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CERTIFICATE BY GUIDE
This is to certify that this Dissertation on
"ABDOMINAL TRAUMA- A CLINICAL PROFILE"has been carried out by Dr.
KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a post graduate student working under my
direction, guidance and supervision, in partial fulfillment of the rules and regulations laid down
by N.T.R University of Health ciences, !i"ayawada, to appear for #. $%eneral urgery&
Degree '(amination to be held in )*R+-/01.
Date2
*lace2 !+)3H)*)TN)#.
Dr. G.ARJUNA, M.S.
*R45'4R 45 %'N'R) UR%'R6
D'*)RT#'NT 45 %'N'R)UR%'R6
)NDHR) #'D+7) 74'%'
3+N% %'4R%' H4*+T)
!+)3H)*)TN)#
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CERTIFICATE BY HOD
This is to certify that the Dissertation on
ABDOMINAL TRAUMA- A CLINICAL PROFILE" is the bonafide work carried
4ut in )ndhra #edical 7ollege 8 3ing %eorge Hospital. !isakhapatnam by
Dr.KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a *ost %raduate student
working under my direction, guidance and supervision, in the partial
fulfillment of rules and regulations laid down by N.T.R. University of Health
ciences, !i"ayawada, to appear for #.. (%eneral urgery& degree e(amination to
be held in )pril /01
P!"# $!isakhapatnam
D!%# Dr.N.SUBBARAO ,M.S.
Pr&'#&r ) HOD &' %*# +#!r%#%
D#!r%#% &' /##r! 0r/#ry
K1/ G#&r/# *&1%!
21!3*!!%!
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ABDOMINAL TRAUMA- A CLINICAL PROFILE
) Dissertation ubmitted to the
Dr. N.T.R. UN+!'R+T6 45 H')TH 7+'N7', !+9)6):)D)
In partial fulfillment of the Rules and Regulations for
#.. ;%eneral urgery< D'%R'' '=)#+N)T+4N
To be held in
)*R+- /01.
Dr. KUMBHA NAGA SUNEETHA, M.B.B.S.,
Under the Direction and Guidance of
Dr.G.ARJUNA M.S.
*R45'4R 45 %'N'R) UR%'R6
D'*)RT#'NT 45 %'N'R) UR%'R6
)NDHR) #'D+7) 74'%'
3+N% %'4R%' H4*+T)
!+)3H)*)TN)# $).*&
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ACKNO4LEDGEMENTS
+ e(press my sincere thanks and deep sense of gratitude
to Dr.N.SUBBARAO M.S. *rofessor of %eneral urgery, )ndhra #edical
7ollege,!isakhapatnam, :ho has taken keen interest and rendered his most
valuable guidance and supervision in each and every step of my effort in
preparing this dissertation.
+ sincerely acknowledge my heartful thanks to my respected professors
Dr.N.Dwarakanadh#..#ch., Dr..!.3umar.#.., Dr.7h.waminaidu.#..,
Dr.)r"una.#.., Dr.T.Narayanarao.#.., Dr.ivakumar.#.., Department of
general surgery, )ndhramedical college, !isakhapatnam for their valuable
guidance. + am thankful for their encouragement and advice.
+t is my great privilege to honestly thank my associate professors
Dr.Ra"agopal.#.., Dr.!.#anmadharao.#.., Dr.R.>havanirao.#.., and
assistant professors Dr.*.).Ramani.#.., Dr.3.9anardhanrao.D.N.>.,
Dr.>.7haitanyababu.#.., Dr..Ratnakishore.#.., for their valuable
guidance, encouragement and advice.
+ also thank *rincipal )ndhra #edical 7ollege, !isakhapatnam,
faculty of Department of Radiology for permitting me to carry out this work.
+ am thankful to all my colleagues for their co-operation and help throughout
the present study.
ast, but not the least + am grateful to the patients who have submitted
themselves for this study and for their remarkable co- operation.
(Dr.RAJESH MUPPANA5
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LIST OF ABBRE2IATIONS
0. %7 %lgasgow 7oma cale
. T+ Therapeutic +ntervention core ystem
?. )+ )bbreviated +n"ury cale
1. + +n"ury everity core@. )*)7H' )cute *hysiological and 7hronic Health
A. D* Diagnostic *eritoneal avage
B. R>7 Red >lood 7ell
C. :>7 :hite >lood 7ell
. +U8 +nternational Units *er iter
0/. +!U +ntravenous Urography
00. 7T 7omputeriEed Tomography
0. 5)T 5ocused )ssessment onography in Trauma
0?. #R+ #agnetic Resonance +maging
01. )>% )rterial >lood %as
0@. 4T 4peration Theatre0A. %+ %astro-intestinal
0B. 'R7* 'ndoscopic Retrograde 7holangio *ancreaticography
0C. 7>D 7ommon >ile Duct
0. +!* +ntravenous *yelogram
/. +!7 +nferior !enecava
0. %' %astro-esophageal
. U% Ultrasonography
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74NT'NT
*age No.
*)RT - +
0 +NTR4DU7T+4N
R'!+': 45 +T'R)TUR'
*)RT - ++
0. )+# )ND 4>9'7T+!'
. #)T'R+) )ND #'TH4D
?. 7)' H''T
1. 4>'R!)T+4N )ND R'UT
@. D+7U+4N
A. 74N7U+4N
B. >+>+4%R)*H6
C.#)T'R 7H)RT
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INTRODUCTION
+n"ury is the leading cause of death and disability in the first four decades of life and is
the third most common cause of death overall.
+n +ndia communicable diseases continue to take the ma"or share even now, still in"ury
is responsible for BF of all deaths. )bout 0 in 1/,/// individuals die in +ndia every year,
whereas appro(imately double the number is disabled and this number is increasing.
>y convention, in"ury is classified into several categories - *enetrating, >lunt or
Nonpenetrating, >last overpressure, Thermal, 7hemical and others including crush and
barotrauma. +n blunt in"uries, the damage may be caused by acceleration, deceleration, rotational
or shearing forces.
Trunkey has pointed out that deaths due to trauma fall broadly into three groups, giving a
distinct trimodal pattern.
0. +mmediate deaths $@/F&
. 'arly deaths $?/F&
?. ate deaths $/F&
+t is among those cases represented by second and third peaks that potentially preventable
deaths occur. 4f one fourth to one third of the deaths from trauma could be prevented by more
effective initial care. The primary aids like airway management, restoration of circulation, care
of cervical spine, cardiopulmonary resuscitation is carried out in the initial stages. Roughly 0/F
have life threatening in"uries and speed in diagnosis and therapy is crucial to their survival.
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coring systems have been developed to facilitate triage, research and Guality assurance.
#ore recently their ability to predict morbidity and mortality particularly septic complications
have been studied.
)bdominal trauma is one of those sub"ects where the skills of the surgeon is "udged, both
in correct diagnosis of the associated visceral in"uries and in treating them, promptly and
skillfully, since the morbidity and mortality is very high if not treated adeGuately.
:ith the increase in the number of motor vehicle accidents, there is rising incidence of
abdominal trauma. The abdomen is the third most commonly in"ured body region, with in"uries
reGuiring operation in about /F of civilian trauma victims. )bdominal in"uries can be
particularly challenging because it is often difficult to assess the intra abdominal pathology in the
multiple in"ured victim. There is also masking of abdominal in"uries by associated conditions
like head in"uries, fractures, alcoholism, drug abuse, shock etc.
+nitial clinical assessment of the abdomen in blunt trauma is accurate in only B/-C/F of
cases. aparotomy should be done when in doubt in a patient with multiple in"uries where all
clinical and other investigations have failed to e(clude the abdomen as a source of shock
syndrome he displays. )s more and more improvements in the diagnostic modalities for
abdominal trauma are forthcoming a therapeutic approach towards conservation with decreased
operative intervention has been increasing especially for solid organ in"uries.
The ob"ect behind my study is to present a comprehensive picture of the recent concepts
in assessment and management of abdominal in"uries in our setup and to highlight upon the
diagnostic difficulty it poses and the distressing high mortality it carries. The dissertation has
review of literature on the sub"ect and report on the nature of in"ury, type of viscera in"ured,
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treatment offered for abdominal in"ury patients, admitted to 3ing %eorge Hospital,
!isakhapatnam during the period of #ay /00 to 4ctober /0?.
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RE2IE4 OF LITERATURE
HISTORICAL RE2IE4
)ristotle was the first person to describe about visceral in"uries due to blunt trauma. ater
on Hippocrates and %alen have given description about this condition. 4ne of the most
interesting early practitioners of trauma care was %alen $0?/-// ).D&. %alens book became
the primary source for treatment of wounds throughout the middle ages.
+ndias system of trauma care has rivaled the Romans. During the reign of )shoka $A-
? >.7&, the )rthashastra was written. This book documented that army had an ambulance
service with well eGuipped surgeons. )t appro(imately the same time a very famous surgeon
ushrutha lived and treated patients in >enaras.
)mbroise *are $0@0/-0@/ ).D& ma"or contribution in treating in"uries include his
treatment of gunshot wounds, use of ligature instead of cautery and use of nutrition during post
in"ury period
Traverse $0CB& has reported fracture of body of pancreas caused by blunt trauma. 4wen in
0C1C gave a graphic description of a case of closed abdominal in"ury and fatal hypovolemic
shock due to liver rupture following a fall.
