Delay in the diagnosis and treatment of abdominal

injuries is one of the most common causes of

preventable death from blunt or penetrating trauma

Approximately 20 per cent of abdominal injuries

will require surgery

It is important to appreciate the difference between

surgical resuscitation and definitive treatment for
abdominal trauma
 Surgical resuscitation includes the technique of
damage control, and implies only that the
surgical procedure is necessary to save life by
stopping bleeding and preventing further
contamination or injury
 Resuscitation of patients with suspected
abdominal injuries should always take place
within the ATLS (Advanced Trauma Life
Support) context

Attention is paid to adequate resuscitative

measures, including adequate pain control
 The diagnosis of injury after blunt trauma can
be difficult and knowledge of the injury
mechanism can be helpful.

Virtually all penetrating injury to the abdomen

should be addressed promptly, especially in
the presence of hypotension
 Physical examination
Bruises, abrasion over the abdomen
Abdominal pain or tenderness
Absent bowel sounds
Unexplained hypotension
Diagnostic peritoneal lavage (DPL)
Ultrasonography: focused abdominal sonography for
trauma (FAST)
Computed tomography (CT)
Diagnostic laparoscopy.
 Blunt trauma
High energy transfer (car accident)
Low energy transfer (fall, fight)

Penetrating
High velocity (85% penetrate peritoneum)
Low velocity (95% need surgery)
Stab (1/3 do not penetrate the peritoneum)
 Airway
Breathing
Circulation
Disability
Environment SHOCK

Hemodynamically
Transient Hemodynamically
Stable Responder Unstable
 The stable patient, who is not haemodynamically nor- mal, will
benefit from investigations aimed at establish- ing the following:

Whether the patient has bled into the abdomen Whether the
bleeding has stopped.

Thus, serial investigations of a quantitative nature will allow the

best assessment of these patients. Computed tomography is
currently the modality of choice, although FAST may also be
helpful, though dependent on the operator.
 Efforts must be made to try to define the cavity where bleeding is taking
place, e.g. chest, pelvis or abdominal cavity

Diagnostic modalities are of necessity limited, because it may not be possible

to move an unstable patient to have a CT scan, even if it were to be readily
available

DPL and FAST can be performed without moving the patient from the
resuscitation area.

During resuscitation, standard ATLS guidelines should be followed, which

should include:
Nasogastric tube or orogastric tube
Urinary catheter.
 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
1. Rectal examination
Prostate
Rectal tone
2. Vaginal examination
3. Gluteal fold
Penetrating injuries = abdominal injuries
 Blood Pressure and Pulse trend
Alertness
Urine Output
Bleeding point
Lactat Clearance
Associated Injuries

RE- ASSESSMENT / EXPECTANT

 Serial Observation
Wound Exploration
Ultrasound
CT scan +/- Contrast
DPL
Laparoscopy
Laparotomy
 Demonstrate presence of free intraperitoneal fluid

Evaluate solid organ hematomas

Advantages
No risk from contrast media or radiation
Rapid results, portability, non-invasive, ability to repeat exams.

Disadvantages
Cannot assess hollow visceral perforation
Operator dependent
Retroperitoneal structures are not visualized
 View Technique:
Morrisons pouch (hepatorenal)
Douglas pouch (retropelvic)
Left upper quadrant (splenic view)
 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
 1. attempt to aspirate free peritoneal blood
2. insert lavage catheter by seldinger, semiopen, or
open
3. lavage peritoneal cavity with saline
Positive test:
10 cc of blood, RBC count > 100,000/mm3
> 500 WBC/ mm3,
Bile
Fecal Material
Amilase > 175/ml
Bilirubin > 0.01
ALP > 2
 Replacing DPL.
98% sensitive in detecting intraperitoneal
bleeding.
Contrast enhanced CT Scan gives useful
anatomical and fuctional information on
organs.
Can identify organ injuries and be used to
determine which injuries can be managed
conservatively in stable patients.
Useful in grading solid organ injuries(liver and
spleen)..
 To determine the depth of penetration in stab
wounds
If peritoneum is violated, must do more diagnostics

Preparation , extend wound, carefully examine

(No blind probing)
Indicated for anterior abdominal stab wounds,
less clear for other areas

Rosens Emergency Medicine, 7th ed. 2009

 Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
especially 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.
 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 perforation/ spillage
In general, leave foreign bodies in and remove in
the OR
BLUNT ABDOMINAL TRAUMA ALGORITHM
BLUNT ABDOMINAL TRAUMA WITH
HEAD INJURY
PENETRATING ABDOMINAL TRAUMA ALGORITHM
 Abdominal injuries should be suspect in all trauma
Preventable trauma death are related to inappropriate
management of abdominal trauma
Close Observation- Re-Assessment
Follow the Flow Chart