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Abdominal trauma
Abdominal Trauma
Dr. AHMED M. 1
Outline

• Introduction

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• Mechanism of injury
• Diagnosis & evaluation

Abdominal trauma
• General management principles
• Specific organ injury
• Reference

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 Introduction
• Injury/trauma has been man’s companion since the earliest
time

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• Trauma is the leading cause of death for people <44 yrs of age.
• The abdomen is the third most common injured region.

Abdominal trauma
• 25% of all trauma victims will requires an abdominal exploration
• Blunt trauma is one of major public health problem, mainly
caused by RTA
• A missed abdominal injury can cause a preventable death.

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 07/12/2024
Abdominal trauma
“At least one person dies out of [every] five car
accidents occurring in this country,” said
Bamlaku Alemayehu, inspector of Ethiopia’s
National Road Safety Coordination Office.
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Epidemiology
• The risk of death from injury varied strongly by
region, age, and sex.

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• Globally, injury accounts for 10% of all deaths;
however, injuries in sub-Saharan Africa are far more

Abdominal trauma
destructive than in other areas.
• age: 1-44 years( peak 14-30)
• According to national and international data,
abdominal trauma is more common in men than
women.
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 Anatomy
• The abdomen can be
arbitrarily divided into 4

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areas.
• intrathoracic abdomen

Abdominal trauma
• Pelvic abdomen
• Retroperitoneal
• True abdomen

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 Cont….
• External Anatomy of Abdomen

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Abdominal trauma
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MECHANISM OF INJURY
1)Blunt abdominal trauma

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2)Penetrating abdominal trauma
• Stab injury

Abdominal trauma
• GSW

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• 1)Blunt abdominal trauma

• The most common mechanism

• Has relatively high mortality rates of

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10% to 30%.
• More difficult to diagnose,

Abdominal trauma
commonly associated with trauma to
multiple organs/systems
• Common causes: MVA (50 - 75% of
cases) > blows to abdomen (15%) >
falls (6 - 9%)

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• Pathophysiology of injury:
1. Crushing of an organ against the spine, pelvis or the abdominal wall.
2. Acceleration and deceleration forces → shear injury
3. Sudden increase of the intraluminal pressure & bursting of a hollow

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viscus.

Abdominal trauma
4. Injury by broken lower ribs
• Pattern of Injury in Blunt Abdominal Trauma
Spleen 40.6% Colorectal 3.5%
Liver 18.9% Diaphragm 3.1%
Retroperitoneum 9.3% Pancreas 1.6%
Small Bowel 7.2% Duodenum 1.4%
Kidneys 6.3% Stomach 1.3% 10
Bladder 5.7% Biliary Tract 1.1%
2)Penetrating abdominal trauma
Low energy (Stab wounds /SW)
• knife inj.,scissor, arrow, pen, fence post,

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or an animal horn
-most survive with prompt Rx.

Abdominal trauma
-3x more common than firearm wounds
-predictable pattern of organ injury.

• most commonly injured organs are as follows :

• Liver (40%),Small bowel (30%),Diaphragm (20%),Colon (15%) 11
High energy (Gun Shot Wound)
• hand gun, shot guns ,rifles
• mortality is high

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• unpredictable pattern of injuries.
• Secondary missiles, such as bullet and bone

Abdominal trauma
fragments, can inflict additional damage
• The closer the higher energy transfer
• the most commonly injured organs are as follows:
• Small bowel (50%),Colon (40%),Liver (30%)
,Abdominal vascular structures (25%)
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Evaluation of pt. with AT
• Prehospital care

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• Primary survey (ABCD + resuscitation)
• Secondary survey

Abdominal trauma
*Patients who present with blunt versus penetrating
mechanisms of injury frequently require varying approaches to
evaluation
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Clinical Evaluation

History:
 Onset, delay in extrusion, For penetrating injuries:
condition of Vehicle,

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passenger/s  The type of fire arm or
 Seat belt impaling object
Abdominal, shoulder

Abdominal trauma
  Number of shots or stabs
pains  Distance
 AMPLE
 Substance abuse, Alcohol
intoxication
 Fall from great height