9ance $0C@A& described a fatal isolated pancreatic in"ury due to a kick. !on
Reclinghausen $0CA0& described renal artery thrombosis occurring as a result of blunt in"ury. +n
0CB/ >urn was the first one to resect the liver successfully and >urkhart in 0CCA controlled
acute traumatic liver haemorrhage by suturing.1
ongrat $0CB@& was the first person to study the pathogenesis of rupture of bowel. +n
0CC, #arion imms began to emphasiEe the need for laparotomy in the case of abdominal
trauma. +n 0CCA, Riolti successfully repaired a torn left dome of diaphragm caused by fall from
a tree. 3een $0C& e(cised left lobe of liver using cautery.
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%rant #ussay $0?& wrote that -in closed abdominal in"uries, early diagnosis is almost
impossible and must be guided by general consideration of clinical picture than presence or
absence of any particular sign.
)inheim in 0?1 described abdominal paracentesis as a diagnostic procedure. Root in
0A@ popularised the techniGue of peritoneal lavage, though it was first suggested by olomon
in 0/A. during the 5irst :orld :ar, the treatment of abdominal in"uries was mainly
conservative with a mortality around BBF. Hence, in :orld :ar ++, e(ploration was done for
all, thus bringing down the mortality to @F.
ANATOMY OF ABDOMEN
M0"# &' Ab+
#uscles of abdomen can be divided into anterolateral and posterior groups.
)NT'R4)T'R) #U7' 45 )>D4#'N
7onsists of four large flat muscular sheets.
0. '(ternal obliGue.
. +nternal obliGue.
?. Transversus abdominis.
1. Rectus abdominis.
*4T'R+4R #U7' 45 )>D4#'N2
There are four muscles forming posterior wall of abdomen.
0. *soas ma"or.
. *soas mr.
?. +liacus.
1. Iuadratus lumborum.
FASCIA
5asciae in relation to abdominal wall can be divided into2
0. Those in relation to anterior abdominal wall.
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. Those in relation to posterior abdominal wall.
5)7+) +N R')T+4N T4 )NT'R+4R )>D4#+N) :)2
0. uperficial fascia which is divided into superficial fatty layer 7amper and deep membranous
layer carpa
. Rectus sheath.
?. Transversalis fascia.
5)7+) +N R')T+4N T4 *4T'R+4R )>D4#+N) :)2 TH4R)74U#>)R
5)7+).
+t has three layers. *osterior layer,middle layer and anterior layer.
NEURO2ASCULAR PLANE
The abdominal wall is supplied by all the lower si( thoracic nerves via intercostal nerves
and the first lumbar nerve via iliohypogastric and ilio-inguinal nerves.
The nerves and vessels run in the plane between transverse abdominis and internal obliGue
musles.
LYMPHATIC DRAINAGE
)bove the umbilicus drain into *ectoral group of a(illary nodes. >elow the umbilicus go to the
uperficial inguinal lymph nodes.
PERITONEUM
*eritoneum is a fibrous membrane lined by mesothelium. That part of peritoenoum which lines
linea alba, the anterior and posterior abdominal walls is the parietal peritoneum. *arietal
peritoneum is supplied by nerves supplying abdominal muscles.
That part of peritoneum investing the viscera is known as visceral peritoneum and is
devoid of nerve supply and hence pain insensitive.
*'R+T4N') 7)!+T6
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The potential space between these two layers containing a few ml, of tissue fluid is known as
peritoneal cavity. This poritoneal cavity is divided into greater sac and lesser sac communicating
through foramen of :inslow or epiploic foramen lying between the first part of duodenum and
the undersurface of liver. +t is limited anteriorly free edge of lesser omentum and posteriorly
inferior venecava.
%R')T'R )7
+t is divided into supracolic compartment and infracolic compartment by the transverse
mesocolon.
upracolic compartment is further divided into right half and left half by falciform
ligament.
upracolic compartment is continuous with right paracolic gutter whereas the left
paracolic gutter is separated by phrenico-colic ligament. +nfracolic compartment is divided into
right and left halves by attachment of mesentry e(tending from duodenal-"e"unal "unction to right
iliac fossa.
''R )7
+t is also called as omental bursa and lies behind the stomach.
OMENTUM
These are peritoneal folds. There are omenta2 %reater and lesser omentum,
%R')T'R 4#'NTU#
This is the largest peritoneal fold. +t consists of a double sheet folded on itself so that it is made
up of four layers. The two layers which descend from the stomach and 0 stpart of duodenum pass
downwards infront of small intestines for a variable distance then turn upon themselves and
ascend as far with upper layer of transverse mesocolon.
That part of greater omentum e(tending from greater curvature to diaphragm is called
gastrophrenic ligament. The part e(tending from greater curvature to spleen is known as
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gastrosplenic ligament. That part between spleen and left kidney is le-renal ligament and the part
between greater curvature and transverse colon is gastrocolic ligament.
''R 4#'NTU#2
+t e(tends form lesser curvature of stomach and commencement of duodenum to the
undersurface of liver. Hepatic attachment is 9 shaped, horiEontal limb corresponding to the
margin of porta hepatis.
2ISCERA
!iscera of supra colic compartment are liver, spleen, and stomach, and that of infracolic
compartment - small intestine and large intestine.
LI2ER
iver is the largest organ in the body situated in right hypochondrium and epigastric region .
+t has 1 lobes and 1 surfaces2
54UR 4>'
0.Right lobe, .eft lobe,?.7audate lobe and 1.Iuadrate lobe.
54UR UR5)7'
0.uperior surface,.*osterior surface ,?.Right surface and 1.+nterior
surface
'%#'NT) )N)T4#6
The line drawn from bed of gall bladder to inferior vena cava divides the iver into right
lobe and left lobe. Right lobe is divided into anterior and posterior segments. eft lobe is divided
into medial and lateral segments. )ll these segments are divided into superior and inferior
segments.
*'R+T4N') 74NN'7T+4N 45 +!'R
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0. 5alciform ligament,.Right triangular ligament,?.eft triangular ligament,1.7oronary
ligament and @.esser omentum.
SPLEEN
*rincipally situated in the left hypochondrium. +ts long a(is lies in line of 0/th
rib.
+t has diaphragmatic and visceral surfaces. Upper and lower border and anterior and posterior
e(tremities.
The diaphragmatic surface is conve(, smooth and faces upwards and to left. The visceral
surface is directed towards the abdominal cavity and has gastric, renal, pancreatic and colic
impressions.
%astrosplenic ligament e(tends form greater curvature of stomach to spleen. e renal
ligament-is the peritoneal fold $ part of greater omentum& e(tending from spleen to left kidney.
STOMACH
tomach has openings - cardia and pylorus , curvatures Jgreater curvature and lesser
curvature , surfaces J antero superior and postero inferior and ? parts J fundus ,body and
antrum.
)NT'R4U*'R+4R UR5)7'
5undic part is in relation to the diaphragm. Upper and left part of this surface is in contact
with the gastric surface of spleen. The right half is in relation to the inferior surface of liver and
anterior abdominal wall.
*4T'R4+N5'R+4R UR5)7'
This is related to diaphragm, left superarenal gland, upper part of left kidney, splenic
artery and anterior surface of pancreas, left colic fle(ure and upper layer of transverse
mesocolon.
These structures from the stomach bed but the stomach is separable from them and can
slide over them due to the intervening omental bursa.
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STRUCTURES OF INFRACOLIC COMPARTMENT
6. SMALL INTESTINE 2
'(tends from pylorus to ileocaecal "unction. +t is A-B meters in length. 4f this 8@ th is
"e"unum and ?8@this ileum. +t covered by peritoneum e(cept over duodenum and is attached to
posterior abdominal wall by mesentry.
DUODENUM$
@cm long and is the most fi(ed part of small intestine.
C&1% &' 7 !r%$
0. 0stuperior, . ndDescending, ?.?rdHoriEontal and 1.1th)scending.
R')T+4N
0- S0#r1&r !r%$ related anteriorly to Guadrate lobe and posteriorly to gastro-duodenal )rtery,
bile duct and portal vein.
- S#"&+ !r%$ related anteriorly to duodenal impression on right lobe of liver, tranverse colon
and transverse mesocolon. *osteriorly to right kidney. )mpulla of vater open into the middle of
this part on postero medial aspect.
?. T*1r+ !r%$ related anteriorly to superior mesenteric artery and the root of mesentry.
*osteriorly to right ureter, +nferior vena cava and aorta $origin of inferior mesenteric artery&.
1. F&0r%* !r%$ related anteriorly to the transverse colon and transverse mesocolon, posteriorly
to the left kidney and ureter.
JEJUNUM AND ILEUM
0. Diameter of "e"unum is $1cm& more than ileum $?.@cm&.
. !ascular arcades are less in "e"unum one as compared to ileum two or more.
?. 9e"unum is double layered $because the mucosa is folded to produce valves&, while ileum is
single layered.
1. #esenteric fat encroaches on to "e"unal wall but not in case of ileum.
COLON
0. 7olon is 0.@ meters long has a greater diameter.
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+t is distinguished by taenia coli formed by longitudinal muscle fibres, the presence of
)ppendices epipoicae and presence of haustrations.
RECTUM
+t is 0 -0C cm. ong, e(tending from ?rdpiece of sacrum to "ust below the tip of coccy(.
The longitudinal muscle spreads to encircle whole circumference. +t has no appendices
epiploicae and haustrations.
5)7+)
0. 5ascia of :aldeyer2 avascular dense connective tissue between sacrum and rectum.
. ateral ligament of rectum, e(tending from lateral wall of pelvis to rectum containing middle
rectal vessels.
?. 5ascia of Denonvillier is the loose areolar tissue between rectum posteriorly and seminal
vesicles and prostrate anteriorly.
STRUCTURES OF RETROPERITONEUM$
6. PANCREAS
*ancreas is situated transversely behind the stomach from the duodenum to the spleen. +t has
head, neck, body and tail.
