Abdominal Injuries

ABDOMINAL INJURY
• Patients who have suffered abdominal trauma
can generally be classified into the following
categories 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.
• A trauma laparotomy is the final step in the pathway to
delineate intra-abdominal injury.
• Occasionally it is difficult to determine the source of
bleeding in the shocked, multiple injured patient.
• If doubt still exists, especially in the presence of other
injuries, a laparotomy may still be the safest option.
• The patient’s physiology must be assessed at regular
intervals and, if there is an indication that the patient is still
actively bleeding, then the source must be identified,
unless the patient is unstable, requiring immediate surgery.
• Blood loss into the abdomen can be subtle and there
may be no clear clinical signs.
• Blood is not an irritant and does not initially cause
any abdominal pain.
• Distension is subjective, and a drop in the blood
pressure may be a very late sign in a young fit patient.
• Examination in unstable patients should take place
either in the ED or in the operating theatre if the
patient is deteriorating rapidly.
 Investigation
• Investigations are driven by the cardiovascular
status of the patient.
• In torso trauma, the best and most sensitive
modality is a CT scan with intravenous contrast;
however, in the unstable patient, this is generally
not possible.
• In patients with penetrating injury, metal markers
(e.g. bent paper clips) should be placed on all
external wounds before plain films are taken,
• irrespective of the area being radiographed, as this
allows an assessment of the trajectory and helps to
correlate the number of holes and the number of
missiles that can be seen within the patient.
• This will help determine whether two holes are
indicative of one missile passing through the
patient, or two missiles, both retained internally.
• A single hole implies that the projectile has been
retained.
 Focused abdominal sonar for trauma and
extended FAST

• is a technique whereby US (sonar) imaging is used

to assess the torso for the presence of free fluid,
either in the abdominal cavity, and is extended
into the thoracic cavities and pericardium (eFAST).
• There should be no attempt to determine the
nature or extent of the specific injury.
• eFAST is usually a rapid, reproducible, portable
and non-invasive bedside test and can be
performed at the same time as resuscitation.
• eFAST is accurate at detecting >100 mL of free blood;
however, it is very operator dependent and, especially if the
patient is very obese or the bowel is full of gas, it may be
unreliable.
• Hollow viscus injury and solid organ injury are difficult to
diagnose, even in experienced hands, as small amounts of
gas or fluid are difficult to assess, and eFAST a low sensitivity
(29–35%) for organ injury without haemoperitoneum.
• eFAST is also unreliable for excluding injury in penetrating
trauma.
• If there is doubt, the eFAST examination can be repeated
 Diagnostic peritoneal lavage
• is a test used to assess the presence of blood or
contaminants in the abdomen.
• A gastric tube is placed to empty the stomach and a
urinary catheter is inserted to drain the bladder.
• A cannula is inserted below the umbilicus, directed
caudally and posteriorly.
• The cannula is aspirated for blood (>10 mL is deemed
as positive) and, following this, 1000 mL of warmed
Ringer’s lactate solution is allowed to run into the
abdomen and is then drained out via the same route.
• The presence of >100 000 red cells/μL or >500 white
cells/μL is deemed positive (this is equivalent to 20
mL of free blood in the abdominal cavity), as is the
presence of vegetable fibre or a raised amylase
level.
• In penetrating trauma, a minimum of one-tenth of
the above would be regarded as evidence of
peritoneal penetration or intraperitoneal injury. In
the absence of laboratory facilities, a urine dipstick
may be useful.
• Drainage of lavage fluid via a chest drain
indicates penetration of the diaphragm.
• Although DPL has largely been replaced by
eFAST, it remains the standard in many
institutions where eFAST is not available or is
unreliable. DPL is especially useful in the
hypotensive, unstable patient with multiple
injuries as a means of excluding intra-
abdominal bleeding.
 Computed tomography scan
• has become the ‘gold standard’ for the intra-
abdominal diagnosis of injury in the stable
patient.
• The scan can be performed using intravenous
contrast.
• CT is sensitive for blood and individual organ
injury, as well as for retroperitoneal injury.
• An entirely normal abdominal CT is usually
sufficient to exclude intraperitoneal injury.
• The following points are important when
performing CT:
●● it remains an inappropriate investigation for
unstable patients;
●● if duodenal injury is suspected from the
mechanism of injury, oral contrast may be helpful;
●● if rectal and distal colonic injury is suspected in
the absence of blood on rectal examination, rectal
contrast may be helpful.
 Laparoscopy
• Laparoscopy or thoracoscopy may be a valuable
screening investigation in stable patients with
penetrating trauma, to detect or exclude peritoneal
penetration and/or diaphragmatic injury.
• may be divided into:
●● Screening: used to exclude a penetrating injury
with breach of the peritoneum.
●● Diagnostic: finding evidence of injury to viscera.
●● Therapeutic: used to repair the injury
• In most institutions, evidence of penetration
requires a laparotomy to evaluate organ
injury, as it is difficult to exclude all intra-
abdominal injuries laparoscopically.
• When used in this role laparoscopy reduces
the non-therapeutic laparotomy rate.
• There is no place for laparoscopy in the
unstable patient.
 INDIVIDUAL ORGAN INJURY
Liver

