ABDOMINAL TRAUMA

Supervised by : Dr. Hussein

Al-Heis

INTRODUCTION
Present in 7-10 % of traumatic
patients.
If unrecognized, can cause
preventable deaths
Death usually result from hemorrhage
and sepsis

Anatomy

Anterior abdomen
Flank
Back
Intraperitoneal contents
Retroperitoneal space contents
Pelvic cavity contents

Mechanism of injury

Blunt Trauma

Penetrating Trauma

Blunt Trauma
Motor vehicle accidents, falls, severe
blows, assaults
Usually cause by impact, acceleration
and deceleration changes (seat belt
injury)
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%

Penetrating Trauma
1) Stab wounds : cause damage by
lacerations / cutting
liver (40%) , small bowel (30%)
,diaphragm (20%) colon (15%)
2) Gunshot wounds
-low , medium, high velocity
-further injury by fragmentation and
cavitation effect

Presentations
Depend on a few factors ; size, site, organ
involve, blunt or penetrating
Visible truncal injury including chest or
abdomen
Abdominal pain
Bleeding
Piercing object
Evisceration
Shock

Evisceration

Piercing object

Initial Evaluation
Primary survey
Evaluation of vitals and resuscitation should be
done concurrently
ABCDE
Any patient persistently hypotension despite
resuscitation ,no obvious cause of blood loss
intrabdominal bleeding
If patient stable
Abdominal CT is
indicated
If patient remains unstable
emergency
laparotomy

Assesment : History
Hx AMPLE

A: Allergy/Airway
M:Medications
P: Past medical history
L: Last meal
E: Event - Whathappened?

Mechanism
MVA:
Speed
heard
Type of collision (frontal, lateral,
sideswipe, rear, rollover)
shot

Gun shots :
# number of shots
type of gun used
Position of pt when
Distance

Types of restraints
Vehicle intrusion into passenger compartment
Deployment of air bag
Patient's positionin vehicle
Fatality at thescene

Examination
Inspect the abdomen and flanks for lacerations,
contusions (eg, seat belt sign), andecchymosis,
abdominal distension, piercing objects, entry and exits for
gunshots
Palpate for tenderness and rigidity,rebound tenderness
Auscultate for presence/absence bowel sounds
Percuss to elicit subtle rebound tenderness
Assess pelvic stability
Examine gluteal regions and
perinum,rectum,penile,vaginal

Seat belt sign (contusion)

laceration

Pelvic stability test

Investigations
Blood and urine sampling
Raised serum amylase may indicate small
bowel / pancreatic injury

FAST
DPL
CT SCAN
LAPAROSCOPY
LAPAROTOMY

Focused Abdominal Sonography

for Trauma (FAST)
Used to identify peritoneal cavity as a source
of significant hemorrhage
Also used for screening test for patients
without major risk factors for abdominal injury
Four ViewTechnique: 4PS
Morrisons Pouch (perihepatic)
Douglas Pouch(pelvic)
Pericardium
Perisplenic

 FAST examination should be performed in all

patients
If the FAST exam is unavailable/ limited (eg, poor
image quality) , DPLshould beperformedas
alternativein hemodynamically unstable patient
Advantages

1.Rapid,
reproducible,
portable, noninvasive
2. Can be
performed
simultaneously
with
resuscitation

Disadvantages

1.It will not reliably detect

less than 100 ml of blood
2.Very operatordependent
3.It doesnt identify inj. to
hollow viscus
4.It cant reliably exclude
inj. In penetrating trauma

Pericardium
Perihepatic
Morrisons pouch

Pelvic / Douglass pouch

Perisplenic

Perihepatic view

Perisplenic view

Pericardium view

Pelvic view

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.
MVA = Motor Vehicle Accident
Morrison pouch = perihepatic. (Remember Morrison=Liverr)

Diagnostic Peritoneal Lavage

(DPL)
Identification of the presence of free
intraperitoneal fluid
DPL is especially useful in the hypotensive,
unstable patient with multiple injuries as a means
of excluding intraabdominal bleeding.

Pre-requests: gastric tube+ urine catheter.

