Case Presentation

Dr. Muhammad Ali

PGR SU II
GHURKI TRUST
TEACHING HOSPITAL
My patient Zulfiqar Rafique 35 years, Driver by
occupation, resident of Harbanspura Lahore
came to Emergency on 23rd march 2016 with
the chief complain of

• Blunt Trauma Abdomen one hour before

• Severe Abdominal pain from half hour
• Vomiting from half hour
 According to the patient he was in his usual
state of health when he got hit by a buffalo in a
street while passing and brought to the
emergency of GHURKI hospital….

He developed generalized, acute, severe

colicky abdominal pain associated with vomiting
2,3 episodes containing food particles but not
blood or Bile.
There was no history of altered sensorium, nose
or ear bleed, headache or blurred vision.
O/E :
• Abdomen was soft, non tender
• Minimal tenderness in Rt Hepato renal area
• Gut sounds audible
• Large bruise on affected area of back

Rest of examination was unremarkable

 On Presentation Vitals were
• Pulse 120/min
• BP 110/70
• Temp: 98F
• R/R 28/min

Patient was shifted to ICU for resuscitation and

Labs sent.
TLC 29.1 Neutrophils 80 % U/C 26 : 1
N/G 200 ml U/output 550 ml Hep B,C negative
U/S Abdomen showed moderate amount of free
fluid in Morrison’s pouch.
CT scan abdomen and pelvis with oral and IV
contrast done but report was awaited.

Mean while patient was becoming more toxic

and heamodynamically unstable.
Shifted to General O.T and Exploratory
Laparotomy was done.
Findings and Procedure
• Descending colon mesentery was shattered
• There was heamoperitoneum app: 2 liter
• App: 10-13 cm of descending colon was
devitalized

• Devitalized colon resected and double barrel

Colostomy was made.
• Up to 5th POD of Exploratory Laparotomy patient
was stable and his condition was improving but
on POD 6th and 7th his Abdominal pain and
Distention was gradually increasing with
hemodynamic instability and Pyrexia.

• Labs sent on urgent basis and patient

resuscitated and shifted to G.O.T for Re-
Exploratory Laparotomy on 30th march 2017.

• TLC 26.1 Neutrophils 80 %

Findings and Procedure

• Necrotic/Gangrenous gut 4 inches proximal

to previous stoma.
• App: 300 ml of pus.
• Mesentery adherent to Transverse colon.

• Descending colon margins were resected and

anastomosed, Loop ileostomy was made.
 Up to 4th POD patient was kept in ICU and
managed and after that he was shifted to male
surgical ward for further management.

On 7th POD of Re-Exploratory laparotomy and

ileostomy on 6th April 2017 patient was
discharged, sent home and advised for scheduled
follow ups.
• His colostomy wound got infected and
debridement of wound done under L/A 3 times
after which wound become healthy and then
healed..

• On 23rd May 2017 patient presented for

Ileostomy reversal
• His general health was satisfactory and
ileostomy was functional.
• CBC, S/albumin and Distal loopogram was
advised.
• TLC 8.3 Neutrophils 40%
• S/Albumin 4.2g/dl U/S abdomen Normal
• Distal loopogram normal

• Patient scheduled for ileostomy reversal on 31st

May 2017 and Ileostomy reversed and abdomen
closed while ileostomy wound skin and subcut:
tissue kept open for proper wound wash and
daily dressing to prevent wound infection.
• Today is 5th POD of Ileostomy reversal.
• Patient is stable.
• Abdomen soft non-tender.
• B/S present.
• Wound clean.
• Dressing dry and intact.
• N/G output 650 ml in last 4 days, no Blood or Bile.
• Catheter out and patient is mobilized.
• Passed flatus and stool.
• Plan
• Allow Oral sips.
Literature Review

Blunt Trauma
Abdomen
 Scheme of presentation
• Regional anatomy of abdomen
• Mechanism of injury
• Initial management
• Examination
• Investigations
• Laparotomy
– Indications
– Approach
• Management of specific injuries
• Abdominal Compartment Syndrome
15
Regions of abdomen
• Anterior Abdomen