0. H')D$ lies in the curve of duodenum and is related to inferior vena cava.
. N'73$ related anteriorly to gastroduodenal artery and its branches, *osteriorly.
?. >4D6$ related anteriorly to omental bursa and posteriorly to aorta and origin of superior
mesenteric artery, left supra renal artery and left kidney.
1. T)+$ contained in the layers of lerenal ligament and intimately related to hilum of spleen.
KIDNEY
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'(tends from upper border of 0 ththoracic vertebra to the lower border of ?rd lumbar vertebra.
Right kidney is at a lower level than the left kidney.
R+%HT 3+DN'6 + R')T'D )NT'R+4R6
Nearer superior pole to suprarenal gland and a large area below this to hepatic area. #edial
border is in contact with descending part of duodenum. +nferiorly kidney is related to right colic
fle(ure.
*osteriorly it is related above to diaphragm and below $from medial to lateral& Guadratus
lumborum andKtransverses tendon.'5T 3+DN'6 + R')T'D )NT'R+4R6
4n superior aspect to suprarenal gland, lateral half to spleen, medial area to stomach, middle area
to pancreas and below the pancreatic area laterally to colon and medially to coils of "e"unum.
%R')T !'' 45 )>D4#'N
0,)>D4#+N) )4RT)
>ranches 0. !entral -7eliac trunk
-uperior mesenteric artery
-+nferior mesenteric artery
. ateral -inferior phrenic artery
-middle suprarenal artery
-renal artery
-artery to testis8 ovary
?. Dorsal -lumbar artery
-middle sacral artery
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1.Terminal Jcommon iliac artery
. +N5'R+4R !'N)7)!)
5ormed by union of two common iliac veins, on right side of the body of @ vertebra,
ascends in front of vertebral column on the right side of aorta.
GENERAL FEATURES OF ABDOMINAL INJURIES
T*# 8!r1&0 C!0# !r# ! '&&9$
Road traffic accidents
+ndustrial accidents
5all from height
)ssault
Run over by vehicles
ports in"ury
M#"*!1 &' 1:0ry$
>lunt in"uries are thought to result from a combination of 0& crushing & deforming ?&
stretching and 1& shearing forces. The magnitude of these forces is directly related to the mass
of the ob"ects involved, the rate of the acceleration or deceleration and the relative direction on
impact. +n"ury results when the sum of these forces e(ceeds the cohesive strength of the tissue
and organs involved.
*enetrating abdominal trauma whereby the abdominal cavity communicates with the
e(terior. The causes are multiple and include gunshots, high velocity missiles and knives. The
e(tent of intra-abdominal in"uries may be difficult to predict. However, a high inde( of suspicion
must be maintained to avoid missing occult in"uries.0AThe increased use of 7T scan in patients
with penetrating abdominal in"uries has reduced the rate of negative and unnecessary
laparotomies. +n one study of 0 patients with penetrating abdominal in"ury who underwent 7T,
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@ had laparotomies and all were positive laparotomies. The remaining 0A were managed
conservatively and all had uncomplicated recovery.
H&% C*!r!"%#r1%1"
)bdominal in"uries associated with rapid deceleration at points of ma(imum fi(ation
include tears of the "e"unum at the ligament of TreitE, the terminal ileum and other points of
adhesion. 4ther host related factors thought to influence the response to trauma include age and
pre-e(isting disease. *atients more than B/ years of age e(perience a mortality rate
appro(imately five times than that of younger adults, due to diminished physiologic reserve and
more fragile tissue. )cute ethanol into(ication reduces the physiologic response to stress.
#otor vehicle accidents accounts for B@F of cases of blunt abdominal trauma.
ome series list the liver rather than spleen as the most commonly in"ured intra
abdominal organL this difference probably reflects the means of diagnosis. mall liver in"uries
are often detected in patients who undergo 7T scan of the abdomen, whereas splenic in"uries in
adults are more likely to be clinically significant and reGuire surgical intervention.
TRIAGE AND INJURY SE2ERITY SCORES
This is based on patient stability, mechanism of in"ury and site of in"ury, as well as
diagnostic and therapeutic maneuvers.
The term triage, which is 5rench, was adopted in to the 'nglish language during :orld
:ar +. +t is defined as a process of sorting and classifying sick and in"ured patients, taking into
consideration the nature of in"ury, the resources available, the time to definite care and the
prognosis of the in"uries. Triage is based on the concept that survival will be optimiEed if the
patients needs can be matched with medical resources in a timely way.
INJURY SE2ERITY SCORING
P*y1&&/1"! S"&r#$
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0. %lasgow 7oma cale $%7&.
. Trauma core.
?. Revised Trauma core.
1. *ediatric Trauma core.
@. Therapeutic +ntervention core ystem $T+&
A. )pache +, ++, +++
A!%&1"! S"&r#$
0. )bbreviated +n"ury cale $)+&.
. +n"ury everity core $+&.
GLASGO4 COMA SCALE(GCS5
This widely used scale relates specifically to the head in"ury component of the in"ured
patient. The three aspects of the coma which are specifically assessed are - eye opening ,verbal
response and motor respnse .
>y adding the scores of the three components, the total %lasgow coma scale is determined. The
higher the scores the better the prognosis.
RE2ISED TRAUMA SCORE
7hampion in 0C revised his own trauma score to incorporate the %7. The Trauma core and
Revised Trauma core differ only in that the latter does not include capillary refill or chest
e(pansion.
T!b# 6$ R#81#+ Tr!0! S"&r#
G!/&9 "&! "!# Sy%&1" b&&+ r#0r# R#1r!%&ry r!%# P&1%
6;-6< MC 6=-6> 7
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>-6? BA-C @?> ;
- @/-B@ -> ?
7-< 0-1 6-< 6
; / = =
!ariables on three organ systems that are vital to survival are thus combined into a single
score. High scoring eGuates with better prognosis.
THERAPEUTIC INTER2ENTION SCORE SYSTEM (TISS5 Devised by 7hampion and
introduced in 0B1, this is a method of Gualifying nursing, medical and technological support
activity and calculated for cost. 7urrently it consists of BA procedures. )ssigned a point score of
0 to 1. +t is a non specific score.
ACUTE PHYSIOLOGICAL AND CHRONIC HEALTH E2ALUATION
(APACHE5 SCORE
Devised by 3naus in 0C@. initially it had ?1 variables selected and weighed by clinical
consensus. +t proved unyielding. +n its second version, mandatory physiological variables were
reduced to 0. The score is computed after 1 hours of +7U care, using the worst values recorded
for each of the 0 variables. This reflects risk of death with CAF accuracy. This is used all over
the world.
ABBRE2IATED INJURY SCORE (AIS5 The first anatomic scoring system, )+ was
published in 0B0 as a scoring system for blunt trauma as a result of motor vehicle accidents.0C
ubseGuently there have been si( revisions. The most recent revision in 0/, classified more
than 0?// in"uries into si( levels of in"ury severity.0The scores were originally based on four
criteria2 threat to life, permanent impairment, treatment period and energy dissipation. The
in"uries were further categoriEed into si( different regions. The )+ allows comparisons only
among patients with similar in"uries.
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HISTORY AND PHYSICAL EAMINATION
)s with any surgical disease or emergency, obtaining a careful history and performing a physical
e(amination are of utmost importance in the case of trauma victim.
H1%&ry$ The history taking should never delay providing appropriate care for the e(sanguinating
patient. ) Guick pertinent history of the in"ury should be obtained from the patient or from
family members, bystanders, police and paramedics, important facts include the time of in"ury,
the type and siEe of the wounding agent, the initial vital signs, and the amount of blood loss at
the scene. pecific details of the in"ury mechanism are critical. :hat was the position of the
victim in the vehicle :hat was the type of accident 5rontal impact, side impact, side swipe,
rear impact and rollover have their own uniGue patterns of in"ury. :hat was the siEe and shape of
the weapon, severity of impact forces
4ther important information such as allergies, bleeding tendencies, current medications,
past or present illness, tetanus immuniEation status and the time of the last meal must be
determined. )ll women of childbearing age should be Guestioned about their last menstrual
period and then asked whether they are pregnant.
The severity of mechanism is related to the force and duration of impact as well as the
mass of patient contact area. )ll details regarding pain abdomen, vomiting, retention of urine,
constipation, distention of abdomen etc. should be obtained.
P*y1"! E!1!%1&$
The physical e(amination has always been the most important part. !ital data and signs
of peritoneal irritation are most helpful.
)s the most freGuent signs of intra abdominal in"uries due to blunt trauma are
hypotension or peritonitis, which can occur simultaneously. They might have blood in one of the
four areas viE. the pleural cavities, the peritoneal cavity, the retro peritoneum or e(ternally .
4n inspection of the abdomen it is important to note contusion of skin, particularly in the
areas of lower ribs on either side. 'cchymosis in the flanks, indicating retroperitoneal
haemorrhage should be noted but it may not occur until late. 4n a patient with right sided
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contusions over the lower chest or upper abdominal wall or fractures in the lower si( ribs, in"ury
to the liver should be suspected. +f the same findings are present in the left lower chest or left
upper Guadrant, in"ury to the spleen should be suspected.
There is a /F chance of splenic in"ury and a 0/F chance of hepatic in"ury, with
fractures of left and right lower si( ribs, respectively.
+nspection in penetrating in"ury will reveal entry and e(it wounds, lacerations, abdominaldistension evisceration, impaled ob"ects and sometimes bullet lodged in subcutaneous tissue.
