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Abdominal Trauma
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Objectives
 Describe external and internal anatomy
 Recognize blunt vs penetrating injury

patterns
 Identify signs of different types of

injuries
 Apply diagnostic and therapeutic

procedures
 Demonstrate and discuss DPL
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Abdominal Trauma
 Unrecognized injury : Cause of
preventable death
 Exam compromised by
• Alcohol, illicit drugs
• Injury to brain, spinal cord
• Injury to ribs, spine, pelvis
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Anatomy
External
 Anterior abdomen
 Flank
 Back
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Anatomy
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Mechanism of injury
Blunt
 Spleen, liver, and hollow viscus
 Compression
 Crushing
 Shearing
 Deceleration (fixed organs)
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Mechanism of injury
Penetrating
 Liver , small bowel, and colon
 Laceration / low energy
 Kinetic energy / high energy
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Assessment : History
Blunt Penetrating
 Speed  Weapon
 Point of impact  Distance
 Intrusion
 Safety devices
 Position
 Ejection
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Assessment : Physical Exam

 Inspection
 Percussion

 Palpation

 Auscultation
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Assessment : Physical Exam

 Local wound exploration by surgeon
 Pain over bony pelvis

 Genitourinary, perineal, rectal,vaginal

and gluteal
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Adjuncts : Intubation
Gastric Tube
 Relieves dilatation
 Decompresses stomach before DPL

• Basilar skull / facial fractures

• May induce vomiting /
aspiration
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Adjuncts : Intubation
Urinary Catheter
 Monitors urinary output
 Decompresses bladder before DPL
 Diagnostic

Urethral injury
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Adjuncts : x – ray Studies

Routine
 Blunt : AP chest, pelvis
 Penetrating : AP chest, abdomen with
markers (if hemodynamically normal)
Contrast
 Urethrogram  GI
 Cystogram  IVP
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Special Studies in Blunt Trauma

DPL US* CT
Time Rapid Rapid Delayed
Transport No No Required
Sensitivity High High? High
Specificity Low Intermediate High
Eligibility All All patients Hemodynami-
patients cally normal
*operator dependent
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Indications for Celiotomy

Blunt Penetrating
 + DPL or ultrasound  + DPL or ultrasound
 ↓BP suspected  Peritoneal /
visceral injury retroperitoneal injury
 Peritonitis  Peritonitis
 Hypotension
 Evisceration
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Indications for Celiotomy

Plain X – ray
• Free air
• Retroperitoneal air
• Ruptured diaphragm
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Indications for Celiotomy

Special Studies
• CT scan : Free air, visceral injury ?
Fluid?
• Cystogram : Bladder rupture,
intraperitoneal injury
• Arteriogram: Renal pedicle occlusion
• Upper GI : Duodenal rupture
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Special Problems : Blunt Trauma

Diaphragm : Abnormal chest x –ray
Duodenum/ Retroperitoneal air,
contrast
Small bowel : Seat belt sign, Chance
fracture, free air
Pancreas : Amylase?, CT?
GU : Extravasation of contrast
nonfunctioning renal
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Pelvic Fractures
 Significant force
applied
 Associated injuries
 Pelvic bleeding
• Ends of bones
• Pelvic muscles
• Veins / arteries
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Pelvic Fractures
Mechanism Classification
 AP compression  Open
 Lateral  Closed
compression
 Vertical shear
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Pelvic Fractures
Assessment
 Inspection
 Palpate prostate
 Pelvic ring
• Leg-length discrepancy , external rotation
• Pain on palpation of bony pelvic ring
• AP x-ray
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Pelvic Fractures : Management

Resuscitate

Transfer as needed with PASG

Determine if intraperitoneal hemorrhage

Operation
Control hemorrhage Fixation device

Possible angiography
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Questions
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Summary
 ABCDEs
 Delineate mechanism
 Repeated exams
 Diagnostics as needed
 High index of suspicion
 Early recognition /prompt celiotomy