© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Arkansas Trauma System Evidence-Based Guidelines for

Abdominal Trauma- Advanced Trauma Techniques-

Lower GI and Pelvis

Section Editor: Charles D. Mabry MD FACS

Introduction-

Trauma to the abdomen remains one of the most common major injuries for humans. The first two

evidence-based guidelines regarding abdominal trauma covered the pre-hospital and emergency

department evaluation and treatment of abdominal trauma and the upper abdomen. This third guideline

is aimed at the patient with major injuries to the lower abdominal organs and pelvis. The last guidelines

will cover damage control / open abdomen surgery.

Lower Abdominal Trauma- Colon, Rectum, Renal / GU, and Pelvis

Colon and Rectal trauma:

Injuries to the colon can be from blunt or penetrating injury, and are typically associated with other

intraabdominal injuries. It is important, if the patient is stable, to evaluate the patient to rule out

retroperitoneal and vascular injury. This is typically done with CT scans with IV contrast. IV contrast is

essential to detect bleeding from intraabdominal organs, major arteries and veins, and to gage how much

damage to solid organs has occurred. Ischemia of the colon due to arterial occlusion or dissection is

another item that can only be viewed when the patient has had IV contrast with the CT scan. 1, 2 Rectal

contrast should be considered for any patient with potential rectal or sigmoid colon injury, to exclude

occult injury. 2, 8

Primary repair of colon injuries is becoming much more common, but it is important to remember to give

the patient both appropriate and adequate IV antibiotics prior to surgery to reduce the incidence of

postoperative infection. Classic contraindications for primary repair of the colon are excessive blood loss

(>6 units), hypotension, gross contamination of the abdomen, and other major co-morbidities. In some

cases, this scenario will mandate damage control surgery, with a second look procedure in a day or two.

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Whether at the first or second-look procedure, depending upon the patient factors, some surgeons will

resect and anastomose colon injuries, to avoid a diverting colostomy or ileostomy. 3

Retroperitoneal penetrating colon and rectal injuries can be handled with either diversion alone or with

diversion, repair, and drainage plus or minus rectal washout. The literature in the past was divided with no

one clear answer available. Current recommendations are to use either proximal diversion alone or

diversion plus repair. Most trauma societies are now recommending avoiding pre-sacral drainage and

rectal washout, as they are associated with an increased (three fold) complication rate. 4, 5, 6 Combined

rectal and GU injuries will be discussed below in the Renal / GU section.

Antibiotics for GI Trauma:

If penetrating abdominal trauma or blunt injury to the bowel is suspected, then prompt administration of

adequate dosage of a broad spectrum antibiotic in the ED is also both indicated and necessary to reduce

late infection and complications. Giving the antibiotic sooner rather than later is always a good rule to

follow and will be in the best interest of the patient. Antibiotics can always be discontinued if it is found

out later that they are not needed. 7 8 Most research now agrees that a short (no more than 24 hours)

course is the best length of antibiotic administration. 9, 10 11 See [Figure A] below for current

recommendations for antibiotics for abdominal trauma:

Figure A: Antibiotics Recommended in

Blunt and Penetrating Abdominal Trauma

Common organisms likely to be encountered: Enteric gram-

negative bacilli, anaerobes, enterococci

Parenteral:

Cefoxitin Δ 2 g IV Two hours

OR cefotetan Δ 2 g IV Six hours

OR cefazolin Δ <120 kg: 2 g IV Four

hours ≥120 kg: 3 g IV

PLUS metronidazole

500 mg IV N/A

OR ampicillin-sulbactam Δ

3 g IV (based on combination)

Two hours

Δ For patients allergic to penicillins and cephalosporins,

clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to

exceed 2 g) with either gentamicin (5 mg/kg IV),

ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or

aztreonam (2 g IV) is a reasonable alternative.

Metronidazole (500 mg IV) plus an aminoglycoside or

fluoroquinolone are also acceptable alternative regimens,

although metronidazole plus aztreonam should not be used,

since this regimen does not have aerobic gram-positive

activity.

Modified from Up-to-Date 10,11 See Evidence Based Guidelines for Antibiotics in Trauma for more details and recommendations.