A cannula is inserted below the umbilicus directed caudally
and posteriorly.
More than 10 ml of aspirated blood is considered positive
Use ringer lactate. Positive if > 100,000 RBC/m3 / >500
WBC/m3

Computerized Tomography
Gold standard
Performed only on a stable patient
Iv contrast / oral contrast
Has the added advantage of
sensitivity for diagnosing
retroperitoneal injury
Entirely normal abdominal CT is
usually sufficient to exclude injury

Diagnostic Laparoscopy
Used as a screening investigation in
penetrating trauma to exclude peritoneal
penetration and/or diaphragmatic injury in
stable pt
Difficult to exclude all abdominal injury
laparoscpically.
Reduces the rate of non therapeutic
laparotomies but its not a substitute
especially in the presence of
hemoperitoneum or contamination

Indications of
laparotomy

Signs of peritonitis
Uncontrolled shock / hemorrhage
Clinical deterioration during observation
Hemoperitonium findings after DPL / FAST
Any knife injury with visible
viscera,clinical peritonitis,hemodynamic
unstable, or developing fever/signs of
sepsis
Any gunshot wound

Individual Organ
Injuries
1. Liver
2. Spleen
3. Pancreas
4. Stomach
5. Duodenum
6. Small bowel
7. Large bowel
8. Rectum
9. Anus

Liver
Majority due to blunt injury
AAST-OIS injury scale
Most important thing is to control the
hemorrhage.
Remember the 4Ps (Manual compression(Push),
Perihepatic Packing, Plug, Pringle Maneuver)
Electrocautery for bleeding from liver surface.
Suture ligation or clips for bleeding vessels.
If the injury has already resulted in massive
blood loss, pack the abdomen with laparotomy
pads and reexplore later.
Drains should always be used.
Biliary tract decompression is contraindicated.

SPLENIC INJURY

The most commonly injured organ in

blunt abdominal trauma, and trauma is
the most common reason for
splenectomy.
It usually occurs from direct blunt
trauma to the overlying ribs (9 th-11th)
General approach
History : Ask details of injury mechanism
PE : Look for peritoneal irritation, Kehrs
sign (severe left shoulder pain), external
signs of injury.

GRADES OF SPLENIC INJURY

MANAGEMENT
Most isolated splenic injuries (esp.children)
can be managed conservatively.
In adults, (esp. in presence of other injury,
physiological instability, coagulapathies
etc; laparatomy and direct
splenorraphy should be considered.
Splenectomy may be a safer option, esp.
in the unstable patient with multiple
potential sites of bleeding.
In certain situations, selective
angioembolisation of the spleen can play
a role.

PANCREATIC INJURY
MECHANISM :
Most pancreatic injury occurs as a result
of blunt trauma. In penetrating trauma
( gunshot wound >> stab wound)
75% of patients with penetrating injury to
the pancreas will have associated injuries
to the aorta, portal vein, or inferior vena
cava.

Pancreatic injury

DIAGNOSIS
INSPECT pancreas during laparotomies
performed for other indications.
Check AMYLASE (may be elevated)
CT : Look for parenchymal fracture,
intraparencymal hematoma, lesser sac
fluid, fluid between splenic vein and
pancreatic body, retroperitoneal
hematoma or fluid.
ERCP : Maybe used in the stable patient
if readily available or available
intraoperatively; also may be used to
evaluate missed injury.

TREATMENT
Non-operative :
May follow with serial labs and exam if patient can be
reliably examined.
Operative:
Classically the pancreas should be treated with
conservative surgery and closed suction drainage.
Injuries to the tail are treated by closed suction
drainage, with distal pancreatectomy if the duct is
involved.
Proximal injuries (to the right of the superior mesenteric
artery) are treated as conservatively as possible,
although partial pancreatectomy may be necessary. The
pylorus can be temporarily closed (pyloric exclusion) in
association with a gastric drainage procedure.
A Whipples procedure (pancreaticoduodenectomy) is
rarely needed and should not be performed in the
emergency situation because of the very high associated
mortality rate.

BOWEL INJURY

STOMACH, JEJUNUM & ILEUM

(Hollow viscus injury)
Mostly happened due to penetrating
trauma .
The most common site of injury is the
small bowel (93%), followed by the
colon/rectum (30.2%) and the stomach
(4.3%) .

Isolated leaks from penetrating trauma lead

to minimal contamination and patients
usually do well if diagnosis is not delayed
(quick!).
Blunt injuries are blowouts resulting
frequently from lap belts, and occur near the
ligament of Treitz and ileocecal valve.
Mesentery can significantly injured
following blunt trauma.

