Abdominal Trauma

Scott Reed, M.D.

Abdominal Trauma

Abdomen
Derived from Latin word abdere
which means to hide
Often referred to as the black box.
Follow the
clues

Abdominal Trauma

Catagorized according to
Mechanism
Penetrating
Gunshot
Stabbings

Blunt
Motor vehicle / Motorcycle accidents
Assault
Falls
Pedestrians struck

Abdominal Trauma

Trauma. Fourth ed.

Abdominal Trauma

Trauma, Fourth ed. Mattox

Abdominal Trauma

Major source of Morbidity and Mortality

Rapid Diagnosis is Key
Autopsy study comparing two trauma
systems
100 consecutive deaths
San Francisco County Trauma system
where all major injuries went to a Level I
trauma center
Orange County Transported to nearest
hospital
West, JG,
Trunkey, DD, Lim, RC: Systems of Trauma
Care: A study of two counties. Arch Surg 114:455,
1979

Abdominal Trauma

San Francisco Co.

16 deaths 1
considered
preventable
Missed Thor. Aortic
injury

Orange County
30 deaths- 22
considered
preventable
10 of 22 died due to
shock from
unrecognized
abdominal injury
8 of 10 died in the
first 6 hours

West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A

study of two counties. Arch Surg 114:455, 1979

Abdominal Trauma - Diagnosis

Physical Exam
Requires neurologically intact patient
Pain / Tenderness
Guarding
Rebound / Peritoneal signs

All thats needed in penetrating

trauma
All thats needed in
hemodynamically unstable blunt
trauma.

Abdominal Trauma Diagnosis

Physical Exam
Penetrating Gunshot
wounds (high energy
injury)
Determining the
trajectory can give an
idea of what is injured
Need even number of
holes and/or bullets on Xray
Must be careful since
bullets can settle to
dependent areas

Abdominal Trauma Diagnosis

Physical Exam
Penetrating Stabbing (Low energy)
More difficult since there is only an
entrance and no trajectory
Injury can be far from the injury
May be all that is needed in
hemodynamically stable patients
(observation). No good study to pick up
hollow viscus injuries.

Abdominal Trauma - Diagnosis

Ultrasound (F.A.S.T.)
Focused Abdominal
Sonogram for Trauma
Really is fast (done in the
trauma bay)
Non-invasive and can be
repeated
Only determines the presence
of fluid in the abdomen
(between 80 95% sensitive)
Not very specific (which
organ) or what type of fluid
(blood, succus, ascites)

Abdominal Trauma X-Rays

Can show
evidence of
free air (hollow
viscus injury)
Can help
determine the
trajectory of
the missile

41 y/o
female
S/P MVA

Level of the Aortic Arch

Abdominal Trauma - Diagnosis

Diagnostic Peritoneal Lavage (DPL)

Has all but been replaced by FAST
exam
Inserted catheter into abdomen

Gross blood (10cc or more) - positive

Instilled 1 liter normal saline

Over 100,000 RBCs, 500 WBC, bile or

fibers of food on micro - positive

Abdominal Trauma - Diagnosis

Diagnostic Peritoneal Lavage

Invasive 1% injury rate
Oversensitive (small amount of blood
can make a positive by micro) 50cc
Non-specific
Problem in the era of non-operative
management of solid organ injury
? Role in CT with fluid but no solid
organ injury (? Hollow viscus injury)

Abdominal Trauma - Diagnosis

Computed Tomography (CT Scan)

Started in mid-1980s and has
revolutionize trauma care.
Sees more than just the abdomen
(spinal and pelvic fractures) Done in
conjunction with the head and C-spine.
More specific (solid organ injury) and
examines the retroperitoneal areas
(pancreas, kidney, duodenum)
Arterial injuries can be studied

Abdominal Trauma - Diagnosis

CT Scan Drawbacks

Misses hollow viscus injuries

Cant evaluate the diaphragm
Involves IV contrast (allergic
reactions 1:1000) and radiation
Tough to run a code in a donut (need
a stable patient)