• Superiorly – b/w costal margins

• Inferiorly – Inguinal ligament &

pubic symphysis

• Laterally – Ant axillary lines

• Majority hollow viscera may be

involved

16
Regions of abdomen
• Thoraco Abdomen
• Inferior to
– Anteriorly: Trans-nipple line
– Posteriorly: Infra-scapular
line
• Includes
– Diaphragm, Liver, Spleen &
Stomach
• Full expiration  diaphragm rises
to 4th ICS  Abdo viscera may be
injured by penetrating wounds/ #
lower ribs
17
Regions of abdomen
• Flank

• Anteriorly – Ant axillary line

• Posteriorly – Post axillary line

• Superiorly – 6th ICS

• Inferiorly – Iliac crest

• Thick musculature – partial barrier

to penetrating wounds
18
Regions of abdomen
• Back

• Posterior to posterior axillary line

• From – tip of scapulae

• To – Iliac crest

19
20
Regions of abdomen
• Pelvis

• Lower part of retroperitoneal and

intraperitoneal spaces

• Rectum, bladder, iliac vessels,

internal reproductive organs
(females)

21
 Stats
• MVAs responsible for 75% of all blunt abdominal trauma

• Multi-organ & multi-system injury

• Solid organ injury >> Hollow viscus injury

• Spleen (40-55%) > Liver (35-45%) > Small bowel (5-10%)

• Retroperitoneal hematoma (15% laparotomies)

22
 Mechanism of injury
• CRUSHING

Direct application of a blunt force to the abdomen

• SHEARING

Sudden decelerations apply a shearing force across

organs with fixed attachments
• BURSTING

Raised intraluminal pressure by abdominal compression

in hollow organs can lead to rupture
• PENETRATION

Disruption of bony areas by blunt trauma may generate

bony spicules that can cause secondary penetrating
injury 24
 Standard initial protocol
• Spinal stabilization

• Maintenance of ABC

• IV access (double) and IV fluids

• Draw and send blood for investigations, blood grouping

• NG tube insertion

• Urinary catheterization
25
 History
• Mode of injury (MVA/ direct blow/ fall from height)

• Type of veh & speed

• Type of collision (frontal/ lateral/ side/ rear/ rollover)

• Response to pre-hospital treatment (by trauma care

personnel)

• Explosion – visceral overpressure injuries (more in closed

spaces and less distance of patient from explosion)
26
 Physical Examination:
Inspection
• Fully unclothe the patient

• Whole body thorough inspection

• abrasions, contusions from restraint devices, lacerations,

penetrating wounds, impaled foreign bodies, evisceration of
omentum or small bowel, and the pregnant state

• Flank, scrotum & perianal area – blood @ meatus, swelling,

bruising, laceration of perineum, vagina, rectum or buttocks
(s/o open pelvic #)
The classical
‘seatbelt’ sign. The
bruising on the left
chest wall is from the
shoulder belt and the
low bruising to the
abdominal wall is
from the lap belt.
28
Cullen’s Sign:
Bluish discoloration
around umbilicus

Diffusion of blood along

periumbilical tissues or
falciform ligament
Hemoperitoneum
Severe pancreatitis
Grey-Turner’s Sign:
Bluish discoloration of the
flanks
• Retroperitoneal Hematoma
• Hemorrhagic pancreatitis.

Kehr’s sign:
Referred pain, Right shoulder
irritation of the diaphragm
• Splenic injury
• free air
• intra-abdominal bleeding
Balance’s Sign
Dullness on percussion of the
left upper quadrant
• Ruptured spleen

Labia andScrotum
• Pooling of blood from
abdominal and pelvic
cavities.
 Physical Examination:
Palpation & Percussion
• Tenderness (Superficial/ deep)

• Rebound tenderness

• Guarding (Voluntary/ involuntary), rigidity

• Dullness/ shifting dullness – intraabdominal

collection

32
 Physical Examination:
Auscultation
• Difficult in a noisy room

• Bowel Sounds +/-

• Reliable only when initially present and change

later

• Absence of bowel sounds – non-specific

33
 Pelvic Stability Testing
• Pelvic hemorrhage occurs rapidly - Unexplained hypotension

• Compression-distraction maneuver

• Perform only once; may result in further hemorrhage

• Ruptured urethra (high riding prostate, scrotal hematoma, blood

@ meatus)