DIAGNOSIS
If the patient is awake and reliable, the
exam is important to look for peritoneal
irritation.
If the exam is not reliable, DPL or
laparoscopy may be required.
CT-scan has a high false-negative rate for
small bowel injuries.
Look for free air on CXR.
Laparotomy for gastric or small bowel
injury with primary repair and peritoneal
lavage except in cases that have heavy
soiling of the peritoneal cavity and present
late, where intestinal diversion must be
considered ( e.g ; ileostomy)

DUODENUM
Mechanisms : Three fourths of injuries result from
penetrating trauma
Diagnosis :
- Upper GI series with water-soluble contrast.
- CT : gas in the periduodenal tissue
*CT and DPL often miss duodenal injuries
Treatment:
- 80% of patients are able to undergo a primary
repair.
- Repair may be protected with an omental patch,
jejunal serosal patch and/or gastric diversion.
- More complex injuries need pyloric exclusion or
rarely pancreaticoduodenectomy ( Whipple
procedure)

CT of blunt duodenal injury

free air in retroperitoneum

LARGE BOWEL

LARGE BOWEL
Injuries generally occur via a penetrating
mechanism (75% gunshot wound, 25% stab wound)
, relatively infrequent due to blunt injury.
Signs & symptoms :
Abdominal distention, tenderness, guaiac-positive
stool(gFOBT)
Diagnosis:
In an awake & reliable patient, exam findings are
consistent with peritonitis.
CXR may show free air.
In a patient with a flank injury but without clear
peritoneal signs, consider a contrast enema.

Treatment
Primary repair : for small or
medium-sized perforations, repair
the perforation or if needed, resect
the affected segment and close with
primary anastomosis.
A proximal diverting stoma (e.g;
ileostomy) is commonly placed.
Anastomosis is contraindicated in the
setting of massive soiling.

RECTUM
Mechanism : Majority are caused by penetrating
injury, although occasionally the rectum may be
damaged following fracture of the pelvis.
Diagnosis :
DRE/guaiac : Suspicion increased by blood in stool
or palpation of defect or foreign body on exam.
Rigid protoscopy : May be done in OR if needed;
mandatory for patients with known trajectory of
knife or gunshot wound across pelvis or transanal; if
patients unstable, maybe delayed until after
resuscitation.
X-ray to look for missiles or foreign bodies.

Treatment :
Diversion via colostomy is key.
Extraperitoneal injuries must be
diverted via colostomy but many
needs to be repaired (if not too big and
not easily accessible).
Colostomy may be closed in 3-4
months.

ANUS
Reconstruct sphincter as soon
as patient is stabilized.
Divert with sigmoid
colostomy

DAMAGE
CONTROL
SURGERY(DCS)

 DEFINITION:

rapid initial control of hemorrhage

and contamination, temporary
closure, resuscitation to normal
physiology in the intensive care
unit, and subsequent reexploration and definitive repair.

Damage control surgery is a

approach which focuses on
doing "just enough" surgery to
stabilize the patient before the
lethal triad of trauma induced
coagulopathy, hypothermia
and metabolic acidosis.

Lethal triad of trauma

STAGES
I

Patient selection

II

Control hemorrhage and

control of contamination

III

Resuscitation continued in ICU

IV

Definitive surgery

Abdominal closure

INDICATIONS FOR DCS

ANATOMICAL
- Inability to achieve haemostasis
- Complex abdominal injury (e.g. liver and
pancreas)
- Combined vascular, solid and hollow organ injury
(e.g : aorta)
- Inaccessible major venous injury (e.g:
retrohepatic vena cava)
- Demand for non-operative control of other
injuries (e.g. fractured pelvis)
- Anticipated need for a time-consuming procedure

 PHYSIOLOGICAL (Decline of physiological

reserve)
-Temperature <34 C
-pH < 7.2 (acidosis)
-Serum lactate > 5 mmol l-1 [N (Normal) < 2.5 mmol l1]
-PT > 16s
-PTT > 60s
->10 units blood transfused
-Systolic BP < 90mmHg for >60min (hypotension)
ENVIRONMENTAL
- Operating time >60 min
- Inability to approximate the abdominal incision
- Desire to reassess the intraabdominal contents
(directed relook)

ABDOMINAL COMPARTMENT
SYNDROME
Definition:
-organ dysfunction caused by intraabdominal hypertension (e.g falling
renal perfusion, respiratory insufficiency) ;
major cause of morbidity and mortality
in critically ill patient.
-sustained elevation above 35 mmHg.
-operative decompression is always
indicated.

Thank you
for your time