ABDOMINAL TRAUMA, HOLLOW

ORGANS
• BY: NSUBUGA IVAN BMS/12264/182/DU
• SUPERVISED BY Dr. MUGENYI

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 ANATOMY OF THE ABDOMEN
• Abdomen: largest cavity in the body. Oval in shape and partially
enclosed by the lower thorax.
• The anterior abdomen: area between the costal margins superiorly,
inguinal ligaments and symphysis pubis inferiorly, and the anterior
axillary lines laterally. Most of the hollow viscera are at risk when
there is an injury to the anterior abdomen.
• The thoracoabdomen: area inferior to the nipple line anteriorly and
the infrascapular line posteriorly, and superior to the costal margins.

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• This area encompasses the diaphragm, liver, spleen, and stomach,
and is somewhat protected by the bony thorax.
• Bcoz the diaphragm rises to the level of the fourth intercostal space
during full expiration, fractures of the lower ribs and penetrating
wounds below the nipple line can injure the abdominal viscera.
• The flank: area between the anterior and posterior axillary lines from
the sixth intercostal space to the iliac crest.

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• The back: area located posterior to the posterior axillary lines from
the tip of the scapulae to the iliac crests. Including the posterior
thoracoabdomen. Musculature in the flank, back, and paraspinal
region acts as a partial protection from visceral injury.
• The flank and back contain the retroperitoneal space. This potential
space is the area posterior to the peritoneal lining of the abdomen.

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• It contains : abdominal aorta; inferior vena cava; most of the
duodenum, pancreas, kidneys, and ureters; the posterior aspects of
the ascending colon and descending colon; and the retroperitoneal
components of the pelvic cavity.
• Injuries to the retroperitoneal visceral structures are difficult to
recognize because: they occur deep within the abdomen, may not
initially present with signs or symptoms of peritonitis, the
retroperitoneal space is not sampled by diagnostic peritoneal lavage
(DPL) and is poorly visualized with focused assessment with
sonography for trauma (FAST).

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• The pelvic cavity: area surrounded by the pelvic bones, contains the
lower part of the retroperitoneal and intraperitoneal spaces. It
contains the rectum, bladder, iliac vessels, and female internal
reproductive organs. Significant blood loss can occur from injuries to
organs within the pelvis and/or directly from the bony pelvis.

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HOLLOW ABDOMINAL VISCERA

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 MECHANISM OF INJURY
• Consideration important bcoz: facilitates the early identification of
potential injuries, directs which diagnostic studies may be necessary
for evaluation, and identifies the potential need for patient transfer.

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 BLUNT
• A direct blow, such as contact with the lower rim of a steering wheel,
bicycle or motorcycle handlebars, or an intruded door in a motor
vehicle crush, can cause compression and crushing injuries to
abdominopelvic viscera and pelvic bones. Deform solid and hollow
organs and can cause rupture with secondary hemorrhage and
contamination by visceral contents, leading to associated peritonitis.
• Vehicular trauma is by far the leading cause of blunt abdominal
trauma.

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• Shearing injuries are a form of crush injury that can result when a
restraint device is worn inappropriately. Patients injured in motor
vehicle crashes and who fall from significant heights may sustain
deceleration injuries, in which there is a differential movement of
fixed and mobile parts of the body. Bucket handle injuries to the small
bowel are examples of deceleration injuries.

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• In patients who sustain blunt trauma, the hollow organs like small
bowel make upto (5% to 10%). Additionally, there is a 15% incidence
of retroperitoneal hematoma in patients who undergo laparotomy for
blunt trauma. Although restraint devices reduce the incidence of
many more major injuries, they are associated with specific patterns
of injury.

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 PENETRATING
• Stab wounds and low-energy gunshot wounds cause tissue damage
by lacerating and tearing. High-energy gunshot wounds transfer more
kinetic energy, causing increased damage surrounding the track of the
missile due to temporary cavitation.
• Stab wounds traverse adjacent abdominal structures and most
commonly involve the liver (40%), small bowel (30%), diaphragm
(20%), and colon (15%) .

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• Gunshot wounds can cause additional intra-abdominal injuries based
on the trajectory, cavitation effect, and possible bullet fragmentation.
Gunshot wounds most commonly injure the small bowel (50%), colon
(40%), liver (30%), and abdominal vascular structures (25%).
• Consider type of weapon, the muzzle velocity, and type of
ammunition in the case of shotguns, the distance between the
shotgun and the patient determines the severity of injuries incurred.