• Limb lengthening discrepancy

• Rotational leg deformity without e/o fracture

34
 Others
• Vaginal examination
– In presence of complex perineal lacerations/ pelvic # or trans-
pelvic GSW

– Vaginal laceration may be seen due to pelvic # or penetrating

wounds

• Gluteal examination
– From iliac crest to gluteal folds
– Penetrating injuries – rectal injuries below peritoneal reflection
– GSWs & stab wounds – associated with intra-abdominal injuries

35
• NG tube
– Relieve acute gastric dilatation
– Decompress stomach before a DPL
– Remove gastric contents
– Blood in NG  Esophageal/ upper GIT injury (after
excluding naso/ oro-pharyngeal sources)

• Urinary catheter (or SPC)

– Relieve retention
– Decompress bladder before DPL
– Monitor UO as indicator of tissue perfusion
– Gross hematuria  trauma to genitourinary tract &
non renal intraabdominal organs
36
 DIAGNOSTIC STRATEGY

INVESTIGATIONS –
Aim

To identify To decide When

(those with injury) (which ones (how quickly
need laparotomy) this must be
undertaken)
 DIAGNOSTIC STRATEGY
cont..
• Complete hemogram with hematocrit

• ABG, Electrocardiogram

• Renal function tests

• Urine analysis –
+nce of hematuria – genitourinary injury
-nce of hematuria – does not rule out it

• Serum amylase / lipase or liver enzymes - se -suspicion of

intraabdominal injuries
 Imaging studies
• Abdominal X-ray

• FAST

• DPL

• CT Scan

• Contrast studies
39
 Abdominal X-ray
• Pneumoperitoneum – hollow viscus perforation

• Ground glass appearance – massive haemoperitoneum

• Dilated gut loops- retroperitoneal hematoma/ injury

• Retroperitoneal air outlining the right kidney – duodenal injury

• Double wall sign – air inside and outside the bowel

• Distortion or enlargement of outlines of viscera – hematoma in

relation to respective organs
40
 Abdominal X-ray
• Medial displacement of stomach – splenic hematoma

• Obliteration of Psoas shadow – retroperitoneal bleeding

• Pelvic bone fracture – bladder/urethral/rectal injury

• Fracture vertebra – ureter injury / retroperitoneal

hematoma

41
 Chest X-ray
• Pneumothorax/haemothorax

• Raised left/right hemidiaphragm – perisplenic/hepatic

hematoma

• Lower ribs fracture – liver/spleen injury

• Abdominal contents in the chest – ruptured

hemidiaphragm

42
Indications for further investigating
• Unexplained hemorrhagic shock

• Major chest or pelvic injuries

• Abdominal tenderness

• Diminished pain response due to

– Intoxication
– Depressed level of consciousness
– Distracting pain
– Paralysis

• Inability to perform serial examination 43

 FAST
(Focused Assessment Sonography in Trauma)

• Views
– Pericardial view (Subxiphoid/ parasternal view)
– Perihepatic view - diaphragm-liver interface and
Morrison’s pouch
– Perisplenic view - diaphragm-spleen interface and
spleen-kidney interface
– Pelvic view (Transverse; before inserting Foley's)

44
 FAST
• Rapid , Accurate
• Sensitivity 86- 99%
• Eliminates unnecessary CT scans
• Helps in management plan
• Cost effective
• FAST can detect between 100-250ml
• 0.5 cm in Morison's Pouch = 500ml
• 1 cm in Morison's Pouch = 1000ml

