Abdominal Trauma

Cindy Kin

Trauma Conference
8 January 2007

Stanford General Surgery

 Blunt Abdominal Trauma

Mechanisms
Direct impact
Acceleration-deceleration forces
Shearing forces

No correlation between size of contact area

and resultant injuries.
Abdomen = potential site of major blood
loss.
 Initial Evaluation and Treatment

Is there a surgical intraabdominal injury?

PE: guarding, peritoneal signs, tenderness, nausea. DRE.

Lower rib fxs: 10-20% a/w spleen/liver injury
Seatbelt sign a/w intestinal injury and mesenteric tears.
Direct blunt trauma: rupture/tear of solid organs.
Flank pain or contusion often late signs of retroperitoneal bleed

Rapid resuscitation
CXR, Pelvic X-ray
FAST v DPL v CT
Labs: Hct, WBC, amylase, UA, ABG, T+C
 Blunt Abdominal Trauma

INDICATIONS for CT
Blunt trauma with closed head injury
Blunt trauma with spinal cord injury
Gross hematuria
Pelvic fx, +/- suspected bleeding
Pt requiring serial exams, but will be lost to PE for prolonged
period (ie orthopedic procedures, general anesthesia)
Pts with dulled or altered sensorium

CONTRAINDICATIONS: unstable patients

 Blunt Abdominal Trauma

CT FAST DPL
Accuracy 96% 95-99% 95%
Sensitivity 97% 90-92% 100%
Specificity 95% 88-90% 85%
Drawbacks Stable pts Cannot evaluate retroperitoneum.
only Cannot identify source of fluid.
0.5% miss intestinal
perforation; cannot
distinguish blood v
bowel contents
 Blunt Abdominal Trauma
INDICATIONS FOR LAPAROTOMY
Shock with
expanding abdomen,
pnemoperitoneum,
retroperitoneal air
Peritoneal signs,
HD unstable,
sepsis
Stable w/
peritoneal signs +

Imaging: equivocal Observe,

CXR +/- re-image
FAST/DPL/CT
 Blunt Abdominal Trauma

ROLE OF DIAGNOSTIC LAPAROSCOPY

Hemodynamically stable patients
Inadequate/equivocal FAST or borderline DPL (80K-
120K RBC/HPF)
Intermittent mild hypotension or persistent
tachycardia
Persistent abdominal signs/symptoms
Potential to decrease # of nontherapeutic
laparotomies
 Blunt Abdominal Trauma

PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME ON FAST

EXAM

Hemoperitoneum score on ultrasound a better predictor of need for

therapeutic laparotomy than admission blood pressure and/or base
deficit.
Hemoperitoneum characterized by measurement and distribution,
scored
Ultrasound score >=3 statistically more accurate than combination of
SBP and base deficit in determining which patient will undergo a
therapeutic abdominal operation
83% sensitivity, 87% specificity, 85% accuracy
McKenney et al, J Trauma 50:650-656, 2001
 Blunt Abdominal Trauma

HEPATIC AND SPLENIC INJURIES

Unstable patients: mandatory laparotomy
Stable patients: selective nonoperative approach
Hepatic injury
-Usually venous bleeding
-Grade I-III: 94% success w/ nonop treatment
-Grade IV-V: 20% amenable to nonop tx
-HD stability, stable Hct, observation
-Complications: delayed hemorrhage, bile
leak, biloma, intra/peri hepatic abscess.
-If stable with ongoing bleeding - angiographic
embolization
 Blunt Abdominal Trauma

SPLENIC INJURIES
Often arterial hemorrhage, therefore nonoperative
management less successful.

Predictive factors for nonop success:

Localized trauma to flank/abdomen
Age<60
No associated trauma precluding obs
Transfusion <4u prbcs
Grade I-III

Grade IV-V: almost invariably require operative intervention

Delayed hemorrhage (hours to weeks post-injury): 8-21%
 Blunt Abdominal Trauma

RETROPERITONEAL HEMORRHAGE
Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx,
retroperitoneal bowel.
Minimal signs on examination; flank pain and contusion are late findings
FAST/DPL negative; CT can identify
 Blunt Abdominal Trauma
DUODENAL AND PANCREATIC INJURY
Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal
air on plain abdominal films.
DPL unreliable.
At laparotomy, central upper abdominal retroperitoneal hematoma, bile
staining, or air: mandates visualization and examination of panc/duo

Duodenal injury:
80% lacs (G I-III) - primary repair
10-15% RYDJ, pyloric exclusion, Whipple
Pancreatic injury
Late complications: time from injury to tx
Abscess, pseudocyst, fistula.
 Blunt Abdominal Trauma