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 BLAST
• Explosive devices: several mechanisms, including penetrating
fragment wounds and blunt injuries from the patient being thrown or
struck by projectiles. The treating doctor must consider the possibility
of combined penetrating and blunt mechanisms in these patients.
• Patients close to the source of the explosion can incur additional
injuries to the tympanic membranes, lungs, and bowel related to blast
overpressure. These injuries may have delayed presentation

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• The potential for overpressure injury following an explosion should
not distract the clinician from a systematic approach to identifying
and treating blunt and penetrating injuries.

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 ASSESMENT AND MANAGEMENT
• History:
Important Historical information in different scenerials:
• Motor vehicle crash: vehicle speed, type of collision (e.g., frontal
impact, lateral impact, sideswipe, rear impact, or rollover), any
intrusion into the passenger compartment, types of restraints,
deployment of air bags, patient position in the vehicle, and status of
other occupants.
• Patients injured by falling: the height of the fall is important historical
information due to the increased potential for deceleration injury at
greater heights.
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• Penetrating trauma: time of injury, type of weapon (e.g., knife,
handgun, rifle, or shotgun), distance from the assailant ( important
with shotgun wounds, as the likelihood of major visceral injuries
decreases beyond the 10-foot or 3-meter range), number of stab
wounds or gunshots sustained, and the amount of external bleeding
noted at the scene.
• Prehospital care providers should supply data regarding vital signs,
obvious injuries, and patient response to prehospital treatment.

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• Other important additional hx: magnitude and location of abdominal
pain, explosions can produce visceral overpressure injuries. Risk
increases when the patient is in close proximity to the blast and when
a blast occurs within a closed space.
• History of medications specially beta-blockers and anticoagulants
should be elicited, if present to be recorded. Even if a patient is not in
hypovolaemia, there can be bradycardia, if patient is taking
propranolol.

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 PATIENT CLASSIFICATION AFTER
PRIMARY SURVEY
Based on their physiological condition after initial resuscitation
• Haemodynamically ‘normal’ – investigation can be completed before
treatment is planned;
• Haemodynamically ‘stable’ – investigation is more limited. It is aimed
at establishing whether the patient can be managed non-operatively,
whether angioembolisation can be used or whether surgery is
required;
• Haemodynamically ‘unstable’ – investigations need to be suspended
as immediate surgical correction of the bleeding is required.

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• A trauma laparotomy is the final step in the pathway to delineate
intra-abdominal injury.
• Examination in unstable patients: done in the ED or in the operating
theatre if the patient is deteriorating rapidly.

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 Secondary Survey and Definitive Care
• Inspection, palpation, percussion and auscultation should be done in the
usual manner. Patient exposed full length: entire chest, abdomen and
pelvis both anterior and posterior.
• Tachycardia and hypotension are the early features of ongoing bleeding.
Patient who is lying down without any pain but anxious may be having
bleeding and one who is not moving but with pain may be having hollow
viscus perforation. Restless patients have often head injuries.
• Abdominal distension: quite often due to solid viscus bleed from liver or
spleen. Also due to perforation of a viscus and retroperitoneal injuries
resulting in paralytic ileus.

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• Abrasions, echymosis, lacerations over the abdominal wall, stab
injuries, foreign bodies, evisceration of omentum or intestines to be
recorded.
• Lapbelt injuries sign: If these are present they indicate underlying
injuries.
• Saree sign(in indian ladies)

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• Inspect the anterior and posterior abdomen, as well as the lower chest
and perineum, for abrasions and contusions from restraint devices,
lacerations, penetrating wounds, impaled foreign bodies, evisceration of
omentum or bowel, and the pregnant state

• Inspect the flank, scrotum, urethral meatus, and perianal area for blood,
swelling, and bruising. Laceration of the perineum, vagina, rectum, or
buttocks may be associated with an open pelvic fracture in blunt trauma
patients. Skin folds in obese patients can mask penetrating injuries and
increase the difficulty of assessing the abdomen and pelvis. For a
complete back examination, cautiously logroll the patient.
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• Palpation: may elicit and distinguish superficial (i.e., abdominal wall)
and deep tenderness. Determine whether a pregnant uterus is
present and, if so, estimate the fetal age.
• Voluntary guarding by the patient may make the abdominal
examination unreliable. In contrast, involuntary muscle guarding is a
reliable sign of peritoneal irritation.
• When rebound tenderness is present, do not seek additional
evidence of irritation, as it may cause the patient further unnecessary
pain.

