Abdominal trauma

PRESENTED BY: Dr Louza Alnqodi, R3

outlines
Background Clinical assessment of pt with blunt , penetrating abdominal injuries Diagnostic tools Clinical approach Conclusion.

R1
Which of the following does not cause a falsely +ve DPL? *Abdominal wall hematoma
*inadequate homeostasis *pelvic # *retroperitoneal injury

R1
Which of the following does not cause a falsely +ve DPL?

*Abdominal wall hematoma

*inadequate haemostasis *pelvic # retroperitoneal injury

R2
Criteria for a +ve DPL include all of the following except: *initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma *>5000 RBC in gunshot or penetrating low chest wound. *presence of bile, bacteria or meat/vegetable fibers

R2
Criteria for a +ve DPL include all of the following except:
initial aspiration of at least 50ml gross blood *>100,000 RBC in blunt trauma *>5000 RBC in gunshot or penetrating low chest wound. *presence of bile, bacteria or meat/vegetable fibers

R3
During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to the rt . No free air is present. What is the main concern?
*bowel perforation *gastric injury *retroperitoneal hematoma *splenic injury

R3
During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to the rt . No free air is present. What is the main concern?
*bowel perforation *gastric injury *retroperitoneal hematoma *splenic injury

R4
All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
*bowel protrusion or evisceration *evidence of diaphragmatic injury *indeterminate local wound exploration Peritoneal irritation on physical examination Significant GI bleeding

R4
All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
*bowel protrusion or evisceration *evidence of diaphragmatic injury *indeterminate local wound exploration Peritoneal irritation on physical examination Significant GI bleeding

R5
A 25 yr old male presents with a stab wound to the upper abdomen. Vital signs are stable. The abdomen is not distended, soft, non-tender. Bowel sounds are present. Upright CXR does not demonstrate a Penumothorax or free air under diaphragm. What should the next step be?
*evaluation of the peritoneal entry by local wound exploration *performing DPL *Proceeding directly to Laprotomy *suturing of the wound and discharging the pt with clear instruction.

R5
A 25 yr old male presents with a stab wound to the upper abdomen. Vital signs are stable. The abdomen is not distended, soft, non-tender. Bowel sounds are present. Upright CXR does not demonstrate a Penumothorax or free air under diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound exploration

*performing DPL *Proceeding directly to Laprotomy *suturing of the wound and discharging the pt with clear instruction.

anatomy
Anterior abdomen flank Back intraperitoneal contents Retroperitoneal space contents Pelvic cavity contents

o Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal ligaments and symphysis pubis.

o flank:
anterior and posterior axillary line ;sixth intercostal to iliac crest

o Back:
posterior axillary line; tip of scapula to iliac crest

 Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small bowel, sigmoid colon

Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending and descending colons

Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia

mechanism
Blunt trauma:
MVC Seatbelt injury fall from ht crash injury sport injury

Penetrating injuries.

Blunt abdominal injuries carry a greater risk of morbidity and mortality than peneterating abdominal injuries.

 associated with severe trauma to multiple intraperitoneal organs and extra-abdominal systems altered mental status, intoxication Peritoneal signs are often subtle and may be obscured by other painful injuries Up to 20% of patients with hemoperitoneum have benign abdominal exams on initial presentation.

Blunt injury
Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Retroperitoneal hematoma: 15%

Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?

CT scan may confirm injury, but should not delay laparotomy

in unstable patients. Twenty percent of patients with left lower rib fractures have associated splenic injury. Focused Assessment with Sonography for Trauma is useful if performed by experienced users. Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.

Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?

CT scan may confirm injury, but should not delay laparotomy

in unstable patients. Twenty percent of patients with left lower rib fractures have associated splenic injury. Focused Assessment with Sonography for Trauma is useful if performed by experienced users. Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.

Seatbelt injuries
Unrestrained front and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts. The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries.

However, abdominal injuries are still ascribed to shoulder-lap and lap-belt systems.

pathogensis
o compression of bowel between the belt and the vertebral column. o an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.

Clinically, two symptom patterns emerge.

~1/4 of pt develop evidence of a hemoperitoneum secondary to mesenteric lacerations. In the remainder, the intestinal injury most commonly involves the jejunum contusion or perforation. Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.

Penetrating abdominal trauma

Mechanism

Stab wound gunshot

 Knives are not the sole implement used in stabbings.

Ice picks, pens, coat hangers, screwdrivers, and broken bottles.

most commonly in the upper quadrants, the left

more commonly than the right.

