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Abdominal Trauma

Cheryl Pirozzi, MD
Fellows Conference 5/4/11
Abdominal Trauma
Penetrating Abdominal Trauma
Stabbing 3x more common than firearm wounds
GSW cause 90% of the deaths
Most commonly injured organs: small intestine > colon > liver
Blunt Abdominal Trauma
Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple organs/systems)
Most commonly injured organs: spleen > liver, intestine is the
most likely hollow viscus.
Most common causes: MVA (50 - 75% of cases) > blows to
abdomen (15%) > falls (6 - 9%)

Rosens Emergency Medicine, 7
th
ed. 2009
Pathophysiology of injury
Penetrating Abdominal Trauma
Stab Wounds
Knives, ice picks, pens, coat
hangers, broken bottles
Liver, small bowel, spleen
Gunshot wounds
small bowel, colon and liver
Often multiple organ injuries,
bowel perforations


Rosens Emergency Medicine, 7
th
ed. 2009
Pathophysiology of injury

Rosens Emergency Medicine, 7
th
ed. 2009
Pathophysiology of injury
Blunt Abdominal Trauma
Rupture or burst injury of a hollow organ by sudden rises in
intra-abdominal pressures
Crushing effect
Acceleration and deceleration forces shear injury
Seat belt injuries
seat belt sign = highly correlated with intraperitoneal
injury


Rosens Emergency Medicine, 7
th
ed. 2009
Physical Exam
Generally unreliable due to distracting injury, AMS,
spinal cord injury
Look for signs of intraperitoneal injury
abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
entrance and exit wounds to determine path of injury.
Distention - pneumoperitoneum, gastric dilation, or ileus
Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
Abdominal contusions eg lap belts
bowel sounds suggests intraperitoneal injuries
DRE: blood or subcutaneous emphysema
Rosens Emergency Medicine, 7
th
ed. 2009
Diagnostic studies
Lab tests: not very helpful
May have Hct, WBC, lactate, LFTs, lipase, tox
screen
Rosens Emergency Medicine, 7
th
ed. 2009
Imaging
Plain films:
fractures nearby visceral damage
free intraperitoneal air
Foreign bodies and missiles

Rosens Emergency Medicine, 7
th
ed. 2009
Imaging
CT
Accurate for solid visceral lesions and intraperitoneal hemorrhage
guide nonoperative management of solid organ damage
IV not oral contrast
Disadvantages : insensitive for injury of the pancreas, diaphragm,
small bowel, and mesentery
Rosens Emergency Medicine, 7
th
ed. 2009
Imaging
Angiography
To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma in an unstable pt
Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma
Rosens Emergency Medicine, 7
th
ed. 2009
FAST
Focused assessment with sonography for trauma (FAST)
To diagnose free intraperitoneal blood after blunt trauma
4 areas:
Perihepatic & hepato-renal space (Morrisons pouch)
Perisplenic
Pelvis (Pouch of Douglas/rectovesical pouch)
Pericardium (subxiphoid)
sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
Extended FAST (E-FAST):
Add thoracic windows to look for pneumothorax.
Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)
Trauma.org Rosens Emergency Medicine, 7
th
ed. 2009
FAST
Morrisons pouch (hepato-renal space)






trauma.org
Rosens Emergency Medicine, 7
th
ed. 2009
FAST

Perisplenic view
trauma.org
Rosens Emergency Medicine, 7
th
ed. 2009
FAST
Retrovesicle (Pouch of Douglas)






Pericardium (subxiphoid)
trauma.org
Rosens Emergency Medicine, 7
th
ed. 2009
FAST
Advantages:
Portable, fast (<5 min),
No radiation or contrast
Less expensive
Disadvantages
Not as good for solid parenchymal damage, retroperitoneum,
or diaphragmatic defects.
Limited by obesity, substantial bowel gas, and subcut air.
Cant distinguish blood from ascites.
high (31%) false-negative rate in detecting hemoperitoneum
in the presence of pelvic fracture

Rosens Emergency Medicine, 7
th
ed. 2009
Diagnostic Peritoneal Lavage
Largely replaced by FAST and CT
In blunt trauma, used to triage pt who is HD unstable
and has multiple injuries with an equivocal FAST
examination
In stab wounds, for immediate dx of
hemoperitoneum, determination of intraperitoneal
organ injury, and detection of isolated diaphragm
injury
In GSW, not used much


Rosens Emergency Medicine, 7
th
ed. 2009
Diagnostic Peritoneal Lavage
1. attempt to aspirate free peritoneal blood
>10 mL positive for intraperitoneal injury
2. insert lavage catheter by seldinger, semiopen, or
open
3. lavage peritoneal cavity with saline
Positive test:
In blunt trauma, or stab wound to anterior, flank, or back:
RBC count > 100,000/mm
3

In lower chest stab wounds or GSW: RBC count > 5,000-
10,000/mm
3


Rosens Emergency Medicine, 7
th
ed. 2009
Local Wound Exploration
To determine the depth of penetration in stab
wounds
If peritoneum is violated, must do more diagnostics
Prep, extend wound, carefully examine (No blind
probing)
Indicated for anterior abdominal stab wounds, less
clear for other areas