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• Percussion causes slight movement of the peritoneum and may elicit
signs of peritoneal irritation.
• Don’t waste time doing unnecessary percussion to find out the fluid bcoz
it will be detected later by FAST.
• Although auscultation is necessary, the presence or absence of bowel
sounds does not necessarily correlate with injury, and the ability to hear
bowels sounds may be compromised in a noisy emergency department.
• Once examination is completed, patient should be covered with warm
blankets to prevent hypothermia. Bcoz hypothermia results in
coagulopathy and ongoing bleeding.

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 ASSESSMENT OF PELVIC STABILITY
• Pelvic fracture: suspect when hypotension is present in a conscious
patient who has no obvious injuries. Blood at the urinary meatus, high
riding prostate, scrotal haematoma, (rupture urethra), limb length
discrepancy suggest pelvic fracture.
• Gentle pressure over iliac bone in a downward and medial direction
is applied. Laxity and instability suggests pelvic fracture. Only one
attempt to test the pelvis should be done. Frequent tests may result
in more bleeding and even dislodge the clot.
• It is better to avoid this test in patients with hypotension.

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 Examination of Pelvic Organs and Gluteal
Region
• Urethra: Blood at meatus and scrotal haematoma suggests urethral
injury. Though signs might be absent immediately after injury.
Catheterisation should not be done in such cases.
• Rectal examination to look for bleeding, loose sphincter and high
riding prostate, rectal mucosal integrity and to identify any palpable
fractures of the pelvis. In cases of rupture of membranous part of
urethra, prostate will not be palpable as it is displaced upwards. It is
called high riding prostate also described as Vermooten’s sign.
• Vaginal examination to be done when you suspect vaginal injuries as
in presence of perineal lacerations and pelvic fractures.

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• Palpation of the prostate gland is not a reliable sign of urethral injury

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 ADJUNCTS TO PHYSICAL
EXAMINATION
• After diagnosing and treating problems with a patient’s airway,
breathing, and circulation, clinicians frequently insert gastric tubes
and urinary catheters as adjuncts to the primary survey.
• Gastric Tubes and Urinary Catheters: The therapeutic goals of a gastric
tube placed early in the primary survey include relief of acute gastric
dilation and stomach decompression before performing DPL (if
needed). Gastric tubes may reduce the incidence of aspiration in
these cases.

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• However, they can trigger vomiting in a patient with an active gag reflex.
The presence of blood in the gastric contents suggests an injury to the
esophagus or upper gastrointestinal tract if nasopharyngeal and/or
oropharyngeal sources are excluded.
• If a patient has severe facial fractures or possible basilar skull fracture,
insert the gastric tube through the mouth to prevent passage of the nasal
tube through the cribriform plate into the brain.
• A urinary catheter placed during resuscitation will relieve retention,
identify bleeding, allow for monitoring of urinary output as an index of
tissue perfusion, and decompress the bladder before DPL (if performed).

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• A full bladder enhances the pelvic images of the FAST. Therefore, if
FAST is being considered, delay placing a urinary catheter until after
the test is completed.

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 DIAGNOSTIC IMAGING
• Focused Assessment with Sonography for Trauma(FAST)
• Diagnostic Peritoneal Lavage (DPL)
• Computed Tomography

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 Esophagus
• Mainly by penetrating trauma through blunt disruption. Combined
tracheoesophageal injuries do occur. Dx, mgt, and outcome for traumatic
esophageal perforations are affected by etiology, location, and duration
between event and intervention.
• Signs of injury: blood in the nasogastric aspirate, subcutaneous cervical
air, and neck hematoma, but none is sensitive.
• Dx: Plain radiography: reveal pneumomediastinum, pleural effusion,
mediastinal contour changes (progress with inflammation), or gas bubbles
in the NG tube or esophagus,=tracheoesophageal communication exists.
Pneumomediastinum without a clear cause is an indication for further
assessment by a contrast study.
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• Contrast study: Dilute/thin barium studies preferred as the initial
diagnostic study, Gastrografin studies can also be used. A contrast
study confirms: location of the leak and the side toward which the
leak is going, and also demonstrates other pathology such as
strictures that may need to be addressed.
• Esophagoscopy and contrast studies are complementary in the
trauma setting. Flexible esophagoscopy: performed in the OR, as
definitive intervention can be done when an injury is found.
• Tendency for the dx to be delayed.