• Blunt liver trauma occurs as a result of direct

injury.
• The liver is a solid organ and compressive forces
can easily burst the liver substance
• The liver is usually compressed between the
impacting object and the rib cage or vertebral
column.
• Most injuries are relatively minor and can be
managed non-operatively.
 n the stable patient, CT is the investigation of choice.
It provides information on the liver injury itself
Liver injury can be graded and managed using the American
Association for the Surgery of Trauma (AAST) Organ
njury Scale (OIS
Bleeding points should be controlled locally when possible,and such patients if required,
subsequently undergo subsequent
angioembolisation
 Management
• The operative management of liver injuries
can be summarised as ‘the four Ps’:
• ●● push;
• ●● Pringle;
• ●● plug;
• ●● pack.
• At laparotomy the liver is reconstituted and
bleeding is controlled by direct bimanual
compression to achieve its normal
architecture as best as possible (push).
• The inflow from the portal triad is
controlled by a Pringle’s manoeuvre, with
direct compression of the portal triad,
either digitally or using a soft clamp
 Biliary injuries

• Isolated traumatic biliary injuries are rare and

occur mainly from penetrating trauma, often
in association with injuries to other structures
that lie in close proximity.
• The CBD can be repaired over a T-tube or
drained and referred to appropriate care as
part of damage control, or even ligated.
 Spleen

• occurs from direct blunt trauma.

• Most isolated splenic injuries, especially in children, can be
managed non-operatively.
• in adults, especially in the presence of other injury or
physiological instability, laparotomy should be considered.
• The spleen can be packed, repaired or placed in a mesh bag.
• Splenectomy may be a safer option, especially in the
unstable patient with multiple potential sites of bleeding.
• In certain situations, selective angioembolisation of the
spleen can play a role.
 Pancreas

• Most pancreatic injury occurs as a result of

blunt trauma.
• The major problem is that of diagnosis, because
the pancreas is a retroperitoneal organ.
• CT remains the mainstay of accurate diagnosis.
Amylase or lipase estimation is insensitive.
• In penetrating trauma, injury may only be
detected during laparotomy.
 Stomach

• Most stomach injuries are caused by

penetrating trauma. Blood presence is
diagnostic if found in the nasogastric 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.
 Duodenum

• Duodenal injury is frequently associated with injuries

to the adjoining pancreas.
• Like the pancreas, the duodenum lies retroperitoneally
and so injuries are hidden, discovered late or at
laparotomy performed for other reasons.
• CT is the diagnostic modality of choice.
• The only sign may be gas or a fluid collection in the
periduodenal tissue, and leakage of oral contrast,
administration of which may improve accuracy of
diagnosis
• Major trauma, especially if the head of the
pancreas is simultaneously injured, should be
treated as part of a damage control procedure
and be referred for definitive care.
• The second part of the duodenum is fixed to
the head of the pancreas with a common
blood supply, and may have a poorer blood
supply compared to the remainder
 Small bowel

• frequently injured as a result of blunt trauma.

