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Abdominal Trauma: Supervised By: Dr. Hussein Al-Heis
Abdominal Trauma: Supervised By: Dr. Hussein Al-Heis
INTRODUCTION
Present in 7-10 % of traumatic patients.
Types of abdominal trauma ??
Blunt & Pentrating
Blunt Trauma
E.x. on blunt traumas??
Motor Vehicle accidents (MVA), Falls, Severe blows
assaults
Usually caused by acceleration deceleration
changes, we call it seat belt injury
What are the affected organs?
Spleen(40-55%), liver (35-45%), small bowel (5-10%)
Penetrating Trauma
Types of penetrating trauma??
Stab wounds & Gunshot wounds
What are the affected organs??
liver, small bowel ,diaphragm , colon
Gunshot wounds
Stab wounds
damage by lacerations /
cutting in the site of
penetration
Presentations
Depend on a few factors ; size, site, organ
involve, blunt or penetrating
Visible truncal injury including chest or abdomen
Abdominal pain
Bleeding
Piercing object
Evisceration
Shock
Evisceration
Piercing object
Assesment : History
Hx MAPLE
M:Medications
A: Allergy/Airway
P: Past medical history
L: Last meal
E: Event - Whathappened?
Mechanism
MVA:
Gun shots :
Speed
# number of
shots heard
Type of collision (frontal, lateral,
type of gun used
sideswipe, rear, rollover)
Position of pt when
shot
Types of restraints
Distance
Vehicle intrusion into passenger compartment
Deployment of air bag
Patient's positionin vehicle
Fatality at thescene
amination
Inspect the abdomen and flanks for lacerations,
contusions (eg, seat belt sign), andecchymosis,
abdominal distension, piercing objects, entry and exits for
gunshots
Palpate for tenderness and rigidity,rebound tenderness
Auscultate for presence/absence bowel sounds
Percuss to elicit subtle rebound tenderness
Assess pelvic stability
Examine gluteal regions and
perinum,rectum,penile,vaginal
Put the pt in the Trendelenburg position to assess for
referred pain
(left shoulder pain kehrs sign splenic injury// right shoulder
pain liver)
laceration
Investigations
Blood and urine sampling
Raised serum amylase may indicate small
bowel / pancreatic injury
FAST
DPL
CT SCAN
LAPAROSCOPY
LAPAROTOMY
approaching 96%
in detecting
Pericardium
Perihepatic
Morrisons pouch
Perisplenic
Pelvic
Pericardium
Perisplenic
Perihepatic
Computerized Tomography
Gold standard
Performed only on a stable patient
Iv contrast / oral contrast
Has the added advantage of
sensitivity for diagnosing
retroperitoneal injury
Entirely normal abdominal CT is
usually sufficient to exclude injury
Diagnostic Laparoscopy
Used as a screening investigation in
penetrating trauma to exclude peritoneal
penetration and/or diaphragmatic injury in
stable pt
Difficult to exclude all abdominal injury
laparoscpically.
Reduces the rate of non therapeutic
laparotomies but its not a substitute
especially in the presence of
hemoperitoneum or contamination
Indications of
laparotomy
Signs of peritonitis
Uncontrolled shock / hemorrhage
Clinical deterioration during observation
Hemoperitonium findings after DPL / FAST
Any knife injury with visible
viscera,clinical peritonitis,hemodynamic
unstable, or developing fever/signs of
sepsis
Any gunshot wound
Individual Organ
Injuries
1. Liver
2. Spleen
3. Pancreas
4. Stomach
5. Duodenum
6. Small bowel
7. Large bowel
8. Rectum
9. Anus
Liver
Majority due to blunt injury
AAST-OIS injury scale
Most important thing is to control the
hemorrhage.
Remember the 4Ps (Manual
compression(Push), Perihepatic Packing, Plug,
Pringle Maneuver)
Electrocautery for bleeding from liver surface.
Suture ligation or clips for bleeding vessels.
If the injury has already resulted in massive
blood loss, pack the abdomen with
laparotomy pads and reexplore later.
Drains should always be used.
Biliary tract decompression is
SPLENIC INJURY
MANAGEMENT
Most isolated splenic injuries (esp.children)
can be managed conservatively.
In adults, (esp. in presence of other injury,
physiological instability, coagulapathies etc;
laparatomy and direct splenorraphy
should be considered.
Splenectomy may be a safer option, esp. in
the unstable patient with multiple potential
sites of bleeding.
In certain situations, selective
angioembolisation of the spleen can play a
role.