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• Lacks specific symptoms and generally occurs in multiple trauma, thus
difficult to diagnose.
• Txt emphasises on primary repair when possible, with some form of
tissue reinforcement.
• The principles of surgical intervention: control of the leak,
débridement of all devitalized tissues, wide drainage, and nutritional
support. Broad-spectrum antibiotic coverage, primary repair should
be done whenever possible. Additional reinforcement with tissues
such as pleura, pericardial fat, diaphragm, or intercostal muscle.

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• Long-term results with primary repair are poor when there is
underlying preexisting esophageal pathology hence esophageal
resection may be needed in these cases.
• Presence of significant inflammation of tissues and/or degree of
shock, delayed perforations: treated with diversions (cervical fistula or
drainage with a T-tube).
• A long cervical esophagostomy can be brought out onto the anterior
chest wall below the clavicle
• Advantages: more comfortable for the patient and maximizing the
length of residual esophagus for later reconstruction.
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 Stomach
• Most stomach injuries are caused by penetrating trauma.
• Blood presence is diagnostic if found in the NG tube, in the absence of
bleeding from other sources.
• Surgical repair is required but great care must be taken to examine
the stomach fully, as an injury to the front of the stomach can be
expected to have an ‘exit’ wound elsewhere on the organ.
• Repaired in two layers, with an inner layer of 3/0 or 4/0 absorbable
sutures followed by an outer layer of 3/0 or 4/0 permanent Lembert
sutures. Pylorus injuries, rare ,if viable tissue is present, shld be closed
with a Heineke-Mikulicz pyloroplasty.
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• Always look out for associated diaphragmatic injuries, if found do
pleural cavity lavage before closure of the diaphragm to avoid epyema

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 DUODENAL INJURIES
• Retroperitoneal duodenum is commonly injured.
• Steering wheel, belt or a blow in the epigastrium may injure the
duodenum as it is crushed against the spine.
• Clinical Features:
• Peritonitis features are not common as it is the retroperitoneal duodenum (part II and
part III) that is injured.

• Tenderness is present on deep palpation.

• Being retroperitoneal, these injuries manifest late with abscess formation or fluid in
lesser sac.

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IMPORTANT ASPECTS TO NOTE FOR DUODENAL INJURIES

Character of the injury (e.g., a simple laceration vs. destruction of the duodenal wall)

Involved circumference of the duodenum

Associated injuries to the biliary tract, pancreas, or major vascular structures

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 Investigations
• X-ray abdomen:
– Obliteration of psoas shadow
– Air outlining the kidney—Chilaiditi’s sign
– Absence of air in the duodenum
• Raised serum amylase is one of the biochemical parameters that
should arouse a suspicion of pancreatic injuries along with duodenal
injury.

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 Treatment
• Golden time to operate is within 6 hours.
• When in doubt, about narrowing of lumen, duodenojejunostomy
may be indicated.
• When in doubt regarding duodenal fistula, tube duodenostomy is
done. Nolonger advised
• Duodenal haematoma is managed conservatively.
• Better to add a feeding jejunostomy
• Adequate drainage of the periduodenal area: leaks are controlled and
do not result in an intra-abdominal abscess

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 SMALL BOWEL INJURIES
• The shearing injuries produce either disruption or laceration of the
bowel between fixed and mobile points, i.e. at the duodenojejunal
flexure or at ileocaecal junction. These are the most common sites of
small bowel injuries.
• Injury to the small bowel can also occur due to crush injury between
spine and a steering wheel or handle bars.
• Bruising on the abdominal wall may suggest perforation.
• Mesentery and its vessels also get damaged and bleeding can be
sufficient to produce hypovolaemia and shock.

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 Clinical Presentation
I. Acute abdominal pain: Features are like that of any perforation peritonitis
with guarding and rigidity. Erect abdominal X-ray shows gas under the
diaphragm.
II. Features of peritonitis with haemoperitoneum are the result of bowel
injury with bleeding from the mesentery.
III. Occult or hidden perforation: A small perforation gets sealed off by coils of
bowel and omentum. Most of these patients present with abdominal pain.
However, very often, features of peritonitis are missed as a result of other
associated injuries such as fracture pelvis or retroperitoneal haematoma.
After 3–4 days, a localised abscess may form and rupture into the
peritoneal cavity, resulting in peritonitis. This is aggravated by intake of oral
fluids which stimulate peristalsis. Repeated examination is the most
honoured, most fruitful investigation in blunt injuries of the abdomen.
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 Investigations
• X-ray abdomen, erect or lateral decubitus, demonstrates free gas
under the right dome of the diaphragm in majority of cases. Four-
quadrant tap or diagnostic peritoneal lavage is also useful.
• When in doubt, CT scan of abdomen should be requested to diagnose
hollow viscus perforation and bleeding.