4n palpation, the overt signs of peritonitis may be elicited. Tenderness from abdominal
wall in"ury and intraabdominal in"ury can sometimes be distinguished, if a cooperative patient
can raise his legs several inches off the e(amining table. +f tenderness disappears, in"ury is
intraabdominal. +f tenderness is increased, in"ury is to the abdominal wall. +f the tenderness is
diminished, in"ury to both is present. igns of overt peritonitis may be masked by shock, head
in"ury, spinal in"ury, alcohol or drug ingestion.
)ppro(imately B@F of all penetrating in"uries to abdomen occur in upper Guadrant.
#a"ority are in the left upper Guadrant reflecting the fact that, when two assailants face each
other, the right handed opponent is most likely to inflict left upper Guadrant in"ury. ocation of
wound will help surgeon to gain a rough idea preoperatively of the e(tent of abdominal in"ury.
)bdomen is percussed for the evidence of obliteration or e(tension of liver and spleen
dullness. 5lanks are percussed for the evidence of free fluid in the peritoneal cavity. The absence
of bowel sounds does not necessarily indicate significant intraabdominal in"ury since shock and
trauma to other areas can cause ileus. The progression from the active bowel sound to diminished
and then absent is a more reliable indication. )lso the presence of bowel sounds does not rule out
the possibility of intraabdominal in"ury. +n stable patients, there is a need for repeated abdominal
e(amination, as they may develop peritoneal signs at a later stage
The back, perineum, rectum and vagina should always be e(amined for wounds of
entrance and e(it. ) rectal e(amination is done for blood, crepitus or high floating prostate and
to know the sphincter tone and integrity of the rectal wall. *resence of blood provides evidence
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of colorectal in"ury whereas a flaccid bladder is indicative of spinal cord in"ury in penetrating
trauma.
) valuable sign of continuing intraabdominal haemorrhage is transient elevation of
blood pressure to normal for a few minutes followed by return to hypotensive levels, with rapid
infusion of @//-0///ml of Ringer actate. *atients who are hypotensive due to minimal blood
loss or neurogenic shock do not behave in this manner.
)bdominal e(amination should be completed by inserting nasogastric tube and foleys
catheter.
L&"! 4&0+ E&r!%1&2
+n the stable patient without obvious signs $eg2 peritonitis&, local wound
e(ploration remains a viable screening option. ocal wound e(ploration is a well-defined
procedure done under local anaesthesia to assess whether peritoneal tear is present.
imultaneous wound debridement is done by e(tending the wound as necessary to follow its
track. ocal wound e(ploration is difficult in stab wounds between nipple and costal margin,
which may lead to pneumothora( and stab in back region because of bulky musculature. +f
wound e(ploration is positive or eGuivocal the incidence of negative laparotomy is still @/F.
S 1&r%!% 1/ !r#-
A5 S#!% b#% 1/$
'cchymosis over the lower abdomen, where a lap seat belt has been compressed against
the iliac crest and lower abdomen, indicates that severe force was applied against the abdominal
viscera, especially a distended caecum.
B5 L&+& 1/$
The presence of pattern bruising of the skin, like an imprint of the clothing, indicates that
a crushing force has been applied sufficient to rupture the bowel against the vertebral column.
This sign is a strong indication for laparotomy.
C5 P&1%1/ %#%$
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+t is a sign of great value in ruptured intestine. The sign may locate accurately the site of
perforation.
D5 Gr#y T0r#r 1/$
Discoloration of flanks from retroperitoneal haemorrhage which is noted a few hours
after in"ury.
E5 C0# 1/$
>luish discoloration around the umbilicus.
F5 K#*r 1/$
*ain is referred to the left shoulder due to irritation of the left half of the diaphragm by
splenic blood indicating in"ury to the spleen.
G5 G1b& 1/$
)n e(tremely scaphoid abdomen following blunt trauma to the abdomen, due to
diaphragmatic in"ury.
H5 H!r+# 1/$
aggital compression of sternum causes sharp pain below the left costal arch, positive in splenic
in"ury.
I5 B!!"# 1/$
*ersistent dullness on the left side of the abdomen due to early coagulation of splenic blood and
shifting dullness on the right side indicates in"ury to the spleen.
J5 S&9 B! 1/$
arge amount of blood coagulated in the *ouch of Douglas causes a bulge which retains the
finger mark like a snow ball.
K5 S!#//##r #1" &1%$
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*ressure with finger tip on the phrenic nerve above the clavicle between the stemomastoid and
the scalenus medius on the left side causes violent pain, positive in splenic rupture.
L5 F& 1/$
>luish discoloration below the inguinal ligament indicates retroperitoneal haemorrhage.
DIAGNOSTIC MODALITIES
+nvestigations are essential in the evaluation of abdominal trauma to make accurate
assessment. +n the multiple in"ured patient additional diagnostic modalities may be of significant
benefit.
LABORATORY STUDIES$
>lood studies of value in the initial evaluation include the hematocrit and serum amylase
or lipase.
a& H!#!%&"r1% 8!0#$ reflects a balance of acute blood loss, endogenous plasma refill and
administration of crystalloid.
b& L#03&"y%# "&0%$ leucocytosis following blunt in"ury abdomen is common but non-specific.
c& S#r0 Ay!#$ elevation is indicative of bowel in"ury or pancreatic in"ury but lacks
sensitivity and specificity for intraabdominal in"ury.
d& H#&/&b1 #8#$ erial estimation of hemoglobin percentage should be done to assess the
amount of haemorrhage.
e& P!! A%r!'#r!# #8#$ may be of some value in the diagnosis of liver in"ury
particularly in children.
f& Ar%#r1! b&&+ /! !!y1$ is warranted in intubated patients or those who are at risk for
subseGuent pulmonary decompensation.
Ur1!y1$ detects presence of microscopic hematuria suggestive of asymptomatic urologic
trauma.
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BEDSIDE IN2ESTIGATIONS$
)& Ry# %0b# !1r!%1& 2 aspirated stomach contents are e(amined for the presence of blood
>& Ab+&1! P!r!"#%#12
5our-Guadrant tap was populariEed by Neuhof and 7ohen in 0A and refined by 5itEgerald and
ider in 0A/ to detect intraperitoneal haemorrhage. +t is simple and Guick procedure with
relatively few complications.
T#"*10#$
The abdomen is painted with antiseptic solution. )n 0C% short level spinal needle is
attached to a syringe $preferably 0/ml& and inserted through the abdominal wall, after prior
infiltration of local anaesthetic. uction is applied to the syringe as the needle is slowly advanced
into the abdomen at various sites. Return of a minimum of /.0ml of non-clotting blood is
considered as positive tap.
Pr#"!0%1&$
0. *uncture of rectus sheath should be avoided, for the risk of causing hematoma of rectus
sheath from rupture of epigastric vessels.
. )reas of abdominal scars or other points of bowel fi(ations to the wall should be avoided.
?. Direction of needle inside the abdominal cavity should be changed only by withdrawing
the needle "ust superficial to peritoneum and then reintroducing.
+t should be avoided in the presence of marked bowel distension because of danger of leak
due to increased intraluminal pressure.
DIAGNOSTIC PERITONEAL LA2AGE (DPL5
Root et al described the techniGue of peritoneal lavage in 0A@ and it was further refined
by 4lsen et al in 0B with the addition of Gualitative analysis of the lavage effluent. This is a
rapid, ine(pensive, accurate, relatively safe and reliable procedure for evaluating patients with
blunt in"ury abdomen.
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T#"*1"! !#"%$ the term peritoneal lavage implies washing of peritoneal contentsL one litre
of normal saline is instilled by catheter into peritoneal cavity, recovered by gravity and analyEed.
*receding this is peritoneal aspiration in which an attempt is made to retrieve free intraperitoneal
blood. This finding indicates intraperitoneal organ in"ury and precludes the need for subseGuent
lavage. The techniGue consists of inserting a standard peritoneal dialysis catheter into the
peritoneal cavity, infra umbilically in midline.
7riteria in whom diagnostic peritoneal lavage should be considered are as follows2
- 'Guivocal physical e(amination
- Une(plained shock or hypotension
- )ltered sensorium $closed head in"ury, drugs, etc&
- %eneral anaesthesia for e(tra abdominal procedures
- 7ord in"ury
The contraindications are 2
- 7lear indication for e(ploratory laparatomy
Relative contraindications2
- *revious e(ploratory laparotomy
- *regnancy
- #orbid obesity
- 7oagulopathy
- ignificant haematomas of abdominal wall related to pelvic
fracture
There are three methods of introducing the D* catheter into the peritoneal cavity2
65 C+ %#"*10# $aEarus Nelson&
+t consists of inserting the catheter in a blind percutaneous fashion. +t has been replacedby the much safer but eGually simple eldinger method.
?5 O# %#"*10# $*arrys method&
The open procedure, traversing the abdominal wall under direct visualiEation, is safer but
more time consuming and introduces air into the peritoneal cavity.
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;5 S#1 %#"*10#
+t is Guick, easy and reliable. >efore lavage, the stomach and bladder are decompressed.
The tap is considered positive if greater than 0/ml of blood is aspirated. ) minimum of B@F
lavage effluent is reGuired for the test to be considered valid. The fluid is sent for laboratory
analysis of red and white blood cell counts, amylase and alkaline phosphatase levels and
e(amination for the presence of bile.
C&1"!%1&$
0. :ound complications include dehiscence, infection and hematoma have been cited up to
AF, but occurred in only /.?F in two large series.@
. +atrogenic intraperitoneal in"ury can be inflicted by the catheter, trocar or wire.
*erforation of small and large bowel has been reported most commonly, and bladder and
vascular punctures have occurred.
?. 5inally, large diaphragmatic rents typical of blunt pathophysiology permit flow of lavage
fluid into the thoracic cavity.