Primary goal is to identify that an injury exists, not necessarily making 14

an accurate diagnosis.
 Physical Examination
Only 60% reliable

• Inspection: abrasions, contusions,

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lacerations, deformity
• Grey-Turner, Seatbelt mark, Cullen
• Auscultation:

Abdominal trauma
• Percussion: signs of peritonitis;
dullness with hemoperitoneum
• Palpation: elicit superficial, deep,
or rebound tenderness;
involuntary muscle guarding

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The abdomen is a diagnostic
black box
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Abdominal trauma
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FIGURE 30-6. “Seatbelt mark” sign is associated with an
incidence of about 20% of intraabdominal injuries.
Local wound exploration

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• For SW (AASW)
• No fascial violation -> discharge
• Fascial penetration -> DPL, Serial P/E, DL

Abdominal trauma
 Contraindication
Need lap, Lower chest wounds, Flank and
back wounds
• SWs to back & flank -> triple contrast CT
• SWs to thoraco-abdomial -> R/O
diaphragmatic injuries, DL

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Abdominal Evisceration
• Never try to replace organ
• Cover with moist gauze ,
sterile dressing

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• Transport immediately

Abdominal trauma
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Diagnostic modality
• Hematology and chemistry laboratory tests
• Radiologic studies

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• procedures FAST
CT

Abdominal trauma
X-ray

DPL
DL

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Radiologic studies

• Plain Radiography

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• Chest X-ray
• pneumoperitonium

Abdominal trauma
• Lower rib #
• Abdominal contents in the chest

• AP pelvis x-ray
Open Book
Pelvic
Fracture 20
FAST(Focused assessment with sonography for
trauma )

• To diagnose free intraperitoneal blood

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• Sonography has become the surgeon’s new
“stethoscope “ for pt’s with BAT or PAT

Abdominal trauma
• 4 areas:
• Perihepatic & hepato-renal space (Morrison’s
pouch)
• Perisplenic
• Pelvis (Pouch of Douglas/rectovesical pouch)
• Pericardium (subxiphoid)
• sensitivity 60 to 95% for detecting 100 mL - 21
500 mL of fluid
 FAST
• Morrison’s pouch (hepato- • Perisplenic view
renal space)

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Abdominal trauma
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 Advantages and Disadvantages of Ultrasound

• Disadvantages
• Advantages
• Examiner dependent
• Noninvasive

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• non cooperative pts, obesity,
• Portable bowel gas, &subcutaneous
• Speed air interfere with image

• Does not require radiation
or contrast
• Useful in the resuscitation
room or ER
• Can be repeated
• Technique is easy to learn
• Low cost
Abdominal trauma
quality
• Injury to solid parenchyma,
the retroperitoneum, or the
diaphragm is not well seen
• Insensitive for detecting
bowel injury
• Blood cannot be
distinguished from ascites 23
Computerised tomography
• CT has become the ‘gold standard’ for the intra-

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abdominal diagnosis of injury in the stable
patient.

Abdominal trauma
• The scan is performed using intravenous contrast.
+-oral contrast

• is sensitive for blood and has the added

advantage of sensitivity for the diagnosis of 24
retroperitoneal injury.
Indications and Contraindications for
Abdominal CT
• Indications
• Hemodynamic stability

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• Normal or unreliable P/E
• Mechanism: Duodenal and pancreatic trauma

Abdominal trauma
• Contraindications
• Clear indication for exploratory laparotomy
• Hemodynamic instability
• Agitation
• Allergy to contrast media 25
Advantages and Disadvantages of Abdominal CT

• Advantages • Disadvantage

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• Adequate assessment of the • Suboptimal sensitivity
retroperitoneum for pancreatic,
• Better defines organ injury diaphragmatic, bowel,

Abdominal trauma
• Nonoperative management of and mesentery injury
solid organ injuries
• IV contrast is needed;
• Noninvasive
• Detects the presence, the • Relatively high cost
source and amount of • Can be unobtainable
hemoperitoneum or harmful to obtain
• Active bleeding often detectable in unstable patients
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• Radiation exposure
Diagnostic Peritoneal Lavage

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• Used to assess the presence of blood in peritoneum
• Largely replaced by FAST and CT