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 Treatment
• Golden time to operate is within 6 hours.(laparotomy and closure of
perforation) small bowel injuries need urgent repair.
• Perforation: Single or multiple, have to be closed, after trimming the edges by
using nonabsorbable sutures such as silk.
• A lacerated or a macerated bowel has to be resected.
• Bleeding mesenteric vessels have to be ligated, haematoma must be
evacuated and bowel should be inspected for any ischaemia. Food particles
and bile should be evacuated.
• A perforation of ileum close to the ileocaecal junction is treated by
ileocolectomy rather than simple closure for the fear of enterocutaneous
fistula, due to suture line leakage.
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 Gall Bladder and Extrahepatic Bile Ducts
• Injuries of the gallbladder: treated by lateral suture or cholecystectomy,
whichever is easier. If lateral suture is performed, absorbable suture
should be used.
• Injuries of the extrahepatic bile ducts are a challenge. If ducts are of
normal size and texture (i.e., small in diameter and thin walled). These
factors usually preclude primary repairs except for the smallest
lacerations. Some injuries can be treated by the insertion of a T-tube
through the wound or by lateral suture using 4-0 to 6-0 monofilament
absorbable suture.
• Virtually all transections and any injury associated with significant tissue
loss will require a Roux-en-y choledochojejunostomy.
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• Injuries of the hepatic ducts: almost impossible to satisfactorily repair
under emergency circumstances. One approach is to intubate the
duct for external drainage and attempt a repair when the patient
recovers. Alternatively, the duct can be ligated if the opposite lobe is
normal and uninjured. For patients who are critically ill, the common
duct also can be treated by intubation with external drainage.

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 COLONIC INJURIES
• Blunt injury of the colon is not uncommon.
• Mobile sigmoid is more prone to injury than fixed parts.
• Steering wheel injury can directly crush the transverse colon and can
cause perforation.
• Bruise or laceration of the colon can undergo ischaemic necrosis and
it can present after 5–7 days with signs of peritonitis/sepsis.
• Diagnosis is by clinical examination/contrast enhanced CT scan.

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• When examining the colon, it pays to be relentlessly paranoid. Bcoz
much of the colon is retroperitoneal or covered with omentum and
pericolic fat, missing a small colonic perforation is easier than you
think.
• Do not leave any subserosal hematoma on the colon, no matter how
small and innocent-looking, without unroofing it by opening the
overlying peritoneum.
• Very often, this seemingly innocent superficial staining hides a
perforation.

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• Depending upon the contamination, contusion or laceration and duration
of injury, treatment can be resection and anastomosis within 6–8 hours of
the injury or simple suturing or diversion colostomy, if gross contamination
is present.
• Even in penetrating injury, primary closure can be done.
• Colostomy may be considered if one or more of these risk factors is
present: increased risk of anastomotic leak—hypotension on presentation,
transfusion requirement of four or more units of packed red blood cells,
underlying medical condition, or Abdominal Trauma Index >25. OR if the
edges of the resected colon do not appear optimal for anastomosis. .
Closure of colostomy is done at later stages after 3-6 months
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Should the Skin Be Closed after Laparotomy
for Colon Injury?
• Injury to the small intestine has not been shown to result in a high
rate of infectious complications and skin closure after small bowel
trauma is generally recommended. However, surgical site infection
rates have been shown to range from 2.7% to over 50% after colonic
trauma.
• This has led some authors to recommend closing only abdominal
fascia and leaving the skin open.
• The best study on this topic is a prospective, randomized trial
published by Velmahos et al.

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• In this trial, the infection rate for open wounds was noted to be 36%,
whereas the infection rate in closed wounds was seen to be 65%.
Wound infection was predictive of risk for wound dehiscence and
necrotizing soft tissue infection. Subjecting patients to this increased
risk of major complications in an effort to avoid the need to care for
an open wound does not seem prudent.