• CT can detect volumes of free fluid as low as 100ml

• Negative FAST doesn’t rule out intra-abdominal injury

• Difficult in subcutaneous emphysema, obese and previously operated
pts
• Pelvic # may decrease the accuracy 45
 The perihepatic scan
The hepatorenal
space (pouch of
Morison)
most dependent
part of the upper
peritoneal cavity
The probe is placed
in the right mid- to
posterior axillary
line at the level of
the 12th ribs.
The Perihepatic scan
 Perisplenic window
• Transducer positioned in
left posterior axillary line
between 10th and 11th ribs
with beam in coronal
plane.
• Demonstrates spleen,
kidney and diaphragm
• May be marred by acoustic
shadows from ribs
• May be improved by
imaging patient whilst in
full inspiration.
Abnormal Perisplenic window
 The pelvic scan
The pelvic examination
visualises the cul-de-sac:
the Pouch of Douglas in
females and the
rectovesical pouch in the
male
Most dependent portion of
the lower abdomen and
pelvis, where fluid will
collect
The transducer is placed
midline just superior to the
symphysis pubis
 The pericardial scan
• The pericardial
examination screens for
fluid between the
fibrous pericardium and
the heart
• The transducer is placed
just to the left of the
xiphisternum and
angled upwards under
the costal margin.
 DPL
(Diagnostic Peritoneal Lavage)

• Rapid & Accurate test used to identify intra-

abdominal injuries
• Predictive value of greater than 90%
• The RBC count for lavage fluid is > 1,00,000/cu m.m.
• A WBC count > 500/cu m.m.
• Test is highly sensitive to presence of
intraperitoneal blood .
 DPL
• Indications
– Patients with spinal cord injury
– Those with multiple injuries and unexplained shock
– Obtunded patients with a possible abdominal injury
– Intoxicated patients in whom abdominal injury is
suspected
– Patients with potential intraabdominal injury who
will undergo prolonged anesthesia for another
procedure

54
 DPL
• Open, semi-open or closed method

• Gross blood aspirated – go for Laparotomy

• No gross blood – instill 1 lit of warm NS (child –

10ml/kg) – gently agitate the abdomen

• Adequate fluid return is > 20% of infused volume

• Negative lavage doesn’t exclude retroperitoneal

injuries e.g. pancreatic or duodenal injuries
57
58
 DPL
• Absolute contraindication = obvious need for laparotomy
• Relative contraindications
– Pregnancy
– Morbid obesity
– H/o multiple abdominal surgeries
• Positive if
– 10 ml grossly bloody aspirate before infusing
lavage fluid
– >100,000/μL RBCs; >500 /μL WBCs;
– Only 30mL blood reqd to produce
microscopically positive DPL result
– ↑ amylase, bile, bacteria, vegetable matter or
urine + 59
 DPL
• Complications
• Hemorrhage (false positive results)
– secondary to injection of local anesthetic
– Incision of the skin or subcutaneous tissues
• Peritonitis due to intestinal perforation from the
catheter
• Laceration of urinary bladder (if bladder full)
• Injury to other abdominal and retroperitoneal
structures requiring operative care
• Wound infection at the lavage site (late
complication)
60
 Abdominal CT Scan
• Hemodynamically stable patient
• Not in emergent need of laparotomy
• ± Contrast administration (non-ionic contrast)
• Organ injury & extent
• Retroperitoneal/ pelvic organ injuries
• Can miss some GI, diaphragmatic and pancreatic
injuries
• Free fluid with no hepatic/ splenic injury 
suspect GI or mesenteric trauma

61
 Contrast studies
• Urethrography

• Cystography

• IVP

• GI Contrast studies

62
THE BIG QUESTION:
WHICH PATIENTS NEED LAPAROTOMY ?

63
 Answer
• Blunt abdominal trauma with hypotension with a
positive FAST or clinical evidence of intraperitoneal
bleeding

• Blunt or penetrating abdominal trauma with a

positive DPL

• Hypotension with a penetrating abdominal wound

• Gunshot wounds traversing the peritoneal cavity or

visceral/vascular retroperitoneum
64
 Answer
• Bleeding from the stomach, rectum, or genitourinary
tract from penetrating trauma

• Peritonitis

• Free air, retroperitoneal air, or rupture of the

hemidiaphragm

• CECT findings of ruptured GIT, intraperitoneal bladder

injury, renal pedicle injury, or severe visceral
parenchymal injury after blunt or penetrating trauma
65
 LAPAROTOMY
• Generous midline incision
• Transverse incision in children < 6 yrs
• Scalpel better than cautery.
• Forget the bleeding from incision till definite source of
bleed found
• Remove blood and blood clots with abdominal swabs
• Palpate spleen and liver first and pack if fractured
• Source localized  direct digital occlusion (vascular
injury) or pad packing (solid organ injury)
• Liver bleed – hepatic pedicle clamping with vascular
clamp (Pringle maneuver)
66
 LAPAROTOMY
• Splenic bleed – clamp splenic hilum (better than
packing alone)