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Renal / Bladder trauma:

Injuries to the kidney and lower GU tract are much less common than injuries in the remainder of the

abdomen, due to their retroperitoneal location and protection by bony structures. If there are injuries to the

kidneys, the large majority of those injures will not require operative intervention or interventional radiology

(85+ % will be Grade I to Grade III injuries). However, due to the force necessary to cause higher grade

injuries with blunt trauma, there typically are other intraabdominal injuries as well that will need surgery. See

[Figure B- chart and illustration] for the AAST renal injury grading scale. 12 ,13

Just as it is important to include delayed phase images with CT scans using IV contrast for liver and spleen

injuries, it is also essential to include delayed imaging of the renal system to detect leakage of urine from the

kidney, ureters, and bladder. 14

The majority of patients that present with trauma will be stable enough to undergo CT scans with IV contrast,

including delayed imaging. However, as in other areas of abdominal trauma, if the patient is unstable then

rapid transport to the operating room is essential. If your trauma center doesn’t have immediate capability

for open surgery, then prompt referral via ATCC to the most appropriate trauma center, without a time-

delaying work up is also essential.

Evaluation and management of renal and GU trauma typically falls out into one of two scenarios:

1. Stable patient- CT scan-with delayed images- open surgery, or

2. Unstable patient- no CT scan- emergent open surgery

For the stable patient with a good CT scan, most of the injury extent to the kidney, ureters, and bladder

should be known or suspected at the time of surgery. The recommendations (below) will apply to that

patient.

For the unstable patient, injury to the kidney often presents itself during damage control surgery with the

discovery of a retroperitoneal hematoma in Zone II. Typically, exploration of the retroperitoneal hematoma in

Zone II is not indicated unless there is an expanding and / or pulsatile hematoma or if there is a penetrating

injury tract going through the kidney (medial tract of a Zone II hematoma). Lateral penetrating injuries to

Zone II can in most instances be observed but not explored, since the kidney and ureters are medial in

position. However, in this instance, a post-operative CT scan with IV contrast should be obtained to fully

evaluate the patient for the extent, if any, of renal injury. 15 Exploration of a non-expanding hematoma over

the kidney often results in nephrectomy for low grade injuries (Grades < IV) that would have healed on their

own if left undisturbed. 13, 14, 15 If a Zone II hematoma needs exploration, there are two methods of

exploration: medial and lateral. The medial approach is typically done for more elective cases, as it takes

more time to isolate and control the renal blood vessels. The lateral approach is quicker and more typically

used for a shattered kidney. Once exposed, by either method, compression of the kidney can help control

bleeding and allow proper decision-making regarding repair or nephrectomy. 15, 16 Nephrectomy should be

done if the kidney is shattered (Grade IV and V injury) and the patient is hemorrhaging from that organ, and

hemorrhage can’t be quickly controlled. In the past, it was recommended that a quick on-table IVP be done

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

prior to nephrectomy, in the unstable scenario where a CT scan hasn’t been obtained, to ensure that a viable

contralateral kidney is present. More contemporary guidance is to palpate for the presence of a normal (not

atrophic or polycystic) contralateral kidney and to ensure that there is a pulse (or ultrasound flow) in that

kidney’s renal artery, before proceeding with nephrectomy. 12

Bladder injuries are uncommon (<1% of all trauma) but are usually associated with pelvic fractures or

penetrating injury to the abdomen. In some cases, the injury to the bladder is found on routine CT scans with

IV contrast, but if suspected (combination of penetrating trauma or combination of gross hematuria with a

pelvic fracture) the patient should additionally have a retrograde CT cystogram. 17 Intraperitoneal rupture of

the bladder should be managed with repair and decompression of the bladder (Foley catheter or suprapubic

catheter). Extraperitoneal rupture of the bladder is primarily treated with just decompression. 17, 18 More

complex injuries of the posterior urethra, prostate, and bladder neck are primarily handled with some sort of

decompression of the bladder and urologic consultation and repair. 19

Combined rectal and bladder injury, while uncommon, is usually the result of penetrating injury and is

managed with primary repair of the rectum and bladder, with bladder decompression. 20 Diverting colostomy

and pelvic drainage is an option, as covered in the Rectal Trauma section (above).