Rosens Emergency Medicine, 7
th
ed. 2009
Laparoscopy
Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
esp for diaphragm injury: Sens 87.5%, specificity 100%
Can repair organs via the laparoscope
diaphragm, solid viscera, stomach, small bowel.
Disadvantages:
poor sensitivity for hollow visceral injury, retroperitoneum
Complications from trocar misplacement.
If diaphragm injury, PTX during insufflation
Rosens Emergency Medicine, 7
th
ed. 2009
Management
General trauma principles:
airway management, 2 large bore IVs, cover penetrating
wounds and eviscerations with sterile dressings
Prophylactic antibiotics: decrease risk of intra-
abdominal sepsis due to intestinal perf/spillage
(eg zosyn 3.375 g IV)
In general, leave foreign bodies in and remove in the
OR
Rosens Emergency Medicine, 7
th
ed. 2009
Management of penetrating abdominal
trauma

forsurenot.com
Management of penetrating abdominal
trauma
Mandatory laparotomy
vs
Selective nonoperative management

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Mandatory laparotomy
standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
Now thought unnecessary in 70% of abdominal stab
wounds
Increased complication rates, length of stay, costs
Immediate laparotomy indicated for shock, evisceration,
and peritonitis

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Selective management used to reduce unnecessary
laparotomies
Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
Strategy depends on abdominal region:
Thoracoabdomen
Nipple line to costal margin
Anterior abdomen
Xiphoid to pubis
Flank and back
Posterior to anterior axillary line

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Thoracoabdomen
Big concern is diaphragmatic injury
7% of thoracoabdominal wounds
Diagnostic evaluation:
CXR (hemothorax or pneumothorax)
Diagnostic peritoneal lavage
FAST
Thoracoscopy

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Thoracoabdomen

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Anterior abdomen
Only 50-70% of anterior stab wounds enter the abdomen
of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of PAT
Anterior abdomen
Rosens Emergency Medicine 7
th
ed
Management of penetrating abdominal
trauma
Back/Flank
Risk of retroperitoneal
injury
Intraperitoneal organ injury
15-40%
Difficulty evaluating
retroperitoneal organs with
exam and FAST
In stable pts, CT scan is
reliable for excluding
significant injury:
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal penetration have
injury requiring operative management
Most centers proceed to lap if peritoneal entry is
suspected
Expectant management rarely done
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosens Emergency Medicine 2009
Management of PAT
Gunshot wounds
assess peritoneal
entry by missile path,
LWE, CT, US,
laparoscopy (all
limited)
Rosens Emergency Medicine, 7
th
ed. 2009
Management of Blunt abdominal trauma



ashwinearl.blogspot.com
Management of Blunt abdominal trauma
Exam less reliable
Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring surgical
repair
FAST, CT, DPL
In HD stable pts, CT is preferred


Rosens Emergency Medicine, 7
th
ed. 2009
Management of Blunt abdominal trauma
Clinical Indications for Laparotomy after Blunt Trauma


MANIFESTATION PITFALL
Unstable vital signs with strongly
indicated abdominal injury
Alternative sources, shock
Unequivocal peritoneal irritation Unreliable
Pneumoperitoneum
Insensitive; may be due to
cardiopulmonary source or invasive
procedures (diagnostic peritoneal
lavage, laparoscopy)
Evidence of diaphragmatic injury Nonspecific
Significant gastrointestinal bleeding Uncommon, unknown accuracy
Rosens Emergency Medicine, 7
th
ed. 2009
Damage Control
Patients with major exsanguinating injuries may not
survive complex procedures
Control hemorrhage and contamination with
abbreviated laparotomy followed by resuscitation
prior to definitive repair
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
0. initial resuscitation
1. Control of hemorrhage and contamination
Control injured vasculature, bleeding solid organs
Abdominal packing
2. back to the ICU for resuscitation
Correction of hypothermia, acidosis, coagulopathy
3. Definitive repair of injuries
4. Definitive closure of the abdomen
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Resuscitation in the ICU
IVF (crystalloid, not colloid)
Transfusion
?1:1:1 PRBC/plt/FFP
Recombinant activated factor VII
Increased thromboembolic complications
Rewarming if hypothermic
Correction of metabolic abnormalities
Low tidal volume ventilation recommended (4-6 ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Open abdominal wounds and definitive closure
40-70% cant have primary closure after definitive repair.
Temporary closure methods


Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Abdominal Compartment Syndrome
Common problem with abdominal trauma
Definition: elevated intraabdominal pressure (IAP) of
20 mm Hg, with single or multiple organ system
failure
APP below 50 mm Hg
Primary ACS: associated with injury/disease in
abdomen
Secondary (medical) ACS: due to problems outside
the abdomen (eg sepsis, capillary leak)
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:2329
Abdominal Compartment Syndrome
Effects of elevated IAP
Renal dysfunction
Decreased cardiac output
Increased airway
pressures and decreased
compliance
Visceral hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
Management
Surgical abdominal decompression
Nonsurgical: paracentesis, NGT, sedation
Staged approach to abdominal repair
Temporary abdominal closure
Sugrue M. Curr Opin Crit Care 2005; 11:333-338 Bailey J. Crit Care 2000, 4:2329
Conclusions
Watch out for implements and missiles violating the abdomen
Laparotomy is mandatory if shock, evisceration, or peritonitis
Diagnostic studies used to determine need for laparotomy in
PAT and BAT
FAST is noninvasive, quick and accurate way to evaluate for
intraperitoneal blood
Damage Control is a principle of staged operative
management with control and resuscitation prior to definitive
repair
Abdominal compartment syndrome is a common problem in
abdominal trauma



References
Biffl WL, Moore EE. Management guidelines for penetrating
abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Waibel BH, Rotondo MF. Damage control in trauma and
abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S421-
30.
Marx: Rosens Emergency Medicine, 7
th
ed. 2009 Mosby
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit
Care 2005; 11:333-338
Bailey J, Shapiro M. Abdominal compartment syndrome. Crit
Care 2000, 4:2329