Stab wound
multiple in 20% of cases involve the chest in up to 10% of cases. Most stab wounds do not cause an intraperitoneal injury the incidence varies with the direction of entry into the peritoneal cavity The liver, followed by the small bowel, is the organ most often damaged by stab wounds.

Gunshot Wounds
handguns, rifles, and shotgun

the degree of injury depends . amount of kinetic energy imparted by the bullet to
the victim mass of the bullet and the square of its velocity Distance .

Missile velocities : low (slower than 1100ft/sec) medium (1100-2000ft/sec) high (faster than 2000-2500ft/sec)

 type I wounds: long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia only. Type II wounds: distance of 3 to 7 yards and may create a large number of perforated structures. Type III wounds occur at point-blank range (<3 yards) and involve a massive destruction of tissue

 multiple organ injuries are sustained, notably perforations to bowel . greatest for small bowel, followed by the colon and then the liver.

Missiles effects
Extensive tissue damage external contaminants tend to be dragged into the wound. the closure of the tract immediately after the bullet's passage may lead to an underestimation of tissue damage. high-velocity bullets can fragment internally

 Small bowel injury is the most common injury resulting from ___ abdominal trauma. penetrating blunt

 Small bowel injury is the most common injury resulting from ___ abdominal trauma. penetrating blunt

CLINICAL ASSESSMENT OF PT WITH ABDOMINAL TRAUMA .

history
Primary goal is to identify that an injury exists, not necessarily making an accurate diagnosis. The patient's history may be unobtainable, elusive, or temporarily abandoned while resuscitative measures are carried out. History from prehospital care team or transferring hospital : the vital signs, physical assessment, prehospital course, and response to therapy should be obtained

Mechanism of injury is an important factor in developing a high index of suspicion; thus a detailed history is helpful if available.

Details about accident Damage to car Velocity Steering wheel damage Type of seatbelts used Air bags deployed All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury

In penetrating trauma: # of shots or stabs Type of weapon Distance b/w firearm and victim

examination

Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is 55% to 65%.

Although the presence of physical findings makes intraperitoneal injury more likely, their absence does not preclude serious pathology, and none is exclusively diagnostic of a specific injury.

 Hypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury. hypotension with significant multiple blunt trauma and is unexplained, one should assume the presence of intraperitoneal hemorrhage until it is excluded.

In conscious, alert pt, look for: Abdo tenderness,90% Peritoneal irritation Penetrating: wounds (log roll pt) Ecchymosis, Cullen and Gray-Turner signs

 Rectal exam is important; assess for blood and palpable bony fragments and position of the prostate. High riding prostate suggests posterior urethral tears.

Urethral disruption should be considered when blood is noted at the meatus.

Vaginal exam for bleeding may suggest bony fragments causing laceration. Implications of bleeding during pregnancy should be considered.

 The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:
abdominal pain and tenderness early bacterial peritonitis development of rebound, guarding and rigidity hypotension and tachycardia palpable mass and radiographic mass effect (may result from confined hemorrhage)

 The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:
abdominal pain and tenderness early bacterial peritonitis development of rebound, guarding and rigidity hypotension and tachycardia palpable mass and radiographic mass effect (may result from confined hemorrhage)

DIAGNOSTIC STRATEGIES
Hct: can be a delayed sign, should do serial. WBC: in stress, peritoneal irritation Pancreatic enzymes: if normal, does NOT r/o pancreatic injury amylase: EtOH, narcotics amylase & lipase: ischemia 2 hypotension both non-specific & non-sensitive for pancreatic injuries

 Are abdo x-rays useful in trauma?

Although plain abdominal films can demonstrate numerous findings, their place in acute trauma is limited. Because of spinal precautions, hemodynamic instability, time consuming or patient discomfort.

Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :
pleural effusion appearance of the nasogastric tube in the chest appearance of bowel loops in the chest elevation of the diaphragm blurring of the diaphragm

Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :
pleural effusion appearance of the nasogastric tube in the chest appearance of bowel loops in the chest elevation of the diaphragm blurring of the diaphragm

Imaging
CT
Able to define organ injury Good for retroperitoneal & vertebral column Non-invasive Not Operator dependant

US
Good for solid organs Portable Fast 100 cc detection blood Mediastinum evaluation No radiation No contrast need Not see well: solid parenchymal, retroperitoneal, diaphragm Problem if: obesity, gas Less sensitive than DPL for hemoperitoneal Operator dependant

Not great for hollow viscus Stable patient Cost $$$ Complications: IV or oral contrast

20 y/o female patient involved in a low velocity MVA. Upon initial exam no abnormalities noted, no complains. The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT Scan which showed Liver Laceration Grade III. This patient was treated nonoperatively.