Abdominal Trauma Angiography

Using catheters via a femoral /

brachial approach to occlude arteries
Used increasingly for solid organ
injury
Liver Embolize either Right/Left hepatic
arteries (Liver has both arterial and
portal blood supplies)
Spleen Can be selective or embolize
the entire organ

Abdominal Trauma Angiography

Can convert what would be a large and

bloody case into a easily managed
situation
Doesnt always work
Now operating later on a sicker patient
Can embolize too much and infarct other
vascular beds

All fluid isnt blood Can miss small

bowel injuries

Abdominal Trauma Observation

Liver and Spleen injuries can be

observed
Acceptable in minor injuries with
minimal bleeding seen on CT scan
Have to observe VERY closely
Repeated abdominal exams
Vital signs, dropping hematocrits

Have to be ready to operate if

needed quickly

Abdominal Trauma - Diagnosis

Laparoscopy
Excellent for stable stab
wounds (peritoneal
penetration/diaphragm
injury)
Hard to see everything
Can run the bowel
hard to see retroperitoneum,
lesser sac, and assess liver /
spleen injuries

Invasive, expensive
may need to to open

Abdominal Trauma - Surgery

Once thought that all repairs

needed to be done at the initial
surgery
Long surgery / multiple repairs on
hemodynamically unstable patients
Cold, Acidotic, Coagulopathic
Patients died

Abdominal Surgery - Surgery

Damage Control surgery

Stop the bleeding and contamination
and then get out.
Pack the liver
Staple out injured small bowel/colon (no
anastamosis needed)
Vascular shunts

Leave abd open or just close skin

Get to ICU for resuscitation/warming

Abdominal Trauma - Surgery

Damage Control Surgery

After 24 to 48 hours go back to the
OR

Patient is resuscitated, warm, stable

Establish GI continuity
Wash out areas of contamination
Vascular repairs
Patients live

Abdominal Trauma - Nursing

The Open Abdomen

A clear, fenestrated plastic layer over
the bowel and viscera (Vi-drape)
OR towel, Kerlex, or sponge in the
dead space
Large drains in the gutters
Cover entire opening with occlusive
dressing (Ioban)
Place drains to suction

Abdominal Trauma - Nursing

Open Abdomen (VacPack, Blue

Towel)

Can be done fast in the OR

Controls abdominal fluids (can measure)
Prevents abdominal compartment
syndrome (more to follow)
Can be taken down in ICU to allow
inspection of the abdomen

Abdominal Trauma - Nursing

Drains
Placed in areas where fluid may collect.
Near an anastomosis
Pancreatic injury

Must look for changes in output

Increase could signal a leak, or sudden
stop could indicate the drain is clogged
Type and quality of the fluid (suddenly
becomes bloody or bilious)

Abdominal Trauma Nursing

Fistulas
Abnormal connection between two
epithelialized compartments.
Named for the two organs
connected

Abdominal Trauma - Nursing

Fistulas
Enterocutaneous (Small bowel to skin)
Most common
Usually involves the wound or
incision
Will see bowel contents in the
wound
Often due to surgical mishaps

Abdominal Trauma - Nursing

Colocutaneous (colon to skin)

Colovesicular (colon to bladder)
The stomach, pancreas,
gallbladder, arteries, and veins
can all be involved in fistulas

Abdominal Compartment
Syndrome

Mechanism: Direct external pressure

on vascular structures,
diaphragm and abdominal wall

Abdominal Compartment
Syndrome
What is normal?

At rest 0 5mmHg
Valsalva
60 80mmHg
Cough 80cmH2O
Vomiting 60cmH2O
Active lifting
Over 150mmHg
During lifting the pressure is related to
the velocity of muscle contraction and
comes back to baseline once the
movement has ended

Abdominal Compartment
Syndrome
Grading System

Grade I
Grade II
Grade III
Grade IV

10 15mmHg
16 - 25mmHg
26 35mmHg
>35mmHg

Abdominal Compartment
Syndrome
Causes (Acute)
Intra-abdominal

Bowel obstruction /
Ileus
Ruptured AAA
Mesenteric venous
obstruction
Abscess
Pneumoperitoneum
Intraperitoneal
bleed / trauma
Viseral edema