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 What Is the Appropriate Duration of
Antibiotics after Colon Injury?
• Recommendation: Antibiotic prophylaxis should be limited to no more
than 24 h after laparotomy for intestinal injury. Grade of
recommendation: A

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 Rectum
• Accounts only 5% .
• Generally from a penetrating injury, although occasionally the rectum may
be damaged following fracture of the pelvis.
• Digital rectal examination will reveal the presence of blood, which is
evidence of intestinal or rectal injury.
• Often associated with bladder and proximal urethral injury.
• Management same as colonic injury.
• Full-thickness extraperitoneal rectal injuries should be managed with
either a diverting end-colostomy and closure of the distal end (Hartmann’s
procedure) or a loop colostomy. Presacral drainage is no longer used.
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MORE ON THE PENETRATING WOUNDS
• Reconstruct the trajectory of the wounding agent. The trajectory must be
linear and make sense. Bullets and knife blades do not disappear into thin
air only to appear out of nowhere in another part of the abdomen. You must
be able to connect the dots. When the trajectory of the wounding missile is
unclear or does not make sense, you probably are missing an injury.
• Be concerned when finding an odd number of holes in the gut. Tangential
wounds certainly occur, and occasionally a missile perforates only one wall,
but this is uncommon. Therefore, an odd number of holes should prompt
you to re-evaluate the area in search of a missed perforation. The only
exception is a single stab wound to the anterior gastric wall, which is
relatively common

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 Ureter
• Rare,
• Present without clear signs or symptoms, many are missed at the
initial assessment and delayed diagnosis is common.
• Most common source of injury: iatrogenic during hysterectomy. These
injuries occur with ligation of the infundibulopelvic ligament where
the ureter crosses the uterine artery.
• In the adult population, penetrating injuries, gunshot wounds
followed distantly by stab wounds, are the most frequent source of
injury associated with external violence.

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• A high degree of suspicion in evaluation of penetrating wounds and
injury when organs anatomically related to the ureter sustain injury:
iliac vessels, bladder, sigmoid colon, and lumbar spine or transverse
processes. Significant deceleration and hyperextension mechanisms
can result in blunt avulsion as well.
• In children, the injury occurs at the UPJ, resulting in avulsion of the
ureter due to increased hyperextensibility of the spine

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• Txt: surgical exploration for associated injuries, allowing the ureter to
be inspected directly. Definitive reconstruction only if the patient is
stable.
• Too long defect for primary repair or patients are hemodynamically
unstable, damage control techniques for urinary diversion:
débridement, drainage of the bladder and retroperitoneum,
cutaneous ureterostomy diversion with a feeding tube, or ligation of
the ureter with percutaneous nephrostomy tube placement.

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• Complete débridement precedes ureter reconstruction, and the level
and length of ureter dictate the type of repair. UPJ disruptions require
formal reconstruction by reanastomosis or ureteropyelostomy.
• For ureteral injuries occurring in the proximal to midureter without
associated renal injury, simple mobilization of the colon without hilar
control can be used to gain access to the ureters

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• Short midureteric injuries are repaired by spatulated end-to-end
anastomosis and low pelvic ureteric injuries are repaired by
ureteroneocystostomy. A nonrefluxing anastomosis is preferred in
children, while a refluxing implant is acceptable in adults.
• Delay in diagnosis: fever, flank pain, fullness, tenderness, atelectasis,
or oliguria as a result of urinoma, hematoma, or abscess. Operative
intervention at the time of delayed diagnosis can result in
nephrectomy. Therefore, mgt includes nephrostomy tube placement,
percutaneous urinoma drainage, and Foley catheter insertion.

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• Stent placement across an injury is delayed for 1 to 2 weeks and
reconstruction is planned at 3 to 6 months to allow for resolution of
periureteral inflammation. Long-term complications of unrecognized
ureteral injury: fistula, fluid collections, ureteral stricture, and
obstructive uropathy.

• Follow-up: imaging in the form of radionuclide scanning or IVU at 3

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 Bladder
• Rare, mostly secondary to blunt trauma
• Penetrating trauma accounts for 0 to 45% of bladder trauma and
blunt trauma accounts for the remainder.
• Frequently associated with Pelvic fractures. (90%) though only 5 to
10% of pelvic fractures result in bladder injury.
• Mechanisms: shearing forces at deceleration resulting in injury at the
fixed sites of pelvic fascial attachment.