• Rotate spleen medially

• Incise lateral peritoneum & endoabdominal fascia
• Spleen and pancreas can be dissected from
retroperitoneum as a composite , ant: to Gerota’s
fascia

67
Liver bleed control

68
Splenic mobilization

69
MANAGEMENT

SPECIFIC INJURIES

70
Liver trauma

71
 Liver trauma
• Primary aim is to arrest bleeding
• Perihepatic packing is effective most of the times, if not
then perform Pringle maneuver
• Difficult to perform perihepatic packing in Lt lobe 
Mobilize it and compress between surgeon’s hands
• Pringle maneuver
– Bleeding stopped => from AHA / PV
– Doesn’t stop => HVs and retrohepatic IVC is the
source  Packing  Failed  direct vascular repair ±
hepatic vascular isolation
• Repair the Hepatic artery proper
• Cholecystectomy if Rt hepatic artery is ligated 85
 Liver trauma
• Minor lacerations
– Manual compression
– Topical hemostats (cautery, argon beam coagulator,
gelfoam, fibrin glue, collagen)
• Shallow lacerations  running suture
• Deep lacerations
– Interrupted Hz mattress parallel to edge of laceration
– Omentum to fill large defects (obliterates dead
space; source of macrophages)
• Deep recalcitrant hemorrhage  hepatic lobar arterial
ligation
86
 Liver trauma
• Repeat laparotomy within 24 hrs for pack removal
• Ongoing hemorrhage – early exploration (<24h h)
• Complex injuries – angioembolization
• Complex injuries – typical ‘liver fever’ upto 5 days post
injury
• Non-anatomical resection – stable without
coagulopathy
• GB injury  cholecystectomy
• EHBD Transaction  Roux-en-Y choledochojejunostomy
• Till then intubate the duct for external drainage
• Complications – hemorrhage, hepatic necrosis, bilomas,
arterial pseudoaneurysms and biliary fistulas 87
 Liver trauma - NOM
• Basis
– 50-80% of liver bleed stops spontaneously
– Better results of NOM in children
– Significant development of CT scan in liver imaging
• Initially introduced for minor injuries (1972)
• Presently being used for grades III – V also
• Selection criteria
– Hemodynamic stability after initial resuscitation
– No other visceral/ retroperitoneal injuries needing
surg
– Multidisciplinary team – Experienced surgeon,
Intensivist, CT scan, 24x7 OT facilities 88
 Liver trauma - NOM
• Failure rate significantly higher in Gd IV & V than Gd I-
III
• Most common reason for intervention – co-existing
abdo injury (e.g. bleed form spleen or kidney)
• Predictors of NOM failure
– Advanced age
– Anaemia & HTN
– Active extravasation on CT
– Massive blood transfusion
• CT follow up for Gd I & II not necessary
• Others need clinical and CT follow up 89
Splenic trauma

90
 Splenic trauma
• Management options
– Observation
– Angiographic Embolization (Gd I-III; age < 55y)
– Surgery (Splenectomy/ partial splenectomy/
splenorrhaphy)
• Depending upon
– Hemodynamic status of pt
– Grade of injury
– Presence of other injuries
– Medical co-morbidities
• Upto 20% patients require early splenectomy
• Delayed hemorrhage/ rupture can occur weeks after injury105
 Splenic trauma
• Splenectomy (with auto-transplantation)
– Hilar injuries
– Pulverized splenic parenchyma
– GD III and above + coagulopathy/ multiple injuries
• Partial splenectomy – isolated polar injuries
• Splenorrhaphy – cautery, argon beam coagulator,
gelfoam, fibrin glue, collagen, envelopment in
absorbable mesh, pledgeted suture repair

• Bleeding edges – Hz mattress sutures + parenchymal

compression 106
Splenic Auto-transplantation

107
Splenic Bleeding Edges

108
 Splenic trauma
• Post splenectomy hemorrhage
– Loosening of tie around splenic vessels
– Improperly ligated/ missed short gastric artery
– Recurrent splenic bleed
• Post-op complications
– Subphrenic abscess (pigtail drainage)
– Pancreatic tail injury (Iatrogenic)
– Gastric perforation (during short gastric ligation)
– OPSI

