1. ByProfessor of General SurgeryFaculty of Medicine Ain Shams University

2. Abdominal TraumaAbdominal injury is a contributing factor in 20% of trauma related deaths either: - early fromexsanguinating hemorrhage or late from bowelinjury, subsequent sepsis or multiple organfailure.Abdominal injury frequently occurs as part ofmultiple injuries, therefore, priorityconsideration issues become paramount in itsmanagement and represents a challengingdilemma for the surgeons. 3. Classification of Abdominal TraumaTraumaBluntCrush injuryBlast injurySeat SyndromePenetratingStab WoundGun Shot WoundIatrogenicEndoscopicExternal cardiac massagePeritoneal dialysisPer-cutaneous trans-hepaticcannulationGuided liver biopsy 4. Clinical presentation It varies widely, as abdominal injury may be isolated orpart of multisystem trauma. In addition the presentationmay be complicated by the patients level ofconsciousness, hemodynamic status and other discharginginjuries. Abdominal signs vary : from acute abdomen with frankperitonitis or marked distention, through the subtle seatbelt sign, to a minimal abdominal tenderness, often boundwith intra-peritoneal bleeding. Thus physical assessment may add scanty information andits vital to have a high index of suspicion and a lowthreshold for directed investigation. 5. Management of Abdominal TraumaDiagnosis : -1. A.M.P.L.E. History taking.2. Initial resuscitation and ABC Traumaprotocol .3. Secondary survey with follows thoroughphysical assessment.4. Appropriately directed investigations. 6. 1. History takingA : AllergyM: MedicineP: Previous illness and operationsL: Last mealE: Events preceding injury and relevantinfo from the scene of accident: - steerwheel compression, seat belt, vehicledamage..etc. 7. 2. ResuscitationThe ABC of emergency with airway,breathing, and circulation includingprimary survey for abdomen as a sourceof occult bleeding.Blood samples are drawn for basic studyfor later comparison and for blood typingand cross matching and ABG. 8. 3. Secondary survey The key objective of physical diagnosis ofabdominal injury is to identify the need foroperation rather than the precise determination oforgan injury. Physical examination should proceed in an orderlyfashion and patient should be evaluated for: -A. Penetrating wounds: -Marked with radio-opaque clips and subsequent x-rayto delineate the path of bullet or knife givingidea about the possible organs injured. 9. B. Blunt trauma: - Abrasion, seat belt sign, ecchymosis, are warning ofsignificant intra abdominal injury. Posterior ecchymosis raises the possibility ofretroperitoneal injury. Patient respiratory pattern: Halted labored in diaphragmatic irritation. Left shoulder pain (khers sign) in splenichemorrhage. Palpation: trying to elicit signs. Inspection of perineum and urethral meatus forblood pelvic fracture. 10. Insertion of indwelling Folys catheter. Urine samplesent for analysis and monitor of UOP. Yet it should bedelayed if suspected urethral injury until ruling it out.P/R : - Integrity of the rectum, injured by fracture pelvic. Position of the prostate, indicates urethral injury. Gross or occult blood, laceration and bleeding Sphincter tone, relaxed in spinal injury.NGT: - acute gastric dilatation and assessment ofpresence of blood. 11. 4. Appropriately directed InvestigationsA. Baseline labs + blood typing and cross match.B. FASTC. DPLD. CTE. Laparoscopy 12. A- Baseline labs They add little value in ruling out the need for surgicalintervention yet they are mainly used for later oncomparison.1. HB : - quantity of blood to replace.2. HCT : - confirm massive Hg (6-12 hrs).3. WBCs : - indicate sepsis or reactive leucocytosis.4. Serum createnin: - pre-renal shut down.5. Glucose and electrolytes: - proper fluid resuscitation.6. Amylase: - gut injury or pancreas (non-specific).7. Urine analysis: - if RBCs >30 50 /mm, radiographicevaluation of kidneys and urinary bladder is a must. 13. B- FAST (Focused Abdominal Sonographic Testing) It is a standard approach to abdominal trauma whichaims at identifying free fluid in peritoneal cavity ratherthan specific inquiries and it includes assessment of: -1. Right upper Quadrant.2. Left upper Quadrant.3. Pelvis4. Pericardial window to assess for pericardial effusion. Sensitivity is 93%. Specificity is 98%. Applications: -1. Mainly in blunt trauma.2. Limited value in penetrating trauma as the least amount ofblood detected by sonar is 100 cc, which restrict itssensitivity. 14. B- FAST (cont.) Advantages: -1. Fast and non-invasive.2. Bedside.3. Portable Disadvantages: -1. Operator dependent.2. Limited by surgical emphysema and obesity.It must be clear that in a hemodynamically stablepatient a positive FAST per se doesnt indicate theneed for surgical exploration. 15. C- Diagnostic peritoneal lavage (DPL) It has been the golden standard for the investigation ofblunt abdominal injury for more than 30 years. Itsaccuracy is 97.3%. False-positive rate is 1.4%. False-negativerate is 1.3%. DPL is considered positive if: -1. Return of 10 ml of non-clotting blood on insertion.2. Lavage count of 100 000 red cells per mm (RCC).3. 500 white cells per mm.4. Amylase greater than 200 IU.5. Presence of bile, faeces, bacteria. 16. C- Diagnostic peritoneal lavage (DPL) (cont.) Indications: -1. Unconscious trauma patient with signs of abdominalinjury.2. Patient with suspected intra-abdominal injury andequivocal physical findings.3. Patients with muitple injuries and unexplainedshock.4. Patients with spinal cord injury.5. Intoxicated patients in whome abdominal injury issuspected. 