Abdominal Trauma

Emergency Medicine Clerkship

Richard W. Stair, MD, FACEP

Abdominal Trauma

• Common site of injury for both blunt and penetrating injuries

• Rapid, life-threatening bleeding can be hidden in the abdomen

• Unrecognized abdominal injuries in the multi-system trauma patient

Abdominal Trauma

• 50% of patients intoxicated with use of alcohol and illicit drugs

• Comorbid injuries (such as brain, spinal cord)

• Vast amount of space to hide volume• Retroperitoneum difficult to evaluate• Initial abdominal exam often normal, and

many may be initially asymptomatic

Mechanism of Injuries

• Blunt Trauma– compression– crush– shearing– deceleration

• Penetrating Trauma– direct injury

History - Blunt vs. Penetrating

• Blunt– how fast

– restraint

– direction of forces

– time of injury

– witness accounts

– prehospital care

• Penetrating– type of weapon

– number of wounds

– time of wounds

– blood loss at scene

– witness accounts

– prehospital care

Physical Exam

• Inspection for overt injury (contusions, cuts, evisceration, bleeding)

• Auscultation is actually worth very little• Palpation for areas of tenderness• Wound exploration in EXPERIENCED

HANDS• Pelvis, perineum, rectal (part of “a finger or

tube in every hole”)

Management

• As always, ABC’s

• Primary survey

• Secondary survey

• Access

• Fluid resuscitation

• Search for blood loss and stop it

Sources of Bleeding in Abdominal Trauma

• Intraperitoneal causes– Liver– Spleen– Vessels

• Extraperitoneal causes– Vessels– Kidneys

Second Tier Abdominal Injuries

• Bleeders take first priority, but:– May get bowel injuries with contamination– Pancreatic injuries with chemical injury– Mesenteric hematomas– Diaphragm injuries

Initial Evaluation in Blunt Trauma

• As always, ABC’s

• Access for fluids, blood products

• Type and cross most important tube to send

• Rapid, focused history and physical

• Prioritize life threats

• Resuscitation comes before testing

Evaluation of Blunt Injuries

• Plain films of the abdomen have virtually no utility in the evaluation

• Ultrasound (F.A.S.T.)

• Diagnostic Peritoneal Lavage

• CT scanning

• Operating room

• Others (urethrogram)

FAST Exam

• Focused Assessment by Sonography for Trauma

• Screens for free fluid, presumed to be blood in the trauma setting

• Decision scheme for positive FAST exam based on clinical scenario

FAST Images

• 4 views to obtain– RUQ view (fluid in Morrison’s pouch)– LUQ view (fluid in splenorenal space)– Subxyphoid (pericardial fluid)– Suprapubic (fluid around bladder)

– Some get additional views to look for pneumo or hemothorax!

Treatment Decisions with FAST

Positive FAST + unstable patient

Operating room

Positive FAST + stable patient

CT evaluation

Negative FAST + unstable patient

Continue resus, consider other causes, repeat FAST, DPL, or OR if continues unstable after adequate resuscitation

Negative FAST + stable patient

CT evaluation or observation

DPL

• Catheter inserted into abdomen, aspirate• If no gross blood, bile or stool, then lavage

with liter of saline• Contraindications exist• In general, positive if:

– > 100,000 RBC/mm3

– >500 WBC/mm3

– Gram stain + for bacteria

CT Scanning

• As opposed to FAST exams, CT is a very specific diagnostic study

• Will visualize retroperitoneum as well as intraperitoneum

• Must have patient enough to get CT scan

Comparison of Diagnostic Studies

FAST CT DPL

Cost cheap expensive cheap

Invasive no no yes

Sensitive yes yes yes

Specific no yes no

Repeatable yes yes no

Rapid yes no yes

Under the knife

• Indications to go under the knife– Blunt trauma with positive DPL or unstable

patient with positive F.A.S.T.– Blunt trauma with recurrent hypotension despite

resuscitation– Peritoneal signs– Penetrating wound with hypotension– GSW across peritoneal cavity, visceral

retroperitoneum

Under the knife

• Indications to go under the knife– GI or GU bleeding from penetrating trauma– Evisceration– Free air, retroperitoneal air– Ruptured diaphragm– CT evidence of ruptured GI tract, renal pedicle

injury, intraperitoneal bladder rupture, or severe perenchymal injury

Specific Injuries

• Diaphragm– left hemidiaphragm more commonly injured– elevation on CXR, but may be normal– difficult to visualize injuries by other means

(including CT, MRI)– injuries may be missed for years

Specific Injuries

• Duodenum– often in unrestrained drivers, handlebar injuries– suspect with history, blood in NGT aspirate, or

retroperitoneal air

Specific Injuries

• Pancreas– often from direct blow compressing pancreas

against vertebral column– very difficult to evaluate,even with CT– ERCP may be helpful

Specific Injuries

• Small bowel– can be from penetration or tearing from

compression or deceleration– think of injury with “seatbelt sign”– DPL good at detection transluminal injuries,

but small bowel bleed little, may be negative– F.A.S.T. and CT not good for small bowel

Specific Injuries

• Solid organs commonly injured– spleen #1 in blunt– liver #2 in blunt, #1 in stabs

• Management depends on extent/grading of injury– observation for small subcapsular tears– emergent laparotomy for grade IV

Specific Injuries

• Kidneys– can be from both blunt and penetrating– management also depends on severity/grading

Specific Injuries

• Pelvic fractures– numerous blood vessels, may result in massive

hemorrhage– usually massive forces involved – classifications based on forces causing injuries– if unstable fracture, must be reduced to control

hemorrhage

Specific Injuries

• Vascular injuries– aorta, IVC– can result in massive hemorrhage– much more likely form penetrating injury

Take home points

• Stay suspicious despite an initially innocuous exam

• ABC’s of trauma

• Know limitations of studies

• Surgeons are definitely your friends when it comes to trauma (irreplaceable)