Abdominal trauma
• Highly accurate for hemoperitoneum (Sn = 97-98%)
• Lead to a non-therapeutic laparotomy rate of 10-15%
• 1% complication rate
• Indicated in HD unstable pt & has multiple injuries with
equivocal FAST examination

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Diagnostic Peritoneal Lavage

1.insert lavage catheter by seldinger, semiopen, or open

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2.attempt to aspirate free peritoneal blood
• >10 mL positive for intraperitoneal injury

Abdominal trauma
3. lavage peritoneal cavity with saline
• Fluid analyzed macroscopically, microscopically &biochemically
• Positive test:
• In blunt trauma, or stab wound ; RBC count > 100,000/mm3
• In lower chest stab wounds or GSW: RBC count >
5,000-10,000/mm3 28
• Enteric contents
 Diagnostic laparoscopy
• screening investigation in penetrating trauma to detect or exclude
peritoneal penetration and/or diaphragmatic injury in stable patients.

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• some diaphragmatic and visceral injuries may be amenable to repair
using DL.

Abdominal trauma
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Rigid sigmoidoscopy ,
proctoscopy

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• GSW to the gluteal region transecting the midline or
pelvic, perineal region injury

Abdominal trauma
• Patients suspected to have rectal injury

• It helps in deciding approach to the management

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Algorithm for the evaluation of
penetrating abdominal injury

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Abdominal trauma
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Algorithm for the initial evaluation of a
patient suspected of BAT

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Abdominal trauma
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GENERAL MANAGEMENT PRINCIPLE OF ABDOMINAL TRAUMA

• ABC’S
• Make a quick evaluation and revision of primary survey

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• Timely decision whether to do laparotomy or not

Abdominal trauma
• Try to prevent hypothermia, acidosis, coagulopathy
• Blood preparation and transfusion
• Maintain & protect retained FB traversing abdominal wall till
defining definitive plan
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Non operative management

Indications Components

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• HD stable patients • HD monitoring
• No signs of peritonitis, • Signs of peritonitis
no need of too much • FAST, DPL as first

Abdominal trauma
transfusion, mentally screening
clear • Resuscitation, keep NPO
• Low grade injuries on do serial Hct, UOP
further investigation • Decide when change of
• Selective penetrating management is needed
injuries (SW,SGW)
• Capable trauma centers 34
Indication for laparotomy
• Blunt trauma • Penetrating Trauma
● HD abnormal with ● HD abnormal

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suspected abdominal ● Peritonitis
injury (DPL / FAST)

Abdominal trauma
● Evisceration
● Free air ● Positive DPL, FAST,
● Diaphragmatic or CT
rupture ● Weapon still in situ
● Peritonitis ● Violation of
● Positive CT-HVI peritoneum 35
Failed non operative management
OPERATIVE MANAGEMENT

• General Preparation
• antibiotic prophylaxis

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• skin preparation

Abdominal trauma
• Incision
• Midline
• Abdominal Exploration
• two urgent priorities: temporary control of any
active bleeding followed by temporary control
of any intestinal spillage.-damage control 36
surgery
Cont….
 Liquid & clotted blood evacuated (suction, pads)  to
identify major source of active bleeding

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 BAT spleen, liver  infracolic mesentery inspected
 Penetrating wound  follow the trajectory of the
penetrating device

Abdominal trauma
Source of hemorrhage localized

- vascular injury digital occlusion

- solid organ injury  pad packing
- Clamping

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Cont…
Exposure of intra abdominal vasculature
-Left medial visceral rotation

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-Right medial visceral rotation

Abdominal trauma
 Identify source of enteric contamination
 Use primary repair of injury or damage
control surgery

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Reference
• Schwartz`s principles of surgery,9th edn, 2010
• ACS surgery; principles & practice, 6th edn, 2007

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• Sabiston text book of surgery,19th edn,2007
• Bailey & Love`s , short practice of surgery, 25th edn,2012

Abdominal trauma
• TRAUMA,DaveidV. Feliciano, Kenneth L. Mattox,Ernest E.
Moore,6th edt. 2008
• UpToDate 19.1

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