Abdominal Trauma - Cpirozzi

Abdominal
Trauma
Abdominal Trauma
• Penetrating Abdominal Trauma (PAT)
– Stabbing 3x more common than firearm wounds
– GSW cause 90% of the deaths
– Most commonly injured organs: small intestine > colon > liver
• Blunt Abdominal Trauma
– Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple organs/systems)
– Most commonly injured organs: spleen > liver, intestine is the
most likely hollow viscus.
– Most common causes: MVA (50 - 75% of cases) > blows to
abdomen (15%) > falls (6 - 9%)
Pathophysiology of injury
Penetrating Abdominal Trauma
• Stab Wounds
– Knives, ice picks, pens, coat
hangers, broken bottles
– Liver, small bowel, spleen
• Gunshot wounds
– small bowel, colon and liver
– Often multiple organ injuries,
bowel perforations
Pathophysiology of injury
Blunt Abdominal Trauma
• Rupture or burst injury of a hollow organ by sudden rises in
intra-abdominal pressures
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
– “seat belt sign” = highly correlated with intraperitoneal
injury
Physical Exam
• Generally unreliable due to distracting injury, spinal
cord injury
• Look for signs of intraperitoneal injury
– abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
– entrance and exit wounds to determine path of injury.
– Distention - pneumoperitoneum, gastric dilation, or ileus
– retroperitoneal hemorrhage
– Abdominal contusions – eg lap belts
– ↓bowel sounds suggests intraperitoneal injuries
– blood or subcutaneous emphysema
Diagnostic studies
• Lab tests: not very helpful
• May have ↓ Hct, ↑ WBC, lactate,
LFTs, lipase.
Imaging
• Plain films:
– fractures – nearby
visceral damage
– free intraperitoneal air
– Foreign bodies and
missiles
Imaging
• CT
– Accurate for solid visceral lesions and intraperitoneal hemorrhage
– guide nonoperative management of solid organ damage
– IV not oral contrast
– Disadvantages : insensitive for injury of the pancreas, diaphragm,
small bowel, and mesentery
Imaging
• Angiography
– To embolize bleeding
vessels or solid visceral
hemorrhage from blunt
trauma in an unstable pt
– Rarely for diagnosing
intraperitoneal and
retroperitoneal hemorrhage
after penetrating abdominal
trauma
FAST
• Focused assessment with sonography for trauma (FAST)
– To diagnose free intraperitoneal blood after blunt trauma
– 4 areas:
• Perihepatic & hepato-renal space (Morrison’s pouch)
• Perisplenic
• Pelvis (Pouch of Douglas/rectovesical pouch)
• Pericardium (subxiphoid)
– sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
• Extended FAST (E-FAST):
– Add thoracic windows to look for pneumothorax.
– Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)
FAST
• Morrison’s pouch (hepato-renal space)
FAST
• Perisplenic view
•
FAST
Retrovesicle (Pouch of Douglas)
• Pericardium (subxiphoid)
FAST
• Advantages:
– Portable, fast (<5 min),
– No radiation or contrast
– Less expensive
• Disadvantages
– Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
– Limited by obesity, substantial bowel gas, and subcut air.
– Can’t distinguish blood from ascites.
Diagnostic Peritoneal Lavage (DPL)
• Largely replaced by FAST and CT