• The individual loops may be trapped, causing high-
pressure rupture of a loop or tearing of the mesentery.
• Penetrating trauma is also a common cause of injury.
• Small bowel injuries need urgent repair.
• Haemorrhage control takes priority and these wounds
can be temporarily controlled with simple sutures.
• In blunt trauma with mesenteric vessel damage, the
bowel ischaemia that results will dictate the extent of a
resection.
 Colon

• Injuries to the colon from blunt injury are relatively

infrequent, and are more frequently a penetrating injury.
• If relatively little contamination is present and the viability
is satisfactory, such wounds can be repaired primarily.
• If, however, there is extensive contamination, the patient
is physiologically unstable or the bowel is of doubtful
viability, then the bowel can be closed off (‘clip and drop’).
• A defunctioning colostomy can be formed later or the
bowel reanastomosed once the patient is stable.
 Rectum

• Only 5% of colon injuries involve the rectum.

• These are 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.
• These injuries are often associated with bladder
and proximal urethral injury
 Renal and urological tract injury

• In the stable patient, CT scanning with contrast is the

investigation of choice.
• For assessment of bladder injury a cystogram should
be performed.
• A minimum of 300 mL of contrast is instilled into the
bladder via a urethral catheter.
• important to assess the films as follows:
●● two views – AP and lateral (and sometimes oblique);
●● two occasions – full and postmicturition
• Ureteric injury is rare and is generally due to penetrating
trauma.
• Most ureters can be repaired or diverted if necessary, or
may even be ligated as part of Damage control procedures.
• Intraperitoneal rupture of the bladder, usually from direct
blunt injury, will require surgical repair.
• Extraperitoneal rupture is usually associated with a fracture
of the pelvis and will heal with adequate urine drainage via
the transurethral route.
 Retroperitoneum

• Injury to the retroperitoneum is often difficult to

diagnose, especially in the presence of other
injury, when the signs may be masked.
• Diagnostic tests (such as ultrasound and DPL)
may be negative.
• The best diagnostic modality is CT, but this
requires a physiologically stable patient.
• The retroperitoneum is divided into three zones
for the purposes of intraoperative management:
In blunt trauma:
●● Zone 1 (central): central haematomas should
always be explored, once proximal and distal
vascular control has been obtained.
●● Zone 2 (lateral): lateral haematomas should
only be explored if they are expanding or pulsatile.
They are usually renal in origin and can be
managed non-operatively, though they may
sometimes require angioembolisation.
●● Zone 3 (pelvic): as with zone 2, these should
only be explored if they are expanding or pulsatile
• In penetrating trauma, every injury should be
explored for damage to structures along the
wound track (e.g. ureter), unless preoperative
investigation allows non-surgical management
of the injury.
• Pelvic haematomas are exceptionally difficult
to control and, whenever possible, should not
be opened; they are best controlled
 THE PELVIS

• mortality following severe pelvic fractures has decreased

dramatically with better methods of controlling
haemorrhage, these patients still represent a significant
challenge to every link of the treatment chain.
• Mortality rates exceeding 40% have recently been
reported.
• pelvic bleeding as one of the ‘hidden bleeding sources’ is
still underestimated or missed, as retrospective chart
analyses of potentially preventable deaths have revealed
• The haemodynamically unstable patient with
severe pelvic fracture has a 90% risk of associated
injuries, and a 30% risk of intra-abdominal
bleeding.
• To save these patients, three questions need to be
addressed:
• ●● Is the patient at high risk of massive bleeding?
• ●● Where is the source of the bleeding?
• ●● How to stop the bleeding?
 Anatomy

