Abdominal

Trauma
 OUTLINES

CAUSES CLINICAL INVESTIGATIO TREATMENT

FEATURES NS AND
MANAGEMEN
T
SOLID ORGAN HOLLOW ORGAN
1. Liver 1. Stomach
2. Spleen 2. Gall bladder
3. Kidney 3. Large, small intestines
4. Pancreas 4. Ureters, urinary bladder
 Major Vascular Structures

•Aorta Injury can cause severe blood loss ;

exsanguination (bleeding out)
•Inferior vena cava
•Major branches

5
CAUSES
•Blunt
•Penetrating
•Blast
•Crush
•Thermal
 BLUNT TRAUMA

1.Compression/Deceleration
Direct blow
External compression vs. fixed object (e.g. lap belt)
Cause:-

-Deform solid and hollow organs:-Laceration of liver and spleen

Shearing force due to rapid deceleration against the small area of
the lap belt and increased intraluminal pressure secondary to
compression of a bowel loop between the seat belt and spine.

Bucket handle injury(mesentric injury of small bowel)

 Common cause – motor vehicle accident(MVA)
 Speed – critical factor
 Ejection from vehicle is associated with a significantly greater incidence
of severe injury.
 Use of seatbelt reduce the risk of death or serious injury for front-seat
occupants by 45 per cent.
• Can cause a specific pattern of internal injury(Seatbelt mark)
• 8 fold increase in intra abdominal trauma.
 PENETRATING TRAUMA
 Important factors:
• Proximity of the underlying viscera to the path of the penetrating
object
• Velocity of the missile
 Distance from the weapon to the wound may give important
information:
• Energy of the injury, therefore predict internal damage

Example : gunshot wound,stabbing wound and surgical incision

The liver, followed by the small bowel, is the organ most often
damaged by stab wounds.
 CRUSH INJURY

Occurs when a body part is subjected to a high degree of force or pressure, usually after being
squeezed between two heavy or immobile objects

direct blow to the epigastrium with crushing of the pancreas over the vertebral colum)
Damage includes:
• Laceration
• Fractures
• Bleeding
• Bruising
• Crush syndrome
• Compartment sydrome
Crush syndrome:

Prolonged crushing leads to reperfusion injury

Releases myoglobin and vasoactive mediators into the circulation.

Sequesters many litres of fluid,reducing intravascular volume and resulting in vasoconstriction and renal ischemia.

Myoglobinuria leads to renal failure.

Compartment syndrome
 Most common in a closed fracture or soft-tissue crush injury
 Pain on passive extension of the muscle is diagnostic
 THERMAL INJURY
Injury which is caused by application of heat or chemical
substances to the external or internal surfaces of the body,
which cause destruction of tissues.
 CLINICAL PRESENTATION
Relating to hemodynamic stability :-
-pale,with cold extremities
-tachycardia,hypotension
Abdominal pain
Lateral lower rib fractures-associated with injury to spleen kidney,liver or kidney.
 SPLEEN INJURY
Splenic hemorrhage-pain in the left hypochondrium and upper
abdomen

Kehr sign:maybe associated with left shoulder tip pain if blood or a

hematoma is irritating the left hemidiaphragm.
Balance Sign: Dull percussion in LUQ. Signs of splenic injury; blood
accumulating in subcapsular or extracapsular space

The pain impulses are referred along the

phrenic nerve supplying the diaphragm C3-C5
nerve distribution.
PANCREAS
Blunt trauma-usually mild epigastric pain with progressive
development to severe pain
Grey Turner sign: Bluish discoloration of the flanks,
lower back-retroperitoneal hemorrhage
RENAL,AND BLADDER
 Renal trauma-flank pain and tenderness upon examination

-bruising Profuse bleeding may cause clot colic

-hematuria sudden between 3rd day-3rd week-clot becoming dislodged

-abdominal distension-retroperitoneal hematoma

 Bladder-sudden severe pain in hypogastrium, often accompanied by syncope

-no urine is passed for several hours

 CLINICAL PRESENTATION
Abdominal findings
• Inspection :
 Abdominal distention, which may be due to
pneumoperitoneum, gastric dilatation secondary to
assisted ventilation or swallowing of air, or ileus
produced by peritoneal irritation.