Pelvic Trauma:

Pelvic trauma typically relates to the fracture of the pelvis. Pelvic fractures are a marker for major energy

trauma and are also a marker for increased mortality in a patient. The most recent data shows that the

presence of a pelvic fracture is associated with an increase in mortality up to 45 percent. 21 Of the various

types of pelvic fractures, the open book fracture is often times the most deadly and is associated with other

major traumatic injures elsewhere. Thus, patients with pelvic fractures should be considered for early

transfer to upper level trauma centers with multi-specialty support for general and orthopedic surgery,

interventional radiology, and in the event of urinary tract trauma, urology expertise.

We will not cover the orthopedic aspects of pelvic fractures in this document, but will focus on the initial

diagnosis and management and stabilization of patients with pelvic fractures. Hemorrhagic shock often

accompanies pelvic fracture, either from associated injuries, or from bleeding within the pelvis itself from

torn arteries and veins. 22 The predominance of bleeding (80-90%) occurs from pelvic veins, while arterial

bleeding typically accounts for 10-20% of cases, and is associated with shearing of arteries due to the

fracture. Quick detection of a shock index >1, hypoperfusion, hemorrhagic shock, acidosis, etc. should lead to

quick transfusion of blood and restriction of IV fluids, warming of the patient, and other supportive measures.

Diagnosis in most EDs is now done with CT scans. As with other CT scans for trauma, these should be done

with IV contrast to detect vascular injury and with delayed films to detect damage to the bladder and urinary

tract, causing spillage of urine. Open pelvic fractures can also be assessed with both CT scans and physical

examination and prompt antibiotic administration appropriate for the types of injury should be started

immediately, in the proper dosage, and then readministered at appropriate intervals. 23

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Pelvic stabilization for pelvic fractures should be done in the field or on arrival at the ED. This can be done

with simple sheets and towel clips or with a manufactured pelvic binder. Several studies, summarized in the

Western Trauma Association guidelines, failed to show any advantage of commercially developed binders

over simple sheet stabilization. 23 The goal of pelvic binding is stabilization of the fracture, to prevent further

injury during movement of the patient, not necessarily compression. In fact, for lateral fractures caused by

side delivered energy to the pelvis, excessive compression can worsen the injury by compression of the bony

elements further into the pelvis. 24

An excellent algorithm for management of pelvic trauma appears in the Western Trauma Association

Guidelines paper and is reproduced in [Figure C]. Another solid algorithm from the World Society of

Emergency Surgery dealing with pelvic trauma is shown in [Figure D]. 25

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Figure B: American Association for the Surgery of Trauma (AAST) Renal Injury Scale

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Figure B: American Association for the Surgery of Trauma (AAST) Renal Injury Scale

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

Figure C- Management of Pelvic Fractures with Shock or Hemodynamic Instability 23

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

World Society of Emergency Surgery (WSES) Pelvic Trauma Algorithm 25

Arkansas Trauma System Evidence-Based Guidelines for Abdominal Trauma- Lower GI and Pelvis

© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

References 1 Scaglione, Mariano, Francesco Iaselli, Giacomo Sica, Beatrice Feragalli, and Refky Nicola. "Errors in imaging of

traumatic injuries." Abdominal imaging 40, no. 7 (2015): 2091-2098. 2 Hinzpeter, R., T. Boehm, D. Boll, Christophe Constantin, Filippo Del Grande, V. Fretz, S. Leschka et al. "Imaging

algorithms and CT protocols in trauma patients: survey of Swiss emergency centers." European radiology 27, no. 5 (2017): 1922-1928. 3 Up to Date: Traumatic gastrointestinal injury in the adult patient. https://www-uptodate-

com.libproxy.uams.edu/contents/traumatic-gastrointestinal-injury-in-the-adult-patient?search=abdominal%20trauma&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5 4 Bosarge, Patrick L., John J. Como, Nicole Fox, Yngve Falck-Ytter, Elliott R. Haut, Heath A. Dorion, Nimitt J. Patel et

al. "Management of penetrating extraperitoneal rectal injuries: an Eastern Association for the Surgery of Trauma practice management guideline." Journal of Trauma and Acute Care Surgery 2016; 80, no. 3 (2016): 546-551. 5 Brown, Carlos VR, Pedro G. Teixeira, Elisa Furay, John P. Sharpe, Tashinga Musonza, John Holcomb, Eric Bui et al.