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• Second mechanism: direct injury from pelvic bone fragments causing
laceration of the bladder. Intraperitoneal blunt injury is due to rapid
deceleration creating a rapid rise in intravesical pressure, resulting in
a “burst”-type injury.
• In the pediatrics, larger proportion of injuries are intraperitoneal
because of the relative intra-abdominal location of the bladder.

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• Gross hematuria: reliable sign of bladder injury (occurring in 95%); do
cystography, urethrography, or both.
• Acutely, pts may complain of inability to void or suprapubic pain, may
be masked by pain from more significant injuries.
• With delayed presentation, frequent symptoms are abdominal
distention, ileus, fever, or urinary ascites as a result of persistent
leakage, pelvic urinoma, or abscess formation.

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• Lab: acidosis, hyperkalemia, hyperchloremia, hypernatremia, and
uremia with intraperitoneal bladder injuries because of the frequency
of these injuries with pelvic fracture.
• Pay attention for concurrent injury.
• Imaging of the bladder: cystography, and is performed in the clinically
stable patient. Postvoid to enhance cytograph.

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• Harborview Medical Center criteria for bladder imaging after blunt
trauma: pelvic ring fracture with greater than 30 RBC/hpf or gross
hematuria; presence of a free intraperitoneal low-density fluid
collection within the first 24 hours postinjury.

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 Urethra
• Blunt disruption of the posterior urethra is managed by bridging the
defect with a Foley catheter. This requires passing catheters through
the urethral meatus and through an incision in the bladder. Strictures
are not uncommon but can be managed electively. Penetrating
injuries are treated by direct repair.

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Continua…………
• Blunt ruptures of the intraperitoneal portion are closed with a
running single layer closure using 3-0 absorbable monofilament
suture.
• Blunt extraperitoneal rupture is treated with a Foley catheter; direct
operative repair is not necessary. The Foley can be removed in 10–14
days. Penetrating bladder injuries are treated in the same fashion
although injuries near the trigone should be repaired through an
incision in the dome to avoid injury to the intravesicular ureter.

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 Gynecological trauma
• Trauma to the uterus and cervix is most commonly found in association
with pregnancy, may be seen as a result of penetrating vaginal or
abdominal trauma.
• Non-infected simple cervical lacerations: repaired to optimize restoration
of normal anatomy (and possibly decrease the risk of cervical
incompetence or stenosis with dysmenorrhea from poor healing).
Absorbable size 2-0 or 0 grade suture can be used.
• Acute penetrating trauma involving the uterine fundus usually causes
little bleeding and can be managed expectantly without repair. Damage to
the uterine wall with bleeding can be repaired with size 0 absorbable
suture.
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Continua………
• Trauma involving the lateral wall of the uterus may cause significant
bleeding, usually controlled by successive ligation of the ascending
and descending branches of the uterine artery.
• Hemorrhage not responding to ligation, or extensive mutilating
damage to the cervix or uterus, should be treated by hysterectomy.
• Prophylactic antibiotics given if proceeding to hysterectomy (first-
generation cephalosporin).

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 Fallopian tubes
• Damage to the wall of the fallopian tube by ruptured ectopic
pregnancy or penetrating abdominal trauma should be treated by
salpingectomy, if there is significant damage to the tube, due to the
risk of subsequent or recurrent ectopic pregnancy if left in situ.
• If the damage is equivalent to a linear salpingotomy, achieve
hemostasis, then allow healing by secondary intention.
• The mesosalpinx is ligated or cauterized, then the tube is ligated and
cut at its connection with the uterine fundus.

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Continua…….
• Unruptured ampullary/isthmic ectopic pregnancy can be treated by
linear salpingotomy, with extraction of the ectopic gestation. The
tubal incision is left open to heal by secondary intention.
• An unruptured or ruptured cornual/interstitial ectopic pregnancy
requires wedge resection of the uterine cornu with salpingectomy.
• An ectopic pregnancy spontaneously aborted into the abdominal
cavity through the end of the tube should be removed, but the tube
may be left in situ if hemostasis is attained.
• Note: precipitous vaginal delivery, emergency cesarean section.