109
 Splenic trauma - NOM
• Basis
– Salvaging functional splenic tissue – avoids surgical &
anesthetic complications
– No risk of post-splenectomy abscess
• Indications
– Hemodynamically stable patients (Gd I - III)
– No other intra-abdominal injuries needing laparotomy
– Active contrast extravasation/ blush on CT
• > 70 % patients still undergo splenectomy after NOM
• Higher failure rates of NOM with increasing grades of
severity
110
 Splenic trauma – NOM
• Absolute bed rest & NPO
• 6 hrly Hb check in first 24h
• Allowed orally if Hb stable & no surg intervention likely
• Follow-up CT: Falling Hb, abdo pain, fever, Lt shoulder
pain
• Duration based on
– Gd of splenic injury
– Nature & severity of other injuries
– Clinical Status (Incl peritoneal signs – missed hollow
viscus injury & Hb levels)
• Embolization – 73-97% success rate 111
 Stomach & Small Intestine
• Gastric Wounds – running single layer suture (full
thickness bites)/ stapler
• Partial gastrectomy – for destructive injuries
• Small intestine injury < 1/3rd of bowel circumference 
transverse running 3-0 PDS
• Multiple injuries/ mesenteric injuries – segmental
resection and anastomosis/ stoma
• Post-op ileus is obligatory
• No enteral feeds for atleast 48 hrs
• TEN to be started at 20mL/h once resuscitation is
complete 112
 Duodenum
• Duodenal hematoma – NG aspiration & parenteral
nutrition
• Small duodenal perforation/ laceration – primary single
layer repair
• 1st part injuries – debridement & end-to end
anastomosis with gastric antrum/ pylorus
• 2nd part injuries – patch with vascularized jejunal graft
• 3rd & 4th part injuries – resection and anastomosis on Lt
side of Superior mesenteric vessels
• Pyloric exclusion – high risk, complex duodenal repairs

113
 Pancreas
• Management depends on location of injury to
– Parenchyma
– Intrapancreatic CBD
– MPD
• Contusion (ductal system intact)/ proximal pancreatic
injuries (to Rt of SM vessels)
– Non operative/ closed suction drain
• Distal duct disruption (body & tail) – distal
pancreatectomy with splenic preservation
• Injury to Head with duct injury – distal duct ligation with
Roux-en-Y choledochojejunostomy 114
 Colon & Rectum
• 3 methods for colonic injuries
– Primary repair
– End colostomy
– Primary repair with diverting colostomy
• Weigh the risk of primary repair Vs colostomy
• Lt colon injuries - Temporary colostomy
• Other high risk pts - Diverting ileostomy with colocolostomy
• Rectal injuries – loop ileostomy/ sigmoid loop colostomy
• Accessible rectal injury – attempt primary repair with diversion
• Extensive rectal injury – End colostomy (Hartmann’s)
• Complications: Intra-abdo abscess, fecal fistula, infection, stomal
complications
115
 Genitourinary Tract
• 90 % Renal injuries managed conservatively
• Hematuria resolves in few days with absolute rest
• Operative intervention – Hypotension due to
– Renovascular injuries
– Destructive parenchymal injuries
• Persistent gross hematuria – embolization
• Urinoma – Percutaneous drainage
• Renal artery repair
– Success rates very low
– Image guided endostent placement can be attempted
116
Grade 1 Subcapsular hematoma
Grade 2 perinephric hematoma
Grade 3 Injury to medulla
Grade 4 Infarction
Grade 5 Shattered Kidney
 Genitourinary Tract
• Renorrhaphy
– Take vascular control for proper visualization
– Preserve renal capsule
– Collecting system is closed separately with absorbable
sutures
– Preserved capsule is closed over collecting system repair
• Ureter injuries
– Primary repair with renal mobilization for tension relief
– Reimplantation (with psoas hitch) for distal ureter injuries
– Damage control – B/L ligation + Nephrostomy

123
Renorrhaphy

124
 Genitourinary Tract
• Bladder injuries
• Intraperitoneal injuries
– Running, single layer 3-0 absorbable monofilament
suture
– Lap repair – if other injuries not needing repair
• Extraperitoneal injuries
– NOM with bladder decompression for 2 wks

• Urethral injuries
– Bridge the defect with Foley’s
– Elective repair for strictures later 125
Vascular Injuries

126
 ABDOMINAL COMPARTMENT
SYNDROME
• Symptomatic organ dysfunction that results from
increased intraabdominal pressure (IAP)

• Increased IAP is an under-recognized source of

morbidity and mortality.