I%#rr#%!%1& &' DPL$
avage markers can be categoriEed as2
0. 7ellular - gross blood, R>7, :>7
.'nEymatic - amylase, alkaline phosphatase
?.#iscellaneous - gram stain, bile, vegetable fibers and protein.
T!b# ?$ T*# "r1%#r1! '&r &1%18# DPL '&&91/ b0% 1:0ry !b+.
I+# P&1%18# E018&"!
)spirate >lood
5luid
lavage
M0/ml
'nteric contents
M@ ml
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R>7s
:>7s
'nEyme
>ile
M0,//,/// 8mm?
M@// 8 mm?$ confirmed by repeat D*&
)mylase M/+U8
)lkaline phosphatase M ? +U 8
7onfirmed biochemically
M
@/,/// 8 mm?
M
// 8 mm?
D* sensitivity range from @ - AF, specificity from CC - BF and accuracy BC - CF
RADIOLOGICAL STUDIES$
65 P!1 F1$
)nteroposterior chest radiographs provide clues to associated thoracic and diaphragmatic
in"ury. mall amount of free intraperitoneal or retroperitoneal air may be detectable in patients
with gastric, duodenal, small bowel or colonic perforations. ) search should be made for rib,
pelvic, vertebral body and transverse spus process fractures as these warrant special
consideration for nearby visceral damage.
'(amination of soft tissue shadows may give information concerning alternations of siEe,
shape or position of many viscera. +ndirect evidence of solid visceral rupture with secondary
hemorrhage may be presumed by an increase in density in the region, by displacement of
neighboring viscera or by accumulation of fluid between the gas filled bowel loops. The
appearance of pneumoperitoneum may be facilitated by in"ecting B@/-0///ml, of air into the
nasogastric tube.
)t least C// ml of intraperitoneal blood is reGuired to be evident on plain abdominal
radiograph. 4bliteration of psoas shadow may indicate retroperitoneal hemorrhage. )ppearance
of gas bubbles around duodenal area may indicate its retroperitoneal rupture. The following
findings may be observed2
0. O5lank-stripe signO - fluid dense Eone separating the ascending or descending colon from
a distinctly outlined lateral peritoneal wall, and the colon is displaced medially.
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. ODog-ear signO - results from accumulation of blood that gravitates between the pelvic
viscera and side walls on each side of the bladder.
?. OHepatic angle signO - loss of definition of the usually distinct inferior and right lateral
borders of the liver as accumulates between the hepatic angle and the right peritoneal
wall.
1. O%round glass appearanceO - with e(tensive hemoperitoneum, small bowel may float
towards the center of the abdomen with the production of Oground glass appearanceO.
There may also be loss of psoas shadow or renal shadow in cases of retroperitoneal
hemorrhage.
@. The in"ured spleen may cause displacement of gastric bubble or indentation of the splenic
fle(ure of the colon.
A. +n chest =-rays loops of bowel can occasionally be identified in the chest which is
suggestive of diaphragmatic in"uries.
B. 5ree air under diaphragmn may have entered through the stab wound and may not be
Pbowel airQ. Therefore abdominal films contribute little to evaluation of stab wound of
abdomen
?5 G!%r&/r!''1 C&%r!% S%0+1#$
+t is indicated in case of in"ury to stomach, duodenum and small bowel. +t is a simple,
safe screening test for high risk patient. The procedure consists of instilling @/ ml. of
%astrograffin via. the nasogastric tube then rolling the patient into the right lateral decubitus
position. Radiological sign of duodenal hematoma include defects in the normal contour of the
duodenal loop and obstruction to contrast flow.
;5 I%r!8#&0 Ur&/r!*y$
+ndications for +!U in the initial evaluation of blunt trauma remain unsettled. Theintravenous urogram is a test of function and its main purpose is to identify irreparable
parenchymal disruption as well as renovascular occlusion. %ross hematuria clearly reGuires an
early pyelogram. +!U should be followed by 7T scanning or arteriography for better definition
of poor renal function.
75 R#%r&/r!+# Cy%&/r!$
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+t is useful in patients with suspected urinary bladder in"uries. +t is performed by instilling
radio opaGue fluid $A/ml of ?@F hypaGue or conray with 0/ml of sterile isotonic saline& into
the bladder through a catheter.
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5)T evaluation of the abdomen consists of visualiEation of the pericardium from a
sub(iphoid view, the splenorenal and the hepatorenal spaces $#orisons pouch&, the paracolic
gutters and the *ouch of Douglas in the pelvic. #orisons pouch view has been shown to be the
most sensitive, regardless of the etiology of the fluid.
5ree fluid, generally assumed to be blood in the setting of abdominal trauma, appears as a
black stripe. 5ree fluid in a hemodynamically unstable patient should prompt e(igent
laparotomyL however, the stable patient with free fluid may be further evaluated by 7T scan.
ensitivity and specificity of these studies range from C@-@F.
+ND+7)T+4N 54R UG IN PATIENTS WITH BLUNT TRAUMAABDOMEN
+ndications are the same as for D*. )dditionally it includes2
0. +n stable patients, as an initial method of
scanning, ultrasound may be used to detect a small amount of free intra-peritoneal blood or
intra-parenchymal haemorrhage.
. +n patients with eGuivocal clinical findings or
with indeterminate peritoneal lavage.
?. +n patients in whom D* is contraindicated
such as patients with multiple previous abdominal operations or pregnancy.
1. *atients in whom a diagnosis has been
established by other means $surgicallyL radiologically as 7T scan, radionuclide scanning,
angiography&, for freGuent monitoring and follow up.
There is no absolute contraindication for ultrasound. +maging may be sub- optional in cases with
gross obesity, and acoustic window may not be available in patients with fracture ribs and
associated subcutaneous emphysema. Use of lower freGuency probes may be useful in obese
patients because of greater penetration
5 CT-S"! !b+
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7T scan was added to the surgeons diagnostic armamentarium for blunt abdominal trauma
in the early 0C/s. )lthough initially widely criticiEed for its lack of sensitivity, the accuracy of
7T scans in abdominal tauma has improved with e(perience and a better understanding of what
constitutes abnormal findings. 7T scan has been e(tensively used in recent years for evaluation
of abdominal trauma. +ts usefulness lies chiefly in hemodynamically stable, co-operative
patients, especially if conservative management is planned, and for evaluation of
retroperitoneum. The high cost of eGuipment, time reGuired, radiation e(posure, need for
administration of oral and i.v. contrast, and persistent availability of radiologists having
necessary e(pertise in interpretation of scan are its main drawbacks. *atients co-operation is
reGuired. ) small but significant number of false negative scans has been reported. +t has proved
e(tremely valuable in assessing the retroperitoneum, an anatomic area of in"ury for which D* is
not helpful. 7T should not be performed in unstable patients, who are best evaluated by
e(ploratory laparotomy or D*.
*eitEman and colleagues have listed five indications for abdominal 7T scans in trauma victims2
0. a hemodynamically stable patient with an eGuivocal abdominal e(aminationL
. a patient with close head in"uryL
?. a patient with spinal cord in"uryL
1. hematuria in the stable patientL and
@. patients with pelvic fractures and significant bleeding.
:ith these indications and a patient who is truly hemodynamically stable, the time
reGuired to perform 7T does not delay surgical procedures and e(pensed personnel are available
for immediate interpretation of the results.
The accuracy of 7T ranges from - CF with low false positive and false negative
results.
5 L!!r&"&y (P#r1%&"&y5$
herwood et al in 0C/ modified the techniGue for the trauma patients using eGuipment
that is portable and readily available for use in the emergency room. The procedure is performed
under local anesthesia and employs a miniature laparoscope with an e(ternal diameter of
@mm.'mergency laparoscopy is very useful in blunt abdominal in"uries and is e(tremely helpful
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in avoiding unnecessary abdominal e(ploration. This is a relatively Guick and reliable
investigation and can be done by the surgeon with relatively few complications
5 A/1&/r!*y$
+t is useful in splenic hematoma, kidney and liver in"ures, retroperitoneal hemorrhage,
)! fistula and pseudo aneurysms. Therapeutic selective hepatic artery emboliEation is useful in
controlling hemorrhage from hepatic in"ury. elective infusion of vasoconstrictive drugs can be
used to control gastrointestinal hemorrhages. Haemostatic agents as well as autologous clot may
be used to selectively emboliEe the bleeding vessels. )ngiography is now a time honored
instrument in managing arterial hemorrhage from blunt and penetrating trauma.
>5 I&% S"!1/$
+t is applicable to liver and splenic in"uries. +t provides an evidence for a lesion or a
reassurance of its absence. The radionuclide most freGuently used is technetium sulphur
colloid and can be performed within 0/-0@ minutes.
6=5 M!/#%1" R#&!"# I!/1/ (MRI5$
+t is an e(cellent non-invasive diagnostic aid e(tremely accurate in anatomic definition of
structural in"ury, though costlier to patients.
MANAGEMENT OF ABDOMINAL TRAUMA PATIENTS
#anagement of )bdominal trauma in multiple in"ured patients should take place in
the priority schemes of primary and secondary surveys of patient. +n primary survey, abdomen
should be considered as the site of blood loss in hypotensive patients after attention to airway,
breathing, circulation and e(ternal bleeding.
+n secondary survey, abdomen should be thoroughly e(amined. #anagement
starts in emergency department and includes airway management $if needed&, insertion of largebore intravenous catheter, and administration of intravenous antibiotics and tetanus to(oid
prophyla(is. '(tent of resuscitation depends on haemodynamic stability of the patients.
Those with haemodynamic instability, peritoneal signs, evisceration, %+T bleed
and gunshot wounds with obvious peritoneal penetration should undergo emergency laparotomy.