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 Gynaecological trauma
• Trauma to the uterus and cervix: most commonly found in association
with pregnancy, may be seen as a result of penetrating vaginal or
abdominal trauma.
• Non-infected simple cervical lacerations should be repaired to optimize
restoration of normal anatomy (and possibly decrease the risk of cervical
incompetence or stenosis with dysmenorrhea from poor healing).
Absorbable size 2-0 or 0 grade suture can be used.
• Acute penetrating trauma involving the uterine fundus usually causes
little bleeding can be managed expectantly without repair. Damage to the
uterine wall with bleeding can be repaired with size 0 absorbable suture.

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Continua………
• Trauma involving the lateral wall of the uterus may cause significant
bleeding, but can usually be controlled by successive ligation of the
ascending and descending branches of the uterine artery.
• Hemorrhage not responding to ligation, or extensive mutilating
damage to the cervix or uterus, should be treated by hysterectomy.
• Prophylactic antibiotics, given if proceeding to hysterectomy (first-
generation cephalosporin).

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 Damage control
• Aims at keeping the pt alive rather than correct the anatomy.
• Its rapid termination of an operation after control of life threatning
bleeding and contamination followed by correction of physiologic
abnormalities and definitive mgt.
• Commonly employed to avoid the “lethal triad” of hypothermia
(defined as a core body temperature <35c), acidosis and
coagulopathy.

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 The three-part sequence
Operating room (OR) (Part I)
a. Rapid control of hemorrhage
b. Control or containment of contamination
c. Restoration of vascular flow when required
d. Intra-abdominal packing
e. Temporary abdominal closure

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Continua……….
Intensive care unit (ICU) (Part II)
a. Core rewarming
b. Optimization of hemodynamics
c. Correction of coagulopathy
d. Ventilatory support
e. Secondary survey and injury identification

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Continua………….
OR (Part III)
a. Pack removal
b. Definitive repair of injuries

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 Who needs damage control:
Recommendation: A “damage control approach” should be taken with
any trauma patient who has any of the following characteristics:
• RTS ≤5 (revised trauma score)
• Patients who require ≥2000 mL of crystalloids for their resuscitation in
the ED
• Patients who require ≥2 units of PRBCs for their resuscitation in the ED
• Patients who have a pH ≤7.2
• SBP <90mmHg with penetrating torso or blunt abdominal trauma or
severe pelvic trauma and a need for resuscitative thoracotomy.

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 How Do We Intraoperatively Identify the
Damage Control Patient?
Recommendation:   In the OR, a “damage control” technique should be
considered when, and if, the following criteria apply:
• Pts who require transfusion of ≥10 units of blood or a total fluid
replacement of >12 L
• Patients who have had an ED or OR thoracotomy
• Patients who have a pH ≤7.2
• Patients who have a temperature of ≤34°C
• If the patient has an inaccessible major venous injury

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Continua………
• If the surgeon cannot achieve hemostasis owing to a recalcitrant
coagulopathy
• If the definitive operative repair is a time-consuming procedure in the
patient with suboptimal response to resuscitation
• If the patient requires the management of an extra-abdominal life-
threatening injury
• If the patient will require a reassessment of intra-abdominal contents

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Continua……….
• If the surgeon cannot re-approximate the abdominal fascia due to
splanchnic reperfusion-induced visceral edema
• Patients with peak inspiratory pressures >40 cm H2O or intra-
abdominal pressure >21 mmHg during attempted closure

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 When Should We Terminate the Initial
“Damage Control” Operation?
Recommendation: Damage control operations should be rapidly
terminated, and the patient should be transferred to the ICU when the
patient meets any of the following criteria:
• Core temperature ≤34°C
• pH ≤7.2
• Prothrombin time ≥ twice normal
• Partial thromboplastin time ≥ twice normal

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 What Is the Morbidity Rate from a “Damage
Control” Approach?
• Expected complication rates from damage control laparotomies range
from 25% to 40% of patients.
• Most common complications: intra-abdominal abscesses and
enterocutaneous fistulae.
• Patients who are discharged with an open abdomen should return to
a quality of life that is similar to that of patients who are discharged
with a closed abdomen by 18 months post-discharge.

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The damage control procedure

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 REFERENCES
• Advanced Trauma Life Support® Student Course Manual Tenth edition.
• Schwatz principles of surgery 10th edition
• Greenfield’s manual of surgery 5th edition
• Manipal Manual of Surgery, 5th edition
• Acute Care Surgery And Trauma: Evidence-based Practice, Second Edition.
• Bailey and Love’s short practice of surgery 27th edition
• Hirshberg & Mattox Top knife, the art and craft of trauma surgery, 1st edition.

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