Abdominal Trauma

A middle aged unidentified lady was hit by a car whilst crossing the road. She was brought to the ER unconscious with multiple injuries to the head chest and pelvis. She was obese and haemodynamically unstable despite aggressive fluid resuscitation. The x-ray shown was taken following primary survey.

1. What does the xray show and what is it’s significance?

2. How do you diagnose abdominal injury

3. Should free intraperitoneal fluid be identified on USS. How would you proceed with the management of such a cas?

Facts

1. Abdominal signs are often subtle and difficult to interpret.

2. Unrecognised abdominal injury is a major cause of death after trauma.

3. Positive (hemoperitoneum) can result in management dilemma.

The SolutionHIGH INDEX OF SUSPICION

• History and mechanism of injury• Positive clinical signs• Knowledge of Anatomy• Objective Data

Goal and Objectives

By the end of this lecture you should be able to :

• Assess the risk of abdominal injury in a poly-trauma patient and provide an index of suspicion for specific injuries.

• Describe the regions of the abdomen and the organs most likely affected within them.

• Discuss the difference between blunt and penetrating injuries

• Plan your management on priority basis• Identify signs suggesting abdominal injury.• Outline diagnostic and therapeutic procedures specific to

abdominal trauma.

Abdominal regions

A. Intraperitoneal cavity• Intrathoracic abdomen• True abdomen• Pelvic abdomen

B. Retroperitoneal cavity

MechanismsBlunt

A. 3 mechanisms:1. Deceleration and shearing

forces: results in linear tears ligamentous attachments and intimal arterial tears

2. Pressure against the lumbar vertebra

3. Sudden compression with raised intra-abdominal pressure.Cause: subcapsular hematoma and deformity of bowel resulting in rupture.

B. The most commonly affected organs: the spleen, liver followed by the small and large intestine

PenetratingFire arms 95% associated injury Chemical thermal

combustion Secondary Missiles from

bony shrapnel The closer the higher

energy transfer Size of entry does not

predict degree of injury. Missile trajectory is

unpredictable

Stab Wound 30% associated injury More predictable damage

Clinical EvaluationOnly 60% reliable

History: Onset, delay in extrusion,

condition of Vehicle, passenger/s

Seat belt Abdominal, shoulder pains AMPLE Substance abuse, Alcohol

intoxication

For penetrating injuries:

The type of fire arm or impaling object

Number of shots or stabs Distance Amount of blood at the scene Any history of hypotension

Examination:Following the ATLS protocolSecondary survey Identify Other injuries in the

chest, back and pelvis Inspection:

Ecchymosis, lacerations Distension In gunshot wounds look for

entry and exist wounds Locate the site of stab wound

Palpation Tenderness and guarding Rebound

Percussion Auscultation: BS, bruit, FAST ( Focused Sonography for

trauma assessment)

Investigations1. Laboratory: CBC, U&E, creatinie, amylase,

glucose, X-match, clotting screen, ABG,

Urine analysis

2. Screening plain x-rays: C-spine, CXR, pelvic x-ray

3. USS 4 acustic windows Sensitivity of 78% A small amount of fluid in

Morison’s pouch on USS may indicate 250-1000 ml

1. CT: Fast and precise Quantifies hemorrhage Identifies retroperitoneal

injuries Marginal use in diaphragmatic

and small bowel injury

2. Contrast studies: urethrogram, cystogram, GI contrast studies

3. DPL Indications Contraindications Positive findings Sensitivity

4. Laparoscopy

Management Conservative

ICU or not Blood transfusion and

intravenous fluids Antibiotics Fluid input / output charts

and aggressive monitoring Prevent hypothermia Correct coagulopathies Repeated lab series Repeated USS

Surgery: The indications

1. Hypotension:1. Gun shot2. Stab wounds3. Frank blood on DPL

2. Bile or bowel content on DPL3. Peritonitis4. Recurrent hypotension

despite adequate resuscitation

5. Free air6. Diaphragmatic rupture7. Urinary Bladder injury

8. Failure of conservative managemnt

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Seat Belt Injury

The seat belt syndrome 75% associated with serious injuries Driver/ F. passenger/ 5% back seat

passengers. 75% front impact It consists of:

Seat belt mark abrasions Musculo-skeletal: Cervical spine, clavicle, sternum,

ribs and lumber spine. Soft tissue damage Neck: Laryngeal injury, carotid tear Chest: Cardiac contusion Abdomen: Duodenum, small bowel. Mesentery, large

bowel, Caecum