"Contemporary management of rectal injuries at level I trauma centers: the results of an American Association for the Surgery of Trauma multi-institutional study." Journal of Trauma and Acute Care Surgery 84, no. 2 (2018): 225-233. 6 Up to Date: Diagnosis and initial management of traumatic retroperitoneal injury. https://www-uptodate-

com.libproxy.uams.edu/contents/overview-of-the-diagnosis-and-initial-management-of-traumatic-retroperitoneal-injury?search=rectum++trauma&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 7 Ma, Xiao-Yuan, Li-Xing Tian, and Hua-Ping Liang. "Early prevention of trauma-related infection/sepsis." Military

Medical Research 3, no. 1 (2016): 33. 8 Brand, Martin, and Andrew Grieve. "Prophylactic antibiotics for penetrating abdominal trauma." Cochrane

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R. Ivatury, and Therese M. Duane. "Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline." Journal of Trauma and Acute Care Surgery 73, no. 5 (2012): S321-S325. 10

Up to Date: Initial Management of Trauma In Adults- antibiotic use 2020 11

Up to Date: Traumatic gastrointestinal injury in the adult patient. 2020 12

Up to Date: Overview of traumatic upper genitourinary tract injury. https://www-uptodate-com.libproxy.uams.edu/contents/overview-of-traumatic-upper-genitourinary-tract-injuries-in-adults?search=rectum%20%20trauma&topicRef=114923&source=see_link 13

Kozar, Rosemary A., Marie Crandall, Kathirkamanthan Shanmuganathan, Ben L. Zarzaur, Mike Coburn, Chris Cribari, Krista Kaup, Kevin Schuster, Gail T. Tominaga, and AAST Patient Assessment Committee. "Organ injury scaling 2018 update: Spleen, liver, and kidney." Journal of Trauma and Acute Care Surgery 85, no. 6 (2018): 1119-1122. 14

Keihani S, Xu Y, Presson AP, et al.Contemporary management of high-grade renal trauma. Journal of Trauma and Acute Care Surgery. 2018;84(3):418–425. 15

Brown CV, Alam HB, Brasel K, et al.Western Trauma Association Critical Decisions in Trauma. Journal of Trauma and Acute Care Surgery. 2018;85(5):1021–1025. 16

Brown CVR, Galante JM. Operative management of renal injuries. In: Martin M, Beekley AC, Eckert MJ, eds. Front Line Surgery. 2nd ed. Cham, Switzerland: Springer; 2017:169–184. 17

Up to Date: Overview of traumatic lower genitourinary tract injury, https://www-uptodate-com.libproxy.uams.edu/contents/overview-of-traumatic-lower-genitourinary-tract-injury?search=rectum%20%20trauma&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 18

EAST guidelines: Management of Genitourinary Trauma 2004. https://www.east.org/education/practice-management-guidelines/genitourinary-trauma-management-of

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© 2020 Arkansas Trauma Society and Arkansas Chapter of the American College of Surgeons

19

Yeung, Lawrence L., Amy A. McDonald, John J. Como, Bryce Robinson, Jennifer Knight, Michael A. Person, Jane K. Lee, and Philipp Dahm. "Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma." Journal of Trauma and Acute Care Surgery 86, no. 2 (2019): 326-336. 20

Osterberg EC, Veith J, Brown CR, et al. Concomitant bladder and rectal injuries. Journal of Trauma and Acute Care Surgery. 2020;88(2):286–291. 21

Yoshihara, Hiroyuki, and Daisuke Yoneoka. "Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality." Journal of Trauma and Acute Care Surgery 76, no. 2 (2014): 380-385. 22

Cullinane, Daniel C., Henry J. Schiller, Martin D. Zielinski, Jaroslaw W. Bilaniuk, Bryan R. Collier, John Como, Michelle Holevar et al. "Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review." Journal of Trauma and Acute Care Surgery 71, no. 6 (2011): 1850-1868. 23

Up to Date: Pelvic Trauma: Initial Evaluation and Management 24

Davis, James W., Frederick A. Moore, Robert C. McIntyre Jr, Christine S. Cocanour, Ernest E. Moore, and Michael A. West. "Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability." Journal of Trauma and Acute Care Surgery 65, no. 5 (2008): 1012-1015. 25

Coccolini, Federico, Philip F. Stahel, Giulia Montori, Walter Biffl, Tal M. Horer, Fausto Catena, Yoram Kluger et al. "Pelvic trauma: WSES classification and guidelines." World Journal of Emergency Surgery 12, no. 1 (2017): 5.