• 1-day point-prevalence observational trial conducted

in 13 medical ICUs of six countries with 97 patients,
8% had IAP > 20mmHg.

• The incidence of ACS in trauma patients is estimated

to be between 2 and 9 percent.
 ABDOMINAL COMPARTMENT
SYNDROME
ETIOLOGY

• Massive volume resuscitation in the leading

cause of ACS.

• Inflammatory states with capillary leak, fluid

sequestration, inadequate tissue perfusion, and
lactic acidosis can develop ACS.

• Gastric overdistention following endoscopy has

resulted in ACS.
 ABDOMINAL COMPARTMENT
SYNDROME
PATHOPHYSIOLOGY
• The IAP is usually 0 mmHg during spontaneous respiration
• Slightly positive in the patient on mechanical ventilation
• IAP increases in direct relation to body mass index.
• Supine hospitalized patients had a mean baseline value of
6.5 mmHg.
• The compliance of the abdominal wall limits the rise in IAP
but increases rapidly after a critical IAP
• Critical IAP varies from patient to patient, based on
abdominal wall compliance on perfusion gradient
• IAH often defined as IAP > 12mmHg
• Previous pregnancy, cirrhosis, morbid obesity, may increase
abdominal wall compliance and can be protective
 ABDOMINAL COMPARTMENT
SYNDROME
CLINICAL MANIFESTATIONS
CENTRAL NERVOUS SYSTEM GASTROINTESTINAL
 Intracranial pressure  Celiac blood flow
 Cerebral perfusion pressure  SMA blood flow
CARDIAC  Mucosal blood flow
Hypovolemia  pHi
 Cardiac output RENAL
 Venous return  Urinary output
 PCWP and CVP  Renal blood flow
 SVR  GFR
PULMONARY HEPATIC
 Intrathoracic pressure  Portal blood flow
 Airway pressures  Mitochondrial function
 Compliance  Lactate clearance
 PaO2  PaCO2 ABDOMINAL WALL
 Shunt fraction  Compliance
 Vd/Vt  Rectus sheath blood flow
 ABDOMINAL COMPARTMENT
SYNDROME
• 50 mL of sterile saline is
instilled into the bladder
via the aspiration port of
the Foley catheter with
the drainage tube
clamped.
• An 18-gauge needle
attached to a pressure
transducer is then
inserted in the aspiration
port, and the pressure is
measured. The
transducer should be
zeroed at the level of the
pubic symphysis.
 MANAGEMENT
GRADING

Pressure
Grade Management
(mmHg)

I 10-15 Maintenance of normovolemia

II 16-25 Volume administration

III 26-35 Decompression

IV >35 Re-exploration
OPERATIVE DECOMPRESSION
Vacuum-assisted
temporary abdominal
closure device:

Thin plastic sheet, a

sterile towel, closed
suction drains, and a
large adherent
operative drape. This
dressing system
permits increases in
intra-abdominal
volume, without a
dramatic elevation in
IAP.
 SUMMARY
• ACS is a clinical entity caused by an acute, progressive
increase in IAP.

• Multiple organ systems are affected, usually in a

graded fashion.

• The gut is the organ most sensitive to IAP.

• Treatment involves expedient decompression of the

abdomen.

• Pt already physiologically compromised  Keep high

degree of suspicion and a low threshold for checking
bladder pressures to prevent the associated mortality.
 References
• ATLS Manual 9th Ed

• Schwartz Principles of Surgery, 10th Ed

• Sabiston Textbook of Surgery, 20th Ed

• Manual of Trauma Surgery, Dept of Surgery,

AFMC, 2013

• Trauma, Moore, 6th Ed

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