• In blunt trauma, used to triage pt who is hemodynamic
unstable and has multiple injuries with an equivocal FAST
examination
• In stab wounds, for immediate dx of hemoperitoneum,
determination of intraperitoneal organ injury, and
detection of isolated diaphragm injury
• In GSW, not used much
Diagnostic Peritoneal
Lavage( cather)
• 1. attempt to aspirate free peritoneal blood
– >10 mL positive for intraperitoneal injury
• 2. insert lavage catheter by semiopen or open
• 3. lavage peritoneal cavity with saline
• Positive test:
– In blunt trauma, or stab wound to anterior, flank, or back: RBC
count > 100,000/mm3
– In lower chest stab wounds or GSW: RBC count > 5,000-
10,000/mm3
Local Wound Exploration (LWE)
• To determine the depth of penetration in stab
wounds
• If peritoneum is violated, must do more diagnostics
• Prep, extend wound, carefully examine (No blind
probing)
• Indicated for anterior abdominal stab wounds, less
clear for other areas
Laparoscopy
• Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
– esp for diaphragm injury: Sens 87.5%, specificity 100%
• Can repair organs via the laparoscope
– diaphragm, solid viscera, stomach, small bowel.
• Disadvantages:
– poor sensitivity for hollow visceral injury, retroperitoneum
Management
• General trauma principles:
– airway management, 2 large bore IVs, cover penetrating
wounds and eviscerations with sterile dressings
• Prophylactic antibiotics: decrease risk of intra-
abdominal sepsis due to intestinal perforation
• In general, leave foreign bodies in and remove in the
OR
Management of penetrating
abdominal trauma
• Mandatory laparotomy
vs
• Selective nonoperative management
abdominal trauma
• Mandatory laparotomy
– standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
– Now thought unnecessary in 70% of abdominal stab
wounds
– Increased complication rates, length of stay, costs
– Immediate laparotomy indicated for shock, evisceration,
and peritonitis
abdominal trauma
• Selective management used to reduce unnecessary
laparotomies
• Diagnostic studies to determine if there is intraperitoneal
injury requiring operative repair
• Strategy depends on abdominal region:
– Thoracoabdomen
• Nipple line to costal margin
– Anterior abdomen
• Xiphoid to pubis
– Flank and back
• Posterior to anterior axillary line
abdominal trauma
Thoracoabdomen
• Big concern is diaphragmatic injury
– 7% of thoracoabdominal wounds
• Diagnostic evaluation:
– CXR (hemothorax or pneumothorax)
– Diagnostic peritoneal lavage
– FAST
– Thoracoscopy
Thoracoabdomen
abdominal trauma
• Anterior abdomen
– Only 50-70% of anterior stab wounds enter the abdomen
– of these, only 50-70% cause injury requiring OR
– 1. is immediate laparotomy indicated ?
– 2. Has peritoneal cavity been violated?
– 3. Is laparotomy required?
Management
• Anterior abdomen
LWE meaning local
wound exploration
abdominal trauma
• Back/Flank
– Risk of retroperitoneal
injury
– Intraperitoneal organ
injury 15-40%
– Difficulty evaluating
retroperitoneal organs
with exam and FAST
– In stable pts, CT scan is
reliable for excluding
significant injury:
abdominal trauma
Gunshot wounds
• Much higher mortality than stab wounds
• Over 90% of pts with peritoneal penetration have
injury requiring operative management
• Most centers proceed to laparotomy if peritoneal
entry is suspected
Management
Gunshot wounds
• assess peritoneal
entry by missile path,
LWE, CT, US,
laparoscopy (all
limited)
Management of Blunt abdominal
trauma
• Exam less reliable
• Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring surgical
repair
– FAST, CT, DPL
– In HD stable pts, CT is preferred
Damage Control
• Patients with major exsanguinating injuries may not
survive complex procedures
• Control hemorrhage and contamination with
abbreviated laparotomy followed by resuscitation
prior to definitive repair
Damage Control
• 0. initial resuscitation
• 1. Control of hemorrhage and contamination
– Control injured vasculature, bleeding solid organs
– Abdominal packing
• 2. back to the ICU for resuscitation
– Correction of hypothermia, acidosis, coagulopathy
• 3. Definitive repair of injuries
• 4. Definitive closure of the abdomen
Damage Control
Resuscitation in the ICU
• IVF (crystalloid, not colloid)
• Transfusion
– Increased thromboembolic complications
• Rewarming if hypothermic
• Correction of metabolic abnormalities
• oxygen is recomended in ICU
Damage Control
Open abdominal wounds and definitive closure
• 40-70% can have primary closure after definitive repair.
• Temporary closure methods
Abdominal Compartment Syndrome
• Common problem with abdominal trauma
• Definition: elevated intra-abdominal pressure (IAP) of ≥20
mm Hg, with single or multiple organ system failure
• Primary ACS: associated with injury/disease in abdomen
• Secondary (“medical”) ACS: due to problems outside the
abdomen (eg sepsis, capillary leak)
• Effects of elevated IAP
– Renal dysfunction
– Decreased cardiac
output
– Increased airway
pressures and
decreased compliance
– Visceral hypoperfusion
• Management
– Surgical abdominal
decompression
– Nonsurgical:
paracentesis, NGT,
sedation
– Staged approach to
abdominal repair
– Temporary abdominal
closure
Conclusions
• Watch out for implements and missiles violating the abdomen
• Laparotomy is mandatory if shock, evisceration, or peritonitis
• Diagnostic studies used to determine need for laparotomy.
• FAST is noninvasive, quick and accurate way to evaluate for
intraperitoneal blood
• Damage Control is a principle of staged operative
management with control and resuscitation prior to definitive
repair
• Abdominal compartment syndrome is a common problem in
abdominal trauma
END

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Abdominal

• Largely replaced by FAST and CT

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