 Contusions, laceration, deformity or abrasions


The classical ‘seatbelt’ sign. The
bruising on the left breast is from the
shoulder belt and the low bruising to
the abdominal wall is from the lap
belt.
Cullen's sign-discolouration around umbilicu
Lap belt ecchymosis often pancreatic haemorrhage or trauma to
Mesenteric, Bowel, and Lumbar liver(blood tracks to umbilicus along the
spine injuries ligamentum teres)
• Palpation :
For tenderness, guarding and/or rigidity, rebound tenderness,fullness and doughy consistency(can be difficult to access)
intraabdominal hemorrhage
- Percussion :
Dullness : Hemoperitoneum
Tenderness:Peritonitis
• Auscultation :
• -Presence/absence of bowel sounds-
• -Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula.
 Digital rectal examination should be performed.

- stool should be evaluated for gross or occult blood. The

evaluation of rectal tone is important for determining the patient’s
neurologic status(low), and palpation of a high-riding prostate
suggests urethral injury.

 Examine the external genitalia:-

-The genitals and perineum should be examined for soft tissue

injuries, bleeding, and hematoma.Pelvic instability indicates the
potential for lower urinary tract injury, as well as pelvic and
retroperitoneal hematoma.
INVESTIGATIONS
• Computed tomography
• Focused abdominal sonar for trauma (FAST)
• Abdominal X-ray
• Diagnostic laparoscopy
• Exploratory laparotomy
• Cystogram
Computed tomography
Gold standard test for intra-abdominal injury (stable
patient)

Should be performed using IV contrast

ADVANTAGES

-CT is sensitive to blood and individual organ injury

-also for retroperitoneal injury

-an entirely normal abdominal CT is sufficient to exclude

an injury
 Focused abdominal sonar for trauma (FAST)

Is a technique whereby ultrasound imaging is used to assess the torso for the presence of free blood in the
abdominal cavity and pericardium

FOCUS ON 6 AREAS:

1. Pericardium

2. Area around liver

3. Area around spleen

4. Right and left paracolic gutters

5. Peritoneal space in the pelvis

Diagnostic peritoneal lavage (DPL)

A tests used to assess the presence of blood 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 and is aspirated for blood (>10ml is deemed positive)

following this 1000ml of warmed Ringlet’s lactate solution is

allowed to run into the abdomen and is then drained out

(presence of >100000 RBC/µl or >500 WBC/µl is deemed positive)
-THIS IS EQUIVALENT TO 20ml OF FREE BLOOD IN THE ABDOMINAL
CAVITY
 Abdominal X-ray
AP chest X-ray is recommended in the assessment of patient with
multisystem blunt trauma

hemodynamically patient with penetrating abdominal wounds do

not require screening x-rays in the ED.

with marker rings or clips applied to all entrance and exit wound
sites, a supine abdominal x-ray may be obtained in a
hemodynamically stable patient to determine the track of missile or
presence of retroperitoneal air
 Diagnostic laparoscopy

may be a valuable screening investigation in stable patients with

penetrating trauma to detect or exclude peritoneal penetration or
diaphragmatic injury

evidence of penetrating injury require laparotomy to evaluate organ

injury as it is difficult to exclude all intra-abdominal injuries
laparoscopically

it is not a substitute for laparotomy especially in the presence of

haemoperitoneum and contamination
Exploratory laparotomy

Indicated when:

-blunt abdominal trauma with hypotension with a positive FAST or clinical evidence of intra-peritoneal bleeding

-blunt or penetrating trauma with positive DPL

-hypotension with a penetrating abdominal wound

-gunshot wounds transversing the peritoneal cavity or visceral retroperitoneum

-evisceration

-bleeding from the stomach, rectum or genitourinary tract, intraperitoneal bladder injury, renal pedicle injury or
severe visceral parenchymal injury after a blunt or penetrating trauma
 Cystogram
For assessment of bladder injury

A minimum of 400ml of contrast is instilled into the bladder via a urethral catheter
(large volume is essential because a small volume may not produce a leak from small
bladder injury once cystic mucle contracts

Important to assess the film

-with 2 views (AP and lateral)

-on 2 occasions (full and post micturition)