PANCREATIC INJURY
MECHANISM :
Most pancreatic injury occurs as a
result of blunt trauma. In penetrating
trauma ( gunshot wound >> stab
wound)
75% of patients with penetrating injury
to the pancreas will have associated
injuries to the aorta, portal vein, or
inferior vena cava.
Pancreatic injury
DIAGNOSIS
INSPECT pancreas during laparotomies
performed for other indications.
Check AMYLASE (may be elevated)
CT : Look for parenchymal fracture,
intraparencymal hematoma, lesser sac fluid,
fluid between splenic vein and pancreatic
body, retroperitoneal hematoma or fluid.
ERCP : Maybe used in the stable patient if
readily available or available
intraoperatively; also may be used to
evaluate missed injury.
TREATMENT
Non-operative :
May follow with serial labs and exam if patient can be
reliably examined.
Operative:
Classically the pancreas should be treated with
conservative surgery and closed suction drainage.
Injuries to the tail are treated by closed suction drainage,
with distal pancreatectomy if the duct is involved.
Proximal injuries (to the right of the superior mesenteric
artery) are treated as conservatively as possible, although
partial pancreatectomy may be necessary. The pylorus can
be temporarily closed (pyloric exclusion) in association with
a gastric drainage procedure.
A Whipples procedure (pancreaticoduodenectomy) is rarely
needed and should not be performed in the emergency
situation because of the very high associated mortality rate.
BOWEL INJURY
DIAGNOSIS
If the patient is awake and reliable, the exam
is important to look for peritoneal irritation.
If the exam is not reliable, DPL or
laparoscopy may be required.
CT-scan has a high false-negative rate for
small bowel injuries.
Look for free air on CXR.
Laparotomy for gastric or small bowel injury
with primary repair and peritoneal lavage
except in cases that have heavy soiling of the
peritoneal cavity and present late, where
intestinal diversion must be considered
( e.g ; ileostomy)
DUODENUM
Mechanisms : Three fourths of injuries result from
penetrating trauma
Diagnosis :
- Upper GI series with water-soluble contrast.
- CT : gas in the periduodenal tissue
*CT and DPL often miss duodenal injuries
Treatment:
- 80% of patients are able to undergo a primary repair.
- Repair may be protected with an omental patch, jejunal
serosal patch and/or gastric diversion.
- More complex injuries need pyloric exclusion or rarely
pancreaticoduodenectomy ( Whipple procedure)
LARGE BOWEL
LARGE BOWEL
Injuries generally occur via a penetrating mechanism
(75% gunshot wound, 25% stab wound) , relatively
infrequent due to blunt injury.
Signs & symptoms :
Abdominal distention, tenderness, guaiac-positive
stool(gFOBT)
Diagnosis:
In an awake & reliable patient, exam findings are
consistent with peritonitis.
CXR may show free air.
In a patient with a flank injury but without clear
peritoneal signs, consider a contrast enema.
Treatment
Primary repair : for small or
medium-sized perforations, repair
the perforation or if needed, resect
the affected segment and close with
primary anastomosis.
A proximal diverting stoma (e.g;
ileostomy) is commonly placed.
Anastomosis is contraindicated in the
setting of massive soiling.
RECTUM
Mechanism : Majority are caused by penetrating
injury, although occasionally the rectum may be
damaged following fracture of the pelvis.
Diagnosis :
DRE/guaiac : Suspicion increased by blood in stool
or palpation of defect or foreign body on exam.
Rigid protoscopy : May be done in OR if needed;
mandatory for patients with known trajectory of knife
or gunshot wound across pelvis or transanal; if
patients unstable, maybe delayed until after
resuscitation.
X-ray to look for missiles or foreign bodies.
Treatment :
Diversion via colostomy is key.
Extraperitoneal injuries must be
diverted via colostomy but many
needs to be repaired (if not too big and
not easily accessible).
Colostomy may be closed in 3-4
months.
ANUS
Reconstruct sphincter as soon
as patient is stabilized.
Divert with sigmoid
colostomy
DAMAGE CONTROL
SURGERY(DCS)
DEFINITION:
STAGES
I
Patient selection
II
III
IV
Definitive surgery
Abdominal closure
ENVIRONMENTAL
- Operating time >60 min
- Inability to approximate the abdominal incision
- Desire to reassess the intraabdominal contents (directed
relook)
ABDOMINAL COMPARTMENT
SYNDROME
Definition:
-organ dysfunction caused by intraabdominal hypertension (e.g falling
renal perfusion, respiratory insufficiency) ;
major cause of morbidity and mortality
in critically ill patient.
-sustained elevation above 35 mmHg.
-operative decompression is always
indicated.
Thank you