17. C- Diagnostic peritoneal lavage (DPL) (cont.) Disadvantages: -The most frequent criticism is the rate of non-therapeuticlaparotomy performed for positive cellcount due to the balance between false-negative resultsand over sensitivity. Its various estimation is 10 - 15 %.It does not allow conservation management in the presenceof blood in the abdominal cavity, but CT may be used asan adjunct in the stable patients. 18. C- Diagnostic peritoneal lavage (DPL) (cont.)Contraindications: -1. Patients with previous abdominal operations.2. Pregnancy.3. Morbid obesity.4. Patients with frank surgical abdomen. Complications: -1. Gut perforation.2. Hemorrhage.3. Infection. 19. D- Computed Tomography It is strictly off-limits to unstable patients.However, in patients who arecardiovasculary normal followingresuscitation CT is the investigation ofchoice especially the spiral CT with IVcontrast.It can comment also on retroperitonealstructures. 20. Blunt abdominal trauma. Right kidney injury with blood in perirenal space. Injury resulted fromhigh-speed motor vehicle collision 21. Blunt abdominal trauma with liver laceration. 22. Blunt abdominal trauma with splenic injury and hemoperitoneum. 23. E- laparoscopyIt is relatively a new investigation witan evolving role. It is 97% accurate inblunt abdominal trauma.Disadvantages:-1. Availability and cost.2. Requires GA3. Insensitivity to hollow viscusperforation. 24. Treatment options of abdominaltraumaNon-operative management of solidorgan injury.Interventional radiologyFormal laparotomy, keeping in minedthe principals of damage-controlsurgery. 25. 1-Non-operative management of solidorgan injury. Indications: -1. Injuries to solid organs shown in CT2. Minimal physical signs.3. Vascular instability (less than 2 unites of bloodneeded).Patients should be available for repeated examination andnursed in ICU unite.This modality may be good for up to 50% of liver injuriesand have 50 80% success rate. In blunt splenic injury,it has 93% success rate. The majority of renal injuries(except renal pedicle) can be treated in such way. 26. 2- Interventional radiologyAs an adjunct to conservativemanagement e.g. angiography andembolisation of bleeding vessels andalso for expanding pelvic hematomawith packing if conservation byotherwise is failed. 27. 3-LaparotomyIndications: -1. Unstable patients with signs of intra-abdominaltrauma.2. Positive DPL or FAST in unstable patients.3. Positive finding in CT unsuitable for non-operativemanagement.4. Peritoneal penetrating stab wound.5. Gunshot wound to the abdomen.6. Evisceration or retained foreign body. 28. The principals of damage controlsurgery are: -1. Control hemorrhage, hypothermia andacidosis with the least possible procedures2. Prevention of contamination by rapidclosure of source of sepsis.3. Avoid further injury.4. Avoid abdominal compartment syndrom. 29. Abdominal compartment syndrome It is due to massive intestinal edema oftenfollowing laparotomy for major trauma withprolonged shock, as a result of crystalloidresuscitations, capillary lesions, activatedinflammatory mediators, and reperfusioninjury combined with retro-peritonealhematomas and intra-abdominal packing. Intra-abdominal pressure may rise to a levelmore than 25 cm h2o leading to significantcardiovascular, and respiratory, renal andcerebral dysfunction. 30. Abdominal compartment syndrome (cont.) Cardiovascular dysfunction: -Fall in the cardiac output due mainly to compression of the inferiorvena cava and reduction in venous return to the heart. Respiratory dysfunction: -Split the diaphragm and rise in peak airway pressure and intra-thoracicpressure that subsequently reduce venous return to theheart.Renal dysfunction: -Oliguria and anuria probably due to compression of the renal veinand renal parenchyma.Cerebral dysfunction: -The rise in intra-abdominal and intra-thoracic pressure lead to risein central venous pressure which prevent adequate venousdrainage from the brain and rise of the intra-cranial pressureand worsening of intra-cerebral edema. 31. Diagnosis of Abdominal CompartmentSyndrome Diagnosis can be confirmed by measuring theintra-abdominal pressure either through a folyscatheter in the bladder or a naso-gastric tubein the stomach. It is possible to connect a pressure transducer toa folys catheter. The normal intra-abdominalpressure is zero or sub-atmospheric. A pressureof over 25 cm H2O is suggestive and over 30 cmH2O is diagnostic of abdominal compartmentsyndrome. 32. Management of Abdominal CompartmentSyndrome The easiest method to control the openabdomen is to use a silo-bag closure. Athree-liter plastic irrigation bag is emptiedand cut open so it lies flat. The edges aretrimmed and sutured to the skin away fromthe skin edges using a continuous 1 silksuture. It is useful to place a sterileabsorbent drape inside the abdomen to soakup some of the fluid and ease control of thelaparotomy. 33. Management of Abdominal CompartmentSyndrome (cont.)An alternative technique is vacuumpack technique:The 3 liter bag is opened and placed into theabdomen to protect the gut contents under thesheath. Two large caliber suction drains areplaced over this , and a large adherentsteridrape is placed over the whole abdomen.The suction catheters are connected to a high-displacementsuction to provide control of fluidloss and create the vacuum pack effect. 34. Sudden release of the abdominalcompartment syndrome may lead to anischemia-reperfusion injury causingacidosis, vasodilatation, cardiacdysfunction and arrest. Prior to release,patient should be pre-loaded withcrystalloid solution. Mannitol andvasodilators such as dobutamine orphosphodiesterase inhibitors may havea place here.