• The surgical anatomy of the pelvis is a key to the

understandingof pelvic injuries.
• ●● The pelvic inlet is circular, a structure that is
immensely strong, but routinely gives way at more
than one point should sufficient force be applied to it.
• isolated fractures of the anterior or posterior pelvic
ring are uncommon.
• ●● The forces required to fracture the pelvic ring do
not respect the surrounding organ systems
• The pelvis has a rich collateral blood supply,
especially across the sacrum and posterior part of
the ileum.
• Postmortem examination has shown that the
extrapelvic peritoneal space can accommodate more
than 3000 mL.
• All iliac vessels, the sciatic nerve roots (including the
lumbosacral nerve) and the ureters cross the
sacroiliac joint; disruption of this joint may cause
severe haemorrhage,
• The pelvic viscera are suspended from the
bony pelvis by condensations of the
endopelvic fascia.
• The pelvis also includes the acetabulum, a
major structure in weight transfer to the leg.
 Classification
• Pelvic ring fractures can be
classified into three types,
using the Tile classification
(for subtypes and other
classifications based on the
severity of the fracture (and
reflecting the energy
required to cause it) .
• However, no fracture
pattern can exclude
significant haemorrhage.
• Type A :are the most common fractures and are
completely stable. They result from lateral
compression.
• Type B:fractures are partially stable, and there is
disruption of the anterior pelvis and partial
disruption of the posterior pelvis.
• Type C: fracture is completely unstable. Both anterior
pelvis and the entire posterior pelvic complexes are
disrupted and the disrupted pelvic bones are free to
displace horizontally and vertically
 Clinical examination

• Pelvic fractures should be easily identified if ATLS

guidelines are followed (i.e. clinical palpation and
compression of the pelvic brim from sacroiliac joint
to pubic symphysis, and a routine chest and pelvic
radiograph for any blunt injury in a patient unable to
walk).
• Clinical examination may reveal instability.
• Any instability felt indicates the presence of major
pelvic fracture, associated with life-threatening
blood loss, and requires appropriate measures.
• Inspection of the skin may reveal lacerations in the
groin, perineum or sacral area, indicating an open
pelvic fracture, the result of gross deformation.
• Evidence of perineal injury or haematuria
mandates radiological evaluation of the urinary
tract from below upwards (retrograde
urethrogram followed by cystogram or CT
cystogram and an excretory urogram, as
appropriate) when the physiology allows.
• Inspection of the urethral meatus may reveal a
drop of blood, indicating urethral damage.
 Diagnosis
Radiograph

• Examination of a plain radiograph of the pelvis

requires an understanding of the mechanism of
injury and a decision on the stability of the pelvic
rim.
• An open book type mechanism causes one or both
ilea to rotate externally (opening, like a book).
• A lateral compression mechanism causes the pelvis
to collapse. An ‘open-book fracture’ is seen as a
widening of the pubic symphysis or widening at the
site of a fracture in the pubic ramus.
• Not only is there disruption of the bony pelvis,
but also tearing of the pelvic floor and thus
the pelvic venous plexus is at risk.
• The more unstable the pelvis, the more likely
the structures are to be damaged
• FAST may be unreliable as it does not localise
intra abdominal bleeding in these patients.
• CT is the diagnostic modality of choice in the
haemodynamically stable patient,
• CT angiography is particularly helpful to
provide details of both the anatomy of the
facture, as well as details of the origin of the
bleeding (venous or arterial).
 Management
• The treatment of bleeding is to stop the bleeding!
• The priorities for resuscitating patients with pelvic
fractures are no different from the standard.
• These injuries can produce a real threat to the circulation,
and management is geared toward controlling this threat.
• Initial management requires the use of a compression
binder or a sheet, applied around the true pelvis at the
level of the greater trochanters (‘reduce the pelvic
volume’), a potentially lifesaving procedure that has to be
done in the emergency room.
• 85% of bleeding originating from the pelvis is of venous
origin and can be controlled by non-operative means,
including compression either by binding or external
fixator, or by extraperitoneal packing (i.e. packing the
loose space between the bony wall of the pelvis and
the peritoneum) to compress the pelvic veins.
• If other sources of bleeding have been ruled out, the
extraperitoneal pelvic packing is done without entering
the peritoneal cavity.
• This may be combined with external fixation.
• If the bleeding is of arterial origin
interventional angioembolisation is the next
choice for bleeding control.
• The techniques for bleeding control
(compression, packing, fixation and
angioembolisation) do not exclude each other
but
 Summary
• In summary, a haemodynamically normal
patient can be safely transferred for
stabilisation of unstable fractures within hours
after injury and following control of the
associated damage.