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+f no indication for immediate laparotomy are present, a more deliberate approach is indicated
and further diagnostic approaches performed.
table patients with stab wounds to anterior abdomen can be managed in different
ways. ocal wound e(ploration is done to rule out peritoneal penetration and patients can be
discharged home after 1 J 1C hours of observation. +f there is peritoneal penetration, peritoneal
tap is performed and is positive, e(ploratory laparotomy is performed. 4therwise patient is
safely observed.
aparoscopy is particularly useful in stab wounds to lower chest or upper abdomen
as none of other investigations are reliable. Those with evidence of peritoneal penetration and
bleeding solid organ can be safely observed. +n patient with stab wound to back or flank,
management by serial observation or by triple contrast 7T can be done and D* is unreliable.
)ll unstable patients and those with peritoneal penetration following gun shot in"uries should
undergo e(ploratory laparotomy.
#anagement of penetrating abdominal trauma in presence of shock or physical
finding of peritoneal irritation should be, immediate laparotomy. Nearly one third of stab wounds
do not penetrate peritoneal cavity and appro(imately @/F that penetrate, cause no significant
in"ury and hence selective conservatism for stab wounds to anterior abdomen is shown to be safe
and effective. ) policy of selective conservatism is advocated patients with no signs or eGuivocal
abdominal findings and haemodynamically stable.
#andatory laparotomy, irrespective of clinical signs is recommended for gunshot wounds
INJURIES TO THE DIAPHRAGM
)ppro(imately ?F of patients with trauma to torso have a diaphragmatic in"ury
identified, with appro(imately two thirds of them secondary to penetrating trauma.
+t occurs from massive increase in the intraabdominal pressure resulting in lacerations
that radiate laterally from the central tendon. B@F of them are left sided because liver protects
the right dome.
#ost common cause of blunt diaphragmatic in"ury is by steering wheel, other causes like
industrial accidents, penetrating in"uries, sports account for only @F of cases.
S1/ &' +1!*r!/!%1" 1:0ry (Br0+#91"*5$
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a. )bsence of respiratory sounds over affected hemi thora(.
b. ) change in position of heart with its displacement to right or left of midline.
c. )bnormal gurgling sounds over affected hemi thora(.
d. ) tympanic note on percussion over affected hemi thora(.
e. Reduced movement over the affected hemi thora(.
f. caphoid abdomen $%ibsons sign&
T!b# ;$ Or/! I:0ry S"!# - +1!*r!/
Gr!+# I:0ry D#"r1%1& )+
I 7ontusion
II aceration cm ?
III aceration - 0/ cm ?
I2 aceration M 0/cm, with tissue loss
@ sG.cm
?
2 aceration with tissue loss M @ sG.cm ?
D1!/&1$
7hest =-ray with in"ection of water soluble contrast medium through nasogastric tube
may confirm the diagnosis. The best radiographic signs of a diaphragmatic defect occur when
herniation is present and include elevation of a hemidiaphragm, contra lateral shift of the
mediastinum, an intrathoracic air bubble or the presence of mass above the diaphragm.
Ultrasonography may demonstrate the right hemidiaphragm as an echogenic curvilinear
structure superior to the liver. ) break in the continuity of this line may signify an in"ury.
7T scan may be able to visualiEe a diaphragmatic defect if it contains herniated
abdominal viscera.
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Diagnostic peritoneal lavage is probably the best non-operative method of diagnosing a
diaphragmatic in"ury. There is almost certainly an in"ury to the diaphragm if lavage fluid e(its
through a thoracostomy tube.
Thoracoscopy and aparoscopy2 4chsner et al found thoracoscopy to be 0//F
diagnostic.
M!!/##%$
During e(ploratory laparotomy, the entire diaphragmatic surface should be e(posed and
directly visualiEed. inear laceration can be repaired with a simple running suture or interrupted
horiEontal mattress sutures using non absorbable material, whereas larger lacerations and tissue
deficits occasionally reGuire repair with prosthetic material. 7are must be taken to avoid
iatrogenic in"ury to the pericardium, heart or lungs.
+f diaphragmatic in"uries are detected more than four weeks after in"ury, they should be
approached through a thoracotomy, so that adhesions to the lung and pleura can be lysed.
Diaphragmatic dysfunction is commoner after repair of large blunt in"uries and may reGuire
prolonged ventilatory support.
4ccasionally the diaphragm with a large chronic defect has atrophied and retracted and
primary repair is not possible. +n such cases, a prosthetic material such as marle( or prolene
mesh may be necessary to close the defect.
INJURIES TO THE ABDOMINAL 4ALL
The abdominal wall contracts when it receives a force thus protecting the viscera inside
but the muscle, fascia and skin take the whole brunt. +n"ury to the abdominal wall without
intraperitoneal in"ury is difficult to diagnose. Types of in"uries of abdominal wall are2 )brasions,
contusions, lacerations and hematomas.
#uscular guarding and rigidity are freGuently present. )bdominal breathing is
diminished over the part. 7orresponding to the site of rupture a bulge of considerable siEe
appears. Tenderness increases on leg raising test if it is a parietal wall in"ury but decreases in
case of intraabdominal in"ury. Hematomas are usually due to rupture of rectus abdominis or
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epigastric arteries. To distinguish this mass from intraabdominal mass, leg raising test should be
carried out.
+f owing to the lesion of posterior rectus sheath, the bowel is pushed forward between the
edges of the torn rectus, the palpatory finding is slightly reminiscent of chronic hernia of the
abdominal wall. The most important aspect of differential diagnosis is to e(clude the lesions of
abdominal cavity. +n purely parietal lesions, the general condition of the patient does not
deteriorate. '(ception is the rupture of epigastric artery. *arietal wall in"ury is never associated
with paralytic ileus.
acerations and abrasions need wound debridement, suturing and dressing. arge
hematoma needs evacuation and ligation of bleeders. Rupture of muscle reGuires immediate
operative intervention.
INJURY TO SOLID ORGANS
SPLEEN
+t is the most commonly in"ured intraabdominal organ in blunt trauma. plenic in"ury
following penetrating trauma is less. +n"ury is suspected whenever there is a blow, fall or sports
in"ury to the left chest $with or without fractures of left lower ribs&, flanks or left upper abdomen.
4nce regarded as Omysterii pleni organonO, the spleen is now considered an important
immunologic factory as well as reticuloendothelial filter. Routine splenectomy remained the
treatment of choice for splenic in"ury. :ith increase in recognition of the haEards of asplenic
state, a more conservative approach to splenic in"ury is now preferred.
Diseased spleen as in infectious mononucleosis, malaria, leukemia, hemolytic anemia,
congestive splenomegaly and polycythemia vera may rupture due to a trivial trauma.
D##+1/ 0& %*# "11"! !1'#%!%1& r0%0r# &' ## 1 "!1'1#+ ! '&&9$
a& A"0%# r0%0r#$ The patient succumbs rapidly, never recovering from the initial shock.
Tearing of the splenic vessels and complete avulsion of the spleen from its pedicle gives rise to
rapid blood loss which can be fatal within minutes.
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b& S0b !"0%# r0%0r#$ +nitial shock, recovery from shock, signs of a ruptured spleen is the
usual type of presentation. )fter the initial shock has passed off, there are signs which point to
intraabdominal bleeding.
c& D#!y#+ %y#$ )fter the initial signs have passed off, the symptoms of a serious
intraabdominal catastrophe are postponed for a variable period of up to two weeks or more. The
delayed type of splenic rupture was described by >audet in 0/ and the asymptomatic interval
between in"ury and rupture is known as Othe latent period of >audetO.
The cause of delayed hemorrhage is local vasoconstriction with or without the formation of
blood clot which seals the tear. The causes of hemorrhage are those of reactionary or secondary
hemorrhage.
C11"! F#!%0r#$
+f the patient complains of pain associated with respiration, suspicion of splenic rupture is
heightened. ) ruptured spleen seems even more likely if the left 0/ or 00 thrib is fractured, a
diagnosis best made during physical e(amination by gentle, careful palpation along the course of
the ribs.
plenic in"ury is always suspected if any penetrating in"ury to left upper Guadrant or left
flank. *enetrating in"ury to spleen cause significant bleeding. The history and physical
e(amination continue to be the basis from which splenic in"ury is diagnosed.
*hysical e(amination has an accuracy of A?F. There is an increasing pallor, a rising
pulse rate, sighing respiration and restlessness. )bdomen may be distendedL tenderness and
guarding may be generaliEed or localiEed to left upper Guadrant. eft lower ribs may be
fractured. ocal bruising may be present in left upper Guadrant.
3ehrs sign, pain at the tip of the shoulder, may be elicited by pressure in the left upper
Guadrant by placing the patient in the Trendelenburg position. >allances sign, fi(ed dullness to
percussion in the left upper Guadrant may be appreciated. Tenderness may be elicited at the
aeggessers splenic point i.e. on phrenic nerve above the clavicle between the sternomastoid and
the scalenus medius on the left side.
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hifting dullness may be present at the flanks. Rectal e(amination freGuently reveals
tenderness and sometimes a soft swelling due to blood or clots in the rectovesical pouch i.e. the
Onow >all signO.
I8#%1/!%1&$
0& aboratory evaluation can demonstrate a wide variability in the hematocrit, increase in the
leukocyte count. ) base deficit ? meG8 obtained from )>% analysis suggests significant
hemorrhage.
.*lain =-ray abdomen2 radiological signs of splenic rupture are 'levation of the left
hemidiaphragm, obliteration of the splenic shadow,obliteration of psoas shadow,enlargement of
splenic shadow, medial displacement of the gastric bubble because of the accumulation of clot in
the gastrosplenic ligament, widening of the space between the splenic fle(ure and preperitoneal
pad of fat, fracture of one or more ribs on the left side $present in BF of cases&
?& Ultrasonography 2 The spleen can usually be visualiEed and a surrounding hematoma may
suggest rupture. erial e(amination by showing a change in splenic siEe can identify an enlarging
sub capsular hematoma.
