DR.R.SRIVATHSAN PG-II

OUTLINEy Anatomic definition of abdomen y Mechanism of injury y Typical injury patterns y Assessment of abdominal trauma y Diagnostic algorithms

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Abdominal traumay Common site of injury for both blunt and penetrating injuries y 29% of polytrauma patient requires abdominal exploration y Rapid, life-threatening bleeding can be hidden in the abdomen y Unrecognized abdominal injuries in the multi-system trauma patient

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Abdomen anatomic boundariesy External:y Anterior abdomen: transnipple line superiorly, inguinal

ligaments and symphasis pubis inferiorly, anterior axillary lines laterally. y Flank: between anterior and posterior axillary lines from 6th intercostals space to iliac crest. y Back: Posterior to posterior axillary lines, from tip of scapulae to iliac crests.

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y Internal:y Upper peritoneal cavity: covered by lower aspect of bony

thorax. Includes diaphragm, liver, spleen, stomach, transverse colon. y Lower peritoneal cavity: small bowel, ascending and descending colon, sigmoid colon, and (in women) internal reproductive organs. y Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women) internal reproductive organs. y Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal aorta, IVC, most of duodenum, pancreas kidneys, ureters, and posterior aspects of ascending and descending colon.

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Intraperitoneal and retroperitoneal cavities

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Mechanisms and Pathologyy Blunt vs Penetrating y Often both occur simultaneously y Blunt injury is the most common mechanism

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y Direct impact y Acceleration-deceleration:

differential movements of fixed and nonfixed structures (e.g. liver and spleen lacerations at sites of supporting ligaments)y Compression, crush, or sheer injury

abdominal viscera deformation of solid or hollow organs, rupture (e.g. small bowel, bladder,gravid uterus)9

Key pointsy No correlation between size of contact area and resultant injuries y Abdomen = Pandora s box y A potential site of major blood loss with little evident signs/symptoms.

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Assessment: Historyy Mechanism y Symptoms, Medications, drugs y MVC:y Speed y Type of collision (frontal, lateral, sideswipe, rear, y y y y

rollover) Vehicle intrusion into passenger compartment Types of restraints Deployment of air bag Patient's position in vehicle11

Assessment: Physical Examy Inspection, auscultation, percussion, palpationy Inspection: abrasions, contusions, lacerations, deformity y Percussion: subtle signs of peritonitis; tympany in

gastric dilatation or free air; dullness with hemoperitoneumy Palpation: superficial, deep, or rebound tenderness;

involuntary muscle guarding

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Physical Exam: Eponymsy Grey-Turner sign:y Bluish discoloration of lower flanks, lower back; associated with

retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

y Cullen sign:y Bluish discoloration around umbilicus, indicates peritoneal

bleeding, often pancreatic hemorrhage.

y Kehr sign:y Left shoulder pain while supine; caused by diaphragmatic irritation

(splenic injury, free air, intra-abd bleeding)

y Ballance sign:y Dull percussion in LUQ. Sign of splenic injury; blood accumulating

in subcapsular or extracapsular spleen.13

Diagnostic modalitiesy Labs: - Complete Blood profile - Coagulation profile - Serum Amylase/Lipase - Urine analysis - Toxicology screen

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Radiological profiley Plain films:

- Chest XRay, - Pelvic XRay - Abdomen XRayy FAST y CT

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DPL - ProcedureFoleys & 2cm incision midway between umblicus and pubic bone under LA dialysis cat eter is passed t roug t e opening in t e peritoneal cavity and advanced towards t e ollow of t e pelvis.

Normal Saline is now connected to t e dialysis cat eter.

e wound is closed wit a stitc

fluid inside t e abdomen is now swis ed around by gentle agitation of t e abdomen so t at it is distributed all over t e peritoneal cavity

allowed to stay for up to 10 minutes

siphoned off by bringing the fluid bag or bottle down to the floor.

the returning fluid is clear then no gross internal injury to the abdomen and no major hemorrhage

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DPLy Standard criteriay 10cc gross blood y RBC > 100,000/mm2 y WBC > 500/mm2 y Amylase > 175 IU/dL y Bile, bacteria, fiber or food.

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y Indications: - Equivocal physical examination - Unexplained shock or hypotension - Altered sensorium (closed head injury, drugs, etc.) - General anesthesia for extra-abdominal procedures - Cord injury

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y Contraindications :

Clear indication for exploratory laparotomy Relative contraindications: - Previous exploratory laparotomy - Pregnancy - Obesity

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DPLy Highly sensitive to intraperitoneal blood, but low specificity p nontherapeutic explorations. y Supraumbilical if pelvic fracture present y Significant injuries may be missedy Diaphragm y Retroperitoneal hematomas y Renal, pancreatic, duodenal y Minor intestinal y Extraperitoneal bladder injuries

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Focused Assessment with Sonography for Trauma (FAST)

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FAST: Strengths and LimitationsStrengths y Rapid (~2 mins) y Portable y Inexpensive y Technically simple, easy to train (studies show competence can be achieved after ~30 studies) y Can be performed serially y Useful for guiding triage decisions in trauma patientsLimitations y Does not typically identify source of bleeding, or detect injuries that do not cause hemoperitoneum y Requires extensive training to assess parenchyma reliably y Limited in detecting 16mmHgy Full blown syndrome >35 mmHg

y Worse with fascial closure97

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