abdominal trauma begashaw m (md). anatomy abdominal trauma two mechanisms _blunt usually causes...

Abdominal Trauma

Begashaw M (MD)

Anatomy

Abdominal Trauma

Two mechanisms

_Bluntusually causes solid organ injury (spleen injury is most common)

_Penetratingusually causes hollow organ injury or liver injury (most common)

Mechanism of Injury

Blunt Force Trauma Penetrating Trauma

Mechanism of Injury Africa style

Mechanism of Injury

Blunt– Speed– Nature of Impact– Position in vehicle– Ejection– Intrusion– Seatbelt– Airbag

Penetrating– Type of weapon– Distance – Number and

location of wounds– Trajectory– Energy– Blast effect

BLUNT TRAUMA

results in two types of hemorrhage

- intra-abdominal bleeding

- retroperitoneal bleedingadopt high clinical suspicion of bleeding in

multi-system trauma

Examination

Abdomen

Inspect: contusions, abrasions, seatbelt sign, distention

Auscultate: bruits,bowel sounds

Palpate: tenderness, rebound tenderness, rigidity, guarding

DRE: rectal tone, blood, bone fragments,prostate location

Placement - NG, foley catheter

Commonly injured organs

SpleenLiverSmall Bowel

Assessment of abdominal trauma

Difficult due to:

_Altered sensorium (head injury, alcohol)

_Altered sensation (spinal cord injury)

_Injury to adjacent structures (pelvis, chest)

Investigations

Labs: CBC, electrolytes,cross & type, glucose, creatinine, amylase, liver enzymes

Imaging

Imaging

Imaging strengths limitations

X-ray Erect CXR Soft tissue not visualized

CT scan Most specific test Radiation,cannot use if hemodynamic instability

Diagnostic peritoneal Lavage

Most sensitive testTest for intra abdominal bleeding

Retroperitoneal hemorrhage, diaphragmatic rupture

Ultrasound FAST Free fluid, Rapid, pericardium, plura

Specific organ injury

FAST

Focused assessment for the sonographic assessment of trauma

Assess for intraperitoneal fluid

o Right upper quadrant

o Left upper quadrant

o Suprapubic region Fluid in subphrenic, subhepatic spaces or Pouch of

Douglas in hypotensive patient Confirms likely need for emergency laparotomy

FAST

Criteria for positive DPL

>10 cc gross bloodBile, bacteria. foreign materialRBC count >I 00,000 WBC >500 Amylase > 1751U

Imaging

Equivocal abdominal examination, suspected intra-abdominal injury

Multiple trauma Unexplained shock/hypotensionFractures of lower ribs, pelvis, spinepositive FAST

Management

General: ABCs, fluid resuscitation and stabilization Surgical: watchful wait vs laparotomy Solid organ injuries: decision based on

hemodynamic stability, not the specific injuries Hemodynamically unstable or persistently high

transfusion requirements: laparotomy Hollow organ injuries: laparotomy Even if low suspicion on injury: admit and observe

for 24 hours

Indications for Laparotomy

Free Fluid on FASTUnstable patient with suspected abdominal

injuryFree AirDiaphragm RupturePeritonitisPositive findings on CT Scan

PENETRATING TRAUMA

High risk of gastrointestinal perforation and sepsis History: size of blade, calibre/distance from gun,

route of entry Local wound exploration under direct vision may

determine lack of peritoneal penetration (not reliable in inexperienced hands) with the following exceptions:

-thoracoabdominal region (may cause pneumothorax)

-back or flanks (muscles too thick)

Penetrating Trauma

Overall condition of the patient

Local wound exploration

DPL?

Penetrating abdominal trauma

Laparomy in penetrating injury

ShockPeitonitisEviserationFree air in abdomenBlood in NG tube, Foley catheter, or on

rectal exam

Management

General: ABCs, fluid resuscitation and stabilization

Gunshot wounds-always require laparotomy