Retroperitoneal
Pancreatitis
Pelvic Frx/bleeds
Ruptured AAA

Abdominal Wall
Burn Eschar
Massive hernia repair
Closing the tight
abdomen

Abdominal Compartment
Syndrome
Constellation of Symptoms

Renal failure

Decreased urine output

Respiratory failure
Dec compliance, inc pulmonary edema / airway
pressure

Cardiac failure
Decreased cardiac output (dec preload / inc afterload)

Visceral failure
Dec blood flow to liver, bowel (bacterial translocation)

Neurologic complications
Increased intracranial pressure

Abdominal wall failure

Dehissence, hernia formation

Abdominal Compartment
Syndrome
Types

Primary
hypertension (IAH) Secondary A process
within or involving the abdomen itself
which leads to increased intra-abdominal
Secondary
IAH which results even though no direct
abdominal injury has occurred
Often overlooked
Strongly related to resuscitation fluids
(iatrogenic)

Saggi et. al Journal of Trauma 1998

Abdominal Compartment
Syndrome
Measuring pressures

Bladder Pressure (gold standard)

Clamp foley catheter
Instill 50-100cc saline into bladder
Use pressure transducer via sampling
port
Accurate

Corresponds well with direct

intra-abdominal catheters and
insufflation during laparoscopy
Reliable and reproducible

Abdominal Compartment
Syndrome
New Perspectives on Old
Concepts

Abdominal Compartment
Syndrome
EVMS Experience

Resuscitation greater than 12

liters in the first 24 hours was a
risk factor for the development of
secondary abdominal
compartment syndrome

R.C. Britt, et. al.

Balough, The
American J. of
Surg. 2003

Abdominal Compartment
Syndrome
Possible Prevention Stratagies

ACS carries high mortality

Abdominal decompression also has
high morbidity and mortality
At risk groups can be identified
High

volume resuscitations (burns,

traumas)
Pts post hemorrhage and shock

ACP can be easily measured

Abdominal Compartment
Syndrome
Peritoneal Catheter Placement
Abdominal pressures over 20
mmHg
Abdominal perfusion pressures
(APP) less than 50mmHg
Abdominal

perfusion pressure
equals the mean arterial pressure
minus the abdominal pressure.
(MAP ACP = APP)

Results Total Group

Thirty minutes after the DPL catheter was

placed: (Avg starting ACP was 24.9mmHg)
Average ACP decreased 7.7mmHg
(p=0.003)
Average MAP increased 9.7mmHg
(p=0.02)
Average APP increased 17.4mmHg
(p=0.007)
Average Pulm Compliance increased 7.9
(p=0.002)

Abdominal Trauma Case

Report

19 y/o male motorcycle crash

Multiple rib fractures
Facial fractures
Bilateral Tibia/fibula fractures
Grade I spleen laceration

Abdominal Trauma Case

Report

Had both lower extremities repaired on

HD#2
Rib fractures managed with pain
control and pulmonary toilet
Facial fractures repair on HD#5
Spleen observed
Left ICU on HD#4 and went to floor

Abdominal Trauma Case

Report

Morning rounds HD#8

HR 70 to 80 bpm
BP 120/75
Using only Percocet for pain
H/H 11/33

Planning D/C home soon

Abdominal Trauma Case

Report

10pm Nurse called for increased pain in

Left Shoulder
Determined this was a new complaint
and no shoulder injury was
documented
Repeated vital signs
HR 110
BP 95/50
Patient was diaphoretic and pale

Abdominal Trauma Case

Report

Nurse immediately contacted house

staff with new complaints and vital
signs
Patients seen and examined
Abdomen now tender with guarding
Repeat H/H 6.5/19

Abdominal Trauma Case

Report

Emergent Abdominal CT Scan revealed

massive hemoperitoneum and delayed
rupture of the spleen
Taken immediately to OR for emergent
splenectomy
Did well and was discharged on
HD#13

Abdominal Trauma Nursing

Quote

I dont need to know exactly

what is wrongI just need to
know that something is wrong

My Mom