DIAPHRAGMATIC RUPTURE
3-5% of all abdominal injuries, L>R
May p/w few signs, need high index of suspicion
Injury mechanism: compartment intrusion, deformity of steering wheel, need
for extrication, fall from great height
Prominence/immobility of L hemithorax
NGT in chest, bowel sounds in thorax
CXR: (50% with non-dx initial CXR):
Obliteration of L diaphragm on CXR
Elevation/irregularity of costophrenic angle
Pleural effusion
Confirm with GI contrast studies, dx laparoscopy
Ex-lap and repair
 Blunt Abdominal Trauma

SMALL BOWEL INJURY

Mechanism: rapid deceleration with compression, shearing

Often at points of fixation: Treitz, ileocecal valve, prior adhesions,
mesentery.
Chance fracture (transverse fx of lower thoracic/lumbar vertebral body)
raises index of suspicion for SB injury
Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs
absent until 6-12h post-injury.
Delayed perforation: due to direct injury, transmural contusion, ischemia
from mesenteric vascular injury; usually presents w/in days.
 Blunt Abdominal Trauma

INJURY TO COLON AND RECTUM

Mechanism: rapid deceleration with steering wheel compression

uncommon
Disruptions of colonic wall or avulsion injury of mesentery
Present with hemoperitoneum, peritonitis.
 Penetrating Abdominal Trauma

Evaluation
Any penetrating wound
between nipples and gluteal
crease = potential intra-
abdominal injury.

Stab wounds: stratify based

on location
GSW: higher potential for
serious injury.
 Penetrating Abdominal Trauma

Evaluation of Stab Wounds

Local exploration FAST
DPL Limited, high false
5cc gross blood on aspiration
negative rate
>20K RBC/mm3
>500 WBC/mm3 Useful for pericardial
>175U amylase/100mL injuries
Bacteria Diagnostic laparoscopy
Bile, Food particles
Useful for assessing
CT peritoneal penetration,
Limited ability to dx hollow organ diaphragm injury
injury
Shorter LOS than
Useful for posterior SW
negative laparotomy
 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest
Flank

Anterior Abdominal
Back

Peristernal Potential Mediastinal

 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest
Flank

Anterior Abdominal Explore locally, manage

expectantly with serial PE
Back

Peristernal Potential Mediastinal

 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest Flank

explore locally
triple contrast CT

Anterior Abdominal Explore locally, manage

expectantly with serial PE
Back

Peristernal Potential Mediastinal

 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest Flank

explore locally
triple contrast CT

Anterior Abdominal Explore locally, manage

expectantly with serial PE Back
admit for obs

Peristernal Potential Mediastinal

 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest
?Thoracoscopy,
Laparoscopy Flank
explore locally
triple contrast CT

Anterior Abdominal Explore locally, manage

expectantly with serial PE Back
admit for obs

Peristernal Potential Mediastinal

 Penetrating Abdominal Trauma

Stab Wounds: Stratification by loci

Lower Chest
?Thoracoscopy,
Laparoscopy Flank
explore locally
triple contrast CT

Anterior Abdominal Explore locally, manage

expectantly with serial PE Back
admit for obs

Peristernal Potential Mediastinal

CVP monitor, U/S
Observe >6h, repeat CXR
 Penetrating Abdominal Trauma
Gunshot Wounds
Usually require urgent exploration
Evaluation for peritoneal penetration v tangential GSW.
CT, diagnostic laparoscopy
Use of DPL controversial due to high false negative rate
Ballistics:
Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles
Permanent and temporary cavities: Yaw, Bullet size and type
Shotgun:
Short range: high-velocity and more concentrated
Distant range: multiple low-velocity projectiles, more diffuse, less severe

Antibiotics: cefotetan or cefoxitin in ED

 Penetrating Abdominal Trauma

ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING

GSW AND NEED FOR LAPAROTOMY

66 GSW underwent DL, 2/3 of GSW in upper torso

Peritoneal penetration ruled out in 62%
29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap,
4% had negative ex-lap
Hospital stay:
4.3 days - negative DL and associated injuries
8.6 days - laparotomy
1.1 days - negative DL and no associated injuries.

Fabian et al, Ann Surg 1993; 217:557

 Penetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
NEGATIVE LAPAROTOMY RATE

Retrospective review 817 pts who underwent ex-lap for abdominal GSW
over 4yr: negative ex-lap rate = 12.4%
22% morbidity, LOS 5.1days
Review of 85 pts with abdominal GSW evaluated with DL
Negative DL in 65%, no missed injuries, no subsequent need for ex-lap;
3% morbidity rate (one pt had urinary retention), LOS 1.4days
Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and
14% nontherapeutic (remaining 2 were observed for nonbleeding liver
lacs)

Sosa et al. J Trauma 1995;38(2):194

 Penetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
NEGATIVE LAPAROTOMY RATE

Prospective study of 121 patients with tangential GSW, HD stable

65% negative DL
Of 25% positive DL, 92.8% (39) underwent ex-lap
82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative
No false negative DLs, no delayed laparotomies
Sensitivity for peritoneal penetration 100%

Sosa et al. J Trauma 1995;39(3):501