Preferred Site of Diagnostic Peritoneal Lavage

Standard adult :Infraumbilical midline C or SO Standard pediatric: Infraumbilical midline C or SO 2ed &3ed trimester pregnancy :Suprauterine FO Midline scarring :Left lower quadrant FO Pelvic fracture: Supraumbilical FO

DPL RBC Criteria (per mm3 )

Positive Indeterminate 20100,000

Blunt Stab wound

Anterior abdomen
Flank Back

100,000

100,000 100,000 100,000

5000 5000

20,000100,000 20,000100,00 20,000100,000

1000-5000 1000-5000

Low chest
Gunshot wound

 List causes false negative DPL?

Catheter preperitoneal space Fluid in compartment 2 adhesions Diaphragmatic tear, so fluid goes into thoracic cavity

-sole absolute contraindication to DPL is the established

need for laparotomy.
Relative contraindications: - prior abdominal surgery - Infections - Coagulopathy - obesity - second- or third-trimester pregnancy.

CLINICAL APPROCHES TO PT WITH:

o o o o BLUNT ABDOMINAL TRAUMA STAB WOUND GUNSHOT ABDOMINAL WITH PELVIC TRAUMA.

Clinical Indications for Laparotomy after Blunt Trauma

Manifestation Pitfall

Unstable vital signs with Alternate sources shock strongly suspected abdominal injury Unequivocal peritoneal irritation Pneumoperitoneum Unreliable
Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy)

Evidence of diaphragmatic injury Significant gastrointestinal bleeding

Nonspecific Uncommon, unknown accuracy

Approach to abdominal stab wound.

Step I: Clinical Indications for Laparotomy. Step II: Peritoneal Violation. Step III: Injury Requiring Laparotomy.

Clinical Indications for Laparotomy Following Penetrating Trauma

Manifestation Premise
vascular injury

Pitfall
Thorax or mediastinum, causal or contributory Unreliable, especially immediately post-injury No injury in one fourth to one third of stab wound cases Rare clinical, radiographic findings

Hemodynamic instability Major solid visceral or Peritoneal signs Evisceration Diaphragmatic injury
Intraperitoneal injury Additional bowel, other injury Diaphragm

Gastrointestinal hemorrhage
Implement in situ

Proximal gut
Vascular impalement

Uncommon, unknown accuracy

Comorbid disease or pregnancy creates high operative risk Insensitive; may be caused by intraperitoneal entry only or be due to cardiopulmonary source

Intraperitoneal air

Hollow viscus perforation

Peritoneal Violation.
1. 2. 3. 4. 5. Evisceration Intraperitoneal air Local wound exploration Ultrasonography Laparoscopy

Stab wound to right lower quadrant with caecal evisceration. No colon injury at laparotomy.

 Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?

Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy. Return all eviscerated organs to the peritoneal cavity. Only organs with vascular compromise should be promptly returned to the abdominal cavity.

 Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?

Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy. Return all eviscerated organs to the peritoneal cavity. Only organs with vascular compromise should be promptly returned to the abdominal cavity.

 In the abdominal stab wound victim without clear indications for exploration (obvious peritoneal penetration, unexplained hypotension, or signs of peritoneal irritation), local wound exploration with local anesthesia should be performed; laparotomy should be performed if the __ is penetrated.

rectus abdominis muscle posterior rectus sheath transversalis fascia.

25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar entered at the level of the epigastrium and exited through the left posterior thoracic wall.

Abdominal stab wound, with hepatic .lesion grade II

Implements in situ
implements in situ of the torso in the operating room. to ensure expeditious control of hemorrhage the implement reside within a vascular space or highly vascularized organ.

exceptions to this practice exist: situations in which emergency department resuscitation is impeded by the presence of the implement the patient is at high risk of significant morbidity from nontherapeutic laparotomy because of severe comorbid conditions or pregnancy.

What is your approach to pelvic #?

conculsion
The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury.

The choice of diagnostic studies for abdominal trauma is based on clinical need first and foremost, as well as study availability and the trustworthiness of that study in a respective center

 Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of hemoperitoneum in the critically ill blunt or penetrating trauma patient.

Clinical indications for laparotomy are more dependable in and more frequently applicable to cases of penetrating

trauma than cases of blunt trauma.

THANK YOU