1& 7T scan 2 especially essential if non-operative therapy is planned. plenic lacerations appear
as irregular intrasplenic low density regions. The paracolic gutters, subhepatic space and cul-de-
sac should be e(amined for the presence of free intraperitoneal blood.
@& Radionuclide scans 2 using technetium sulfur colloid, collections of blood within the splenic
parenchyma will compress the surrounding tissues and produce focal areas of decreased uptake.
A& )rteriography 2 Direct signs include e(travasation or pooling of contrast material in the
parenchyma, arteriovenous shunting or pseudo aneurysm formation.
*eritoneal avage2 This is a rapid, ine(pensive, accurate, relatively safe and reliable procedure to
detect hemoperitoneum. +t has an accuracy rate of @-CF.
T!b# 7$ Or/! I:0ry S"!# - S##$
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Gr!+# I:0ry D#"r1%1&
I Haematoma ub capsular, non-e(panding 0/F surface area
aceration 7apsular tear, lcm parenchymal depth
II Haematoma ub capsular, 0/-@/F surface area, intraparenchymal,
@cm diameter.
aceration 0-? cm parenchymal depth which does not involve a
trabecular vessel.
III Haematoma ub capsular M@/F of surface area or e(panding, ruptured
sub capsular hematoma with active bleeding.
+ntraparenchymal hematoma M@cm or e(panding.
aceration M?cm parenchymal depth or involving trabecular vessels.
I2 Haematoma Ruptured intraparenchymal hematoma
aceration +nvolving segmental or hilar vessels producing ma"or
devascularisation $M@F spleen&
2 aceration 7ompletely shattered spleen
!ascular Hilar vascular in"ury which devascularises spleen.
M!!/##%$
Non-operative #anagement2
7lass +, ++ or +++ splenic in"uries may be candidates for non-operative management if there is2
0& No hemodynamic instability after initial fluid resuscitation
& No serious associated intra-abdominal in"ury.
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?& 1 hour availability of emergency 7T scan, 4.T. and surgeon round the clock.
These patients are managed in the surgical intensive care unit on complete bed Rest with
close monitoring by repeated physical e(amination and serial hematocrits. )n empiric 1-A weeks
of convalescence with reduced activity for ? months has been recommended.
4perative #anagement2
The principle goal of operation for splenic in"ury is to control bleeding. ) midline
incision provides rapid and e(cellent access to the management of splenic in"ury. 7omplete
mobiliEation of the spleen is the key to adeGuate assessment of in"ury and safe repair. The lerenal
and phrenicoleinal ligaments are avascular and can be incised away from lateral margin of the
spleen. !essels in lecolic ligament are ligated and divided. pleen is rotated into the wound by
bluntly dissecting the plane posterior to the pancreas and anterior to the %erotas fascia. Then
short gastric vessels in the gastroleinal ligament should be divided.
)fter adeGuate mobiliEation, clots over spleen are removed by gentle irrigation or
grasping with forceps. )fter adeGuate mobiliEation and clot removal, severity of in"ury is
assessed. 5urther operative management depends on the assessment of degree of in"ury to the
spleen.
0& %rade + in"ury 2 generally reGuire little treatment $Tamponade, topical hemostat& or no
treatment.
%rade ++ in"ury2 can be treated with haemostatic agents $including microfibrillar collagen,
gelfoam soaked in topical thrombin or surgicel& with tamponade to control bleeding.
?& %rade +++ in"ury 2 various techniGues have been described. The principles are removal of clot
and devitaliEed tissue, complete reappro(imation of parenchymal edges to the depth of the
wound to avoid leaving dead space and suture placement within the fibrous capsule well away
from the wound margin to prevent tearing. '(panding sub capsular hematoma should be opened,
the clot evacuated and a diligent search made for parenchymal arterial bleeding, which can be
controlled with suture ligature.
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1& %rade +! in"ury 2 often reGuires partial splenectomy. Hemostasis is attained by selected
ligation of the appropriate segment artery. Debridement is accomplished by finger fracture or
sharp resection at the line of demarcation. The resected splenic surface is treated with a
combination of through and through capsular suture and haemostatic agents. )n omental pedicle
may be used to seal raw surface. Use of an absorbable mesh wrap has been described. Topical
and intraparenchymal in"ections of fibrin glue $a mi(ture of fibrgen thrombin, aprotinin and
calcium chloride& have produced hemostasis in cases with deep splenic in"ury and coagulopathy.
@& %rade ! in"ury 2 splenectomy should be performed.other indications of plenectomy 0. +f
splenorrhaphy is unsuccessful in other grades, .rupture of diseased spleen and ?.multiple intra
abdominal in"uries with hypotension.
Routine drainage of the splenic bed is not used for either splenectomy or splenorrhaphy.
+f there is associated in"ury to tail of pancreas, closed suction drainage is employed. *olyvalent
pneumococcal vaccine should be administered immediately after splenectomy, to prevent the risk
of overwhelming pneumococcal sepsis.
C&1"!%1&2
0. Hemorrhage - *rimary and reactionary
. eft lower lobe atelectasis, pneumonia $especially left lower lobe& left pleural effusions.
?. %astric complications - gastric dilatation and fistula, gastric necrosis when the short
gastric vessels are ligated ad"acent to the stomach.
1. Haematemesis,
@. ubphrenic abscess,
A. Thrombocytosis. plenectomy increase the platelet count by ?/F
B. *ancreatitis - The overall incidence is F following splenectomy
C. +nfection - 'arly infection occurs in appro(imately @F of patients. :ound infection
occurs in @F of patients who have had splenectomy for trauma.
O8#r9*#1/ P&% S##"%&y I'#"%1& (OPSI5 has been defined by Diamond as a
fulminant bacterial illness that usually progresses to death within 1 hours of recognition and
does not always e(hibit the usual prodromal signs of infection. 5ollowing splenectomy, young
children are particularly at high risk to develop fulminant infections due to treptococcus
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pneumoniae, H. influenEa and Neisseria meningitides. )ll patients of splenectomy should be
given polyvalent pneumococcal vaccine. 7hildren should also receive the H. influenEa type >
!accine.
#ortality 2 4verall mortality following splenic in"ury is 0/F. #orbidity correlates with degree
of associated in"ury.
LI2ER
>ecause of its siEe and location in the abdominal cavity, the liver is freGuently in"ured in
penetrating in"ury and is the second most commonly in"ured organ following blunt trauma. +n
pregnancy, sickle cell anemia, primary hepatocellular carcma and hepatic adenoma, the liver
may be fragile and fractured by a mr blow.
+t may result from direct blows, compression between the lower ribs on the right and
spine or shearing at fi(ed points secondary to deceleration. fractures of the lower ribs on the right
freGuently accompany blunt trauma to the liver.
C11"! F#!%0r#$
)ll lower chest stabs on the right side and upper abdominal stab wounds should be
suspect, especially if considerable blood volume replacement has been reGuested. imilarly crush
in"ury to right lower chest or upper abdomen, often combine rib fracture, haemothora( and
damage to liver.) subcutaneous emphysema or ecchymosis on abdominal skin should greatly
arouse suspicion of blunt trauma.
*atient can present with profound hypotension, temporarily responsive to the infusion of
blood and fluids. *atient can have abdominal distension, guarding, rigidity and tenderness in the
right hypochondrium. The area of liver dullness may be enlarged. 7ompression of the lower end
of the sternum elicits tenderness over the lower coastal arch. There may be hemothora( on right
side.
I8#%1/!%1&$
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0. *lain =-ray of abdomen - may reveal fracture of vertebrae and right lower ribs,
hemothora( on right side, elevation of right dome of diaphragm, increased liver shadow,
obscured psoas shadow and concomitant in"uries with free or retroperitoneal air.
. U% of abdomen - Useful in tracking of parenchymal or sub capsular hematoma and
appro(imate loss of blood into the peritoneal cavity.
?. D* - 5or hemoperitoneum, accurate in /F of cases
1. +sotope scanning - The radionuclide most freGuently used is Technetium sulphur
colloid.
@. 7T scan - +t is highly sensitive and specific in defining the presence of an intra-hepatic
hematoma or hepatic laceration and the appro(imate volume of blood loss into the
peritoneal cavity.
A. )ngiography - 5or diagnostic purpose and therapeutic purpose of hepatic artery
emboliEation.
T!b#
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I2 aceration *arenchymal disruption involving @-B@F hepatic lobe or 0-?
7ouinaud segments
2 aceration *arenchymal disruption involving MB@F of hepatic lobe or M?
7ouinaud segments within a single lobe
!ascular 9u(tahepatic venous in"uries $i.e., retrohepatic venecava 8 central
ma"or hepatic veins&
2I !ascular Hepatic avulsion
M!!/##%
Non operative management criteria2
Hemodynamic stability
)bsence of peritoneal signs
Neurological integrity
7T can delineation of in"ury
)bsence of associated intra abdominal in"uries
Need for not more than hepatic related blood transfusions
7T scan documented improvement or stabiliEation with time
4perative #anagement
+ndications2
0. tab or gunshot wounds that have penetrated the abdomen
. igns of peritonitis
?. *atients with une(plained shock, uncontrolled heamorrhage or clinical deterioration
during observation.1. )ssociated other intraabdominal in"uries.
