ABDOMINAL TRAUMA

Supervised by : Dr. Hussein Al-Heis

• Present in 7-10 % of traumatic patients.

• If unrecognized, can cause preventable deaths

• Death usually result from hemorrhage and sepsis

INTRODUCTION

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 Trauma1) 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 indicatedIf patient remains unstable emergency laparotomy

Assesment : History Hx AMPLE A: Allergy/Airway M: Medications P: Past medical history L: Last meal E: Event - What happened? Mechanism MVA: Gun shots : Speed # number of shots heard Type of collision (frontal, lateral, type of gun used sideswipe, rear, rollover) Position of pt when shot Distance Types of restraints• Vehicle intrusion into passenger compartment Deployment of air bag Patient's position in vehicle Fatality at the scene

Examination • Inspect the abdomen and flanks for lacerations, contusions (eg, seat belt

sign), and ecchymosis, 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

InvestigationsBlood and urine sampling Raised serum amylase may indicate small bowel /

pancreatic injury

FASTDPLCT SCANLAPAROSCOPYLAPAROTOMY

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 View Technique: 4P’SMorrison’s Pouch (perihepatic)Douglas Pouch (pelvic)PericardiumPerisplenic

• FAST examination should be performed in all patients • If the FAST exam is unavailable/ limited (eg, poor image

quality) , DPL should be performed as alternative in hemodynamically unstable patient

Advantages Disadvantages

1.Rapid, reproducible, portable, non-invasive

2. Can be performed simultaneously with resuscitation

1.It will not reliably detect less than 100 ml of blood2.Very operator-dependent3.It doesn’t identify inj. to hollow viscus 4.It can’t reliably exclude inj. In penetrating trauma

Pericardium

Perisplenic PerihepaticMorrison’s pouch

Pelvic / Douglas’s pouch

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 non-operatively.

MVA = Motor Vehicle AccidentMorrison 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 Gold standard • Performed only on a stable patientPerformed only on a stable patient• Iv contrast / oral contrastIv contrast / oral contrast• Has the added advantage of sensitivity for Has the added advantage of sensitivity for

diagnosing retroperitoneal injury diagnosing retroperitoneal injury • Entirely normal abdominal CT is usually Entirely normal abdominal CT is usually

sufficient to exclude injurysufficient to exclude injury

Diagnostic Laparoscopy• Used as a Used as a screening investigation screening investigation in penetrating in penetrating

trauma trauma to exclude peritoneal penetration to exclude peritoneal penetration and/or and/or diaphragmatic injury diaphragmatic injury in stable ptin stable pt

• DifficultDifficult to exclude all abdominal injury to exclude all abdominal injury laparoscpically.laparoscpically.

• Reduces the rate of non therapeutic laparotomies Reduces the rate of non therapeutic laparotomies but its not a substitute especially in the presence of but its not a substitute especially in the presence of hemoperitoneum or contamination 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.Liver2.Spleen3.Pancreas4.Stomach5.Duodenum6.Small bowel7.Large bowel8.Rectum9.Anus

Liver• Majority due to blunt injury• AAST-OIS injury scale• Most important thing is to control the hemorrhage.• Remember the 4”Ps (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 (9th-11th)

General approach History : Ask details of injury mechanismPE : Look for peritoneal irritation, Kehr’s 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.

TREATMENTNon-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 Whipple’s 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)

DUODENUMMechanisms : 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 injuryfree air in retroperitoneum

LARGE BOWEL

LARGE BOWELInjuries 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 re-

exploration 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

V 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 l–1]-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 intra-abdominal 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.

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