram stain + for bacteria

Sensitivity 76 - 90%

Specificity 95 - 100%

The larger the

hemoperitoneum, the
higher the sensitivity. So
sensitivity increases for
clinically significant
hemoperitoneum.
How much fluid can FAST
detect?

250 cc total

100 cc in Morisons
pouch

Diagnostic Peritoneal
Lavage

Insertion of peritoneal dialysis catheter

into peritoneal cavity after midline
subumbilical incision
Instillation of 500 1000ml normal saline
Blood staining indicates intra-abdominal
injury
High in sensitivity
Negative result does not exclude serious
injury

FAST:Strengths and
Limitations
Strengths
Rapid (~2 mins)
Portable
Inexpensive
Technically simple, easy to
train (studies show
competence can be
achieved after ~30
studies)
Can be performed serially
Useful for guiding triage
decisions in trauma
patients

Limitations
Does not typically identify
source of bleeding, or detect
injuries that do not cause
hemoperitoneum
Requires extensive training
to assess parenchyma
reliably
Limited in detecting <250 cc
intraperitoneal fluid
Particularly poor at detecting
bowel and mesentery
damage (44% sensitivity)
Difficult to assess
retroperitoneum
Limited by habitus in obese
patients

CT scan

CT is recommended for evaluation of

hemodynamically stable patients with
equivocal findings on physical examination,
associated neurologic injury, or multiple extraabdominal injuries.

CT is the diagnostic modality of choice for

nonoperative management of solid visceral
injuries.

Does FAST replace CT?

Only at the extremes.
Unstable patient, (+) FAST OR
Stable patient, low force injury, (-) FAST consider
observing patient.
CT is far more sensitive than FAST for detecting and
characterizing abdominal injury in trauma. The
gold standard for characterizing intraparenchymal
injury.
Death begins with a CT. Never send an unstable
patient to CT. FAST, however, can be performed
during resuscitation.

EAST Algorithm: Unstable

Eastern Association for the Surgery of Trauma, 2001

EAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

Stab Wounds
Physical examination
Serial PE, are accurate in evaluating stab

wound

DPL
Closed technique
The accuracy increases from ~78-90% as the

threshold for positivity decreases

Must be observed in hospital for at least 12-24
hr

Local wound exploration

Surgical procedure require expertise
If no violation of anterior fascia, Discharge
If fascial violation, DPL can confirmed

diagnosis

Gunshot Wounds
To determine whether the missile

traverse the peritoneal cavity

Mostly requiring surgery
Penetrating trauma to the back and
flank can be investigated with contrast
enhanced CT enema
Likewise, FAST is now being used for
penetrating trauma
A +ve FAST has a +ve predictive value of

>90%
A ve FAST cannot exclude injury

Management
Principles of ATLS should be followed with priorities
given to ;

Airway : establish and maintain

Breathing : High flow O2 for

conscious pt. unconscious pt may

require intubation
Circulation : 2 large bore branula. In
haemodynamically unstable pt, fluid
resuscitation
Send blood for GXM, FBC, BUSE/creat

Management
Surgical intervention only effective therapy
Laparotomy is the gold standard therapy
Definitive, rarely misses an injury
Allows for complete evaluation of the abdomen

and retroperitoneum
Indication for immediate laparatomy
Evisceration, stab wounds with implement insitu and gunshot wounds traversing the
abdominal cavity
Any penetrating injury with haemodynamic
instability or peritoneal irritation
Persistent upper or lower GI bleed
X ray evidence of pneumoperitoneum or
diaphragmatic rupture