The abdomen should be rapidly opened and a Guick appraisal of bleeding sites made. )ll blood
clots and debris should be removed rapidly by scooping them out. Temporary control of bleeding
sites may be obtained by placement of packs and the use of manual compression. ) Guick
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e(ploration should be carried out of the liver, spleen and ma"or vessels. +f ma"or bleeding from
the liver is noted, compression of the portal triad between the thumb and inde( finger to include
the hepatic artery and portal vein $*ringle maneuvre& may be useful ad"unct to packs and manual
compression. )n atraumatic clamp may be placed across the hepatoduodenal ligament. +f these
fail, a simple hepatic tourniGuet may be constructed by using a large De >akey aortic clamp and
a penrose drain.
The aorta is to be temporarily occluded "ust below the diaphragm using manual
compression with an aortic compressor of the hand of an assistant, when persistent hemorrhage
is found and continues in spite of the use of packing and the *ringles maneuvre, in"ury to hepatic
vein or retro hepatic venecava is likely. +n this situation, control of infra and supra hepatic
venacava must be obtained. They may then be temporarily occluded. This is a last resort
temporiEing maneuver, since occlusion of inferior venacava impedes A/F of the blood return to
the right atrium and may lead to further deterioration of the patient. Recently, the use of various
intracaval shunts has alleviated this problem. The method is that described by 6ellis, consisting
of a number C endotracheal tube with multiple side holes cut into it and inserted through a purse
string suture in the right atrial appendage@1.
65 Dr!1!/#
%rades + and ++ in"uries make up C@F of all liver in"uries. +n the past most surgeons
agreed that all liver in"uries should drained, however this has recently been challenged.
?5 S0%0r1/
Hemorrhage from grade ++ liver in"uries can usually be halted by the placement of heavy
mattress sutures $0-/ or -/& of an absorbable material on a blunt tipped liver needle. +f
buttressing is necessary, the use of omentum is preferred.
;5 L1/!%0r# &' B##+1/ P&1%
Directly ligate the bleeding points with suture or surgical hot clips. 'lectrocautery may be
useful in obtaining hemostasis in the diffuse ooEe. )lternatively application of one of the topical
haemostatic agents like o(idiEed cellulose $surgicel& and gelatin sponge $%elfoam&.
75 D#br1+##%
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)nother important aspect of treatment is the debridement of the non viable parenchyma.
This does not imply a formal resection, but rather it is carried out along the planes of in"ury
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there is e(tensive damage isolated to one lobe of the liver . The techniGue of resection is similar
to that used in elective resection. The use of cell-saver device may limit the need for transfusion
and the recently developed ultrasonic aspirator $7U)& described by Hodgson may be helpful.
%rade ! in"uries are rare. These in"uries can often be managed by primary repair and an
intracaval shunt is necessary only in the e(treme situation.
C&1"!%1&$
0.Hemorrhage,.Respiratory insufficiency, ?..7oagulopathy, 1..Hypoglycemia ,@.>iliary fistula
or other bile duct in"ury, A.Hemobilia,B.ub diaphragmatic or intraparenchymal abscess
formation ,C.Hypoalbuminemia,.Transient hyperbilirubinemia,
PANCREATIC TRAUMA
The *ancreas, because of its close pro(imity to lumbar vertebrae, is more susceptible to
crushing in"uries due to direct blow or seat belt in"uries. +ncidence of in"uries to this organ is 0/-
0F of all abdominal in"uries. >ecause of its retroperitoneal location, symptoms are usually
delayed.
*enetrating in"uries to pancreas is associated with mortality rate of ?-?F. *ancreas is
rarely in"ured in isolation and occur in F patients, because of its location. Therefore, ma"ority
of its associated mortality is due to haemorrhage and other associated in"uries
The site of in"ury is prognostically important because damage to the pancreatic head has a
mortality rate double that of either body or tail in"ury.
C11"! F#!%0r#$
oft tissue contusion in the upper abdomen away from bony prominences indicates that a
significant force has been dissipated in this areaL epigastric pain out of proportion to the
abdominal e(amination is often due to a retroperitoneal in"ury.
I8#%1/!%1&$
0. erum )mylase - neither sensitive nor very specific for pancreatic in"ury.
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. D* - estimation of amylase in peritoneal fluid.
?. Radiography
i. *lain =-ray abdomen may reveal obliteration of psoas shadow, retroperitoneal air
along psoas margin or upper pole of right kidney or pleural effusion and elevated
diaphragm, especially with in"ury to tail of pancreas. +n later stages, there may be
ground glass appearance.
ii. Upper %.+. studies with water soluble contrast media may show, widening of 7-loop of
duodenum, abnormal displacement of stomach and colon and sometimes leakage of
contrast medium.
1. )ngiography - may reveal splenic vein thrombosis and portal hypertension.
@. Ultrasound - not helpful in the acute phase, helpful during follow-up for the development of
pseudocyst or abscess formation.
A. 'ndoscopic retrograde cholangio pancreaticography $'R7*& - for ductal disruption.
B. 7T scan - will reveal early pseudocysts, mild traumatic pancreatitis, pancreatic contusions,
lacerations and fractures with high degree of accuracy.
C!1'1"!%1&$
ucas developed the following classification for pancreatic in"ury 2 7lass +2
7ontusions or abrasions to the pancreas but not involving the main ducts. 7lass ++2 evere distal
pancreatic laceration or disruption with suspected ductal in"ury. 7lass +++2 7lass ++ type of in"ury
only to pro(imal rather than distal pancreas. 7lass +!2 evere combined pancreaticoduodenal
in"ury.
M!!/##%$
The following are the key principles for the management of pancreatic in"ury.
0. 7ontrol hemorrhage and control bacterial contamination.
. Debride devitaliEed pancreatic tissue.
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?. *reserve at least /-@/F of functional pancreatic tissue whenever possible
1. *rovide adeGuate internal or e(ternal drainage of pancreatic in"uries or resections.
7lass +2 '(ternal drainage, infreGuent distal pancreatectomy.
7lass ++2 Distal pancreatectomy
7lass +++2 Distal pancreatectomy or Rou(-en-6 pancreatico"e"unostomy
7lass +!2 Repair 8 e(clude duodenum, treat pancreas as 7lass +, ++, and +++.
*ancreaticoduodenectomy.
C&1"!%1&$
0. 5istula - in @ to F of patients
. econdary Hemorrhage - @-0/F
?. *ancreatitis - occurs in less than @F of patients
with in"ury.
1. *seudocyst - about .@F, more common after
non-operative management.
+n most series, there is up to @F mortality rate that occurs early, as a result of associated
vascular in"uries.
ETRAHEPATIC BILLARY TRACT
+n"uries to gall bladder and e(trahepatic biliary tract are rare with incidence of 0.1F.
%all bladder is commonly in"ured part and attributed to its superficial location and larger siEe.
#ortality rate for e(trahepatic biliary tract varies between 1F - 00F and depends on associated
in"ury. #ortality rate can be @/F when biliary in"ury is associated with vascular in"ury.
C11"! Pr##%!%1&$
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*atient may present with shock due to chemical peritonitis caused by bile which leads to
outpouring of fluids into peritoneal cavity. )bsorption of bile salts may cause cholaemia,
bradycardia is a valuable diagnostic sign.
I8#%1/!%1&$
Diagnosis of in"uries to the e(trahepatic biliary tract is rarely made preoperatively. +t is
usually made intra operatively.
0. *eritoneal tap 8 D* positive for bile salt or pigments.
. Radionuclide hepatobiliary imaging with Technetium m.
T!b# $E%r!*#!%1" B11!ry Tr!"% 1:0ry S"!# $
Gr!+# D#"r1%1&
I %all >ladder contusion8Haematoma. *ortal triad
contusion8Haematoma.
II *ortal %all >ladder avulsion from liver bedL cystic duct intact,
laceration or perforation of %all bladder.
III 7omplete gall bladder avulsion from liver bed, cystic duct
laceration
I2 *artial or complete right hepatic duct laceration.
*artial or complete left hepatic duct laceration.
*artial common hepatic duct laceration $ @/F&.
2 *artial common hepatic duct laceration $M @/F&. M
@/F transection of common hepatic duct.
M @/F transection of common bile duct.
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M!!/##%$
The treatment depends on general condition of the patient and on the e(tent of damage to gall
bladder.
(A5 I:0r1# %& /! b!++#r !+ "y%1" +0"%$
0. imple suture 8 cholecvstorrhaphv2 This can be employed for mr in"uries. +t is not
recommended now days because of the risk of bile leakage.
7holecystectomy2 +s indicated if the general condition of the patient is satisfactory and there is
avulsion of gall bladder from liver bedL e(tensive laceration or in"ury to pathological gall
bladder, for in"ury to cystic duct or if right hepatic artery is ligated for haemorrhage control and
in gunshot in"uries
7holecystostomy 2 +ndications are
$a& :hen general condition is not satisfactory
$b& There are severe associated in"uries
$c& :hen anatomy of biliary tree is obscured by in"ury.
(B5 I:0r1# %& b1# +0"% $
0. *artial bile duct in"uries2 mall lacerations can probably be closed without a T-tube . +n"uries
with less than @/F tissue loss along the medial or posterior aspect of the duct can be repaired
primarily using @-/ vicryl.
. in"uries to left and right hepatic duct2 +n unstable patient, ligation of either duct can be
performed. +f the patient is stable, then a Rou(-en-6
?. +n"uries to common hepatic duct2 The standard approach is hepatico"e"unostomy.
1. +n"uries to common bile duct2 +n"ury to the supra and retro duodenal portions of the 7>D can
be managed by cholecysto"e"unostomy, choledochoduodenostomy can be used for more distal
in"uries of the common bile duct. +f there is significant destruction to the surrounding tissues
including the duodenum, then a pancreaticoduodenectomy is advised.
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