Abdominal Trauma

Abdominal Trauma

Dr. mohanad alsherefi Professor assistant Head of department of surgery

Abdominal Trauma

Penetrating Abdominal Trauma Stabbing 3x more common than firearm wounds GSW cause 90% of the deaths Most commonly injured organs: small intestine > colon > liver Blunt Abdominal Trauma Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) Most commonly injured organs: spleen > liver, intestine is the most likely hollow viscus. Most common causes: MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%)
Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Penetrating Abdominal Trauma Stab Wounds Knives, ice picks, pens, coat hangers, broken bottles Liver, small bowel, spleen Gunshot wounds small bowel, colon and liver Often multiple organ injuries, bowel perforations
Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Blunt Abdominal TraumaRupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures Crushing effect Acceleration and deceleration forces → shear injurySeat belt injuries“seat belt sign” = highly correlated with intraperitoneal injury Rosen’s Emergency Medicine, 7th ed. 2009

Physical Exam

Generally unreliable due to distracting injury, AMS, spinal cord injuryLook for signs of intraperitoneal injuryabdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotensionentrance and exit wounds to determine path of injury. Distention - pneumoperitoneum, gastric dilation, or ileusEcchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhageAbdominal contusions – eg lap belts↓bowel sounds suggests intraperitoneal injuriesDRE: blood or subcutaneous emphysema Rosen’s Emergency Medicine, 7th ed. 2009


Diagnostic studies
Lab tests: not very helpfulMay have ↓ Hct, ↑ WBC, lactate, LFTs, lipase. Rosen’s Emergency Medicine, 7th ed. 2009

Imaging

Plain films: fractures – nearby visceral damagefree intraperitoneal air Foreign bodies and missiles Rosen’s Emergency Medicine, 7th ed. 2009

Imaging

CT Accurate for solid visceral lesions and intraperitoneal hemorrhage guide nonoperative management of solid organ damage IV not oral contrast Disadvantages : insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery
Rosen’s Emergency Medicine, 7th ed. 2009

Imaging

Angiography To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable pt Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma
Rosen’s Emergency Medicine, 7th ed. 2009

FAST

Focused assessment with sonography for trauma (FAST) To diagnose free intraperitoneal blood after blunt trauma4 areas:Perihepatic & hepato-renal space (Morrison’s pouch)PerisplenicPelvis (Pouch of Douglas/rectovesical pouch)Pericardium (subxiphoid)sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluidExtended FAST (E-FAST): Add thoracic windows to look for pneumothorax.Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%) Trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009

FAST

Morrison’s pouch (hepato-renal space) trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009


FAST
Perisplenic view
trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009

FAST

Retrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)

trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009

FAST

Advantages: Portable, fast (<5 min),No radiation or contrastLess expensiveDisadvantagesNot as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air.Can’t distinguish blood from ascites. high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture Rosen’s Emergency Medicine, 7th ed. 2009

Diagnostic Peritoneal Lavage

Largely replaced by FAST and CT In blunt trauma, used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examination In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury In GSW, not used much
Rosen’s Emergency Medicine, 7th ed. 2009

Diagnostic Peritoneal Lavage

1. attempt to aspirate free peritoneal blood >10 mL positive for intraperitoneal injury 2. insert lavage catheter by semiopen, or open 3. lavage peritoneal cavity with saline Positive test: In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3 In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm3
Rosen’s Emergency Medicine, 7th ed. 2009


Local Wound Exploration
To determine the depth of penetration in stab wounds If peritoneum is violated, must do more diagnostics Prep, extend wound, carefully examine (No blind probing) Indicated for anterior abdominal stab wounds, less clear for other areas
Rosen’s Emergency Medicine, 7th ed. 2009

Laparoscopy

Most useful to eval penetrating wounds to thoracoabdominal region in stable pt esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel. Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation
Rosen’s Emergency Medicine, 7th ed. 2009

Management

General trauma principles: airway management, 2 large bore IVs, cover penetrating wounds and eviscerations with sterile dressings Prophylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal perf/spillage In general, leave foreign bodies in and remove in the OR
Rosen’s Emergency Medicine, 7th ed. 2009

Management of penetrating abdominal trauma

forsurenot.com

Management of penetrating abdominal trauma

Mandatory laparotomy vs Selective nonoperative management
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating abdominal trauma

Mandatory laparotomy standard of care for abdominal stab wounds until 1960s, for GSWs until recently Now thought unnecessary in 70% of abdominal stab wounds Increased complication rates, length of stay, costs Immediate laparotomy indicated for shock, evisceration, and peritonitis
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617


Management of penetrating abdominal trauma
Selective management used to reduce unnecessary laparotomies Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair Strategy depends on abdominal region: Thoracoabdomen Nipple line to costal margin Anterior abdomen Xiphoid to pubis Flank and back Posterior to anterior axillary line

Management of penetrating abdominal trauma

Thoracoabdomen Big concern is diaphragmatic injury 7% of thoracoabdominal wounds Diagnostic evaluation: CXR (hemothorax or pneumothorax) Diagnostic peritoneal lavage FAST Thoracoscopy
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Thoracoabdomen

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating abdominal trauma

Anterior abdomen Only 50-70% of anterior stab wounds enter the abdomen of these, only 50-70% cause injury requiring OR 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required?
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of PAT

Anterior abdomen
Rosen’s Emergency Medicine 7th ed

Management of penetrating abdominal trauma

Back/Flank Risk of retroperitoneal injury Intraperitoneal organ injury 15-40% Difficulty evaluating retroperitoneal organs with exam and FAST In stable pts, CT scan is reliable for excluding significant injury:
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617


Management of penetrating abdominal trauma
Gunshot wounds Much higher mortality than stab wounds Over 90% of pts with peritoneal penetration have injury requiring operative management Most centers proceed to lap if peritoneal entry is suspected Expectant management rarely done
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617Rosen’s Emergency Medicine 2009

Management of PAT

Gunshot wounds assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited)
Rosen’s Emergency Medicine, 7th ed. 2009

Management of Blunt abdominal trauma

ashwinearl.blogspot.com

Management of Blunt abdominal trauma

Exam less reliable Diagnostic studies to determine if there is hemoperitoneum or organ injury requiring surgical repair FAST, CT, DPL In HD stable pts, CT is preferred

Rosen’s Emergency Medicine, 7th ed. 2009

Management of Blunt abdominal trauma
Clinical Indications for Laparotomy after Blunt Trauma


MANIFESTATION
PITFALL
Unstable vital signs with strongly indicated abdominal injury
Alternative sources, shock
Unequivocal peritoneal irritation
Unreliable
Pneumoperitoneum
Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy)
Evidence of diaphragmatic injury
Nonspecific
Significant gastrointestinal bleeding
Uncommon, unknown accuracy
Rosen’s Emergency Medicine, 7th ed. 2009

Damage Control

Patients with major exsanguinating injuries may not survive complex procedures Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

0. initial resuscitation 1. Control of hemorrhage and contamination Control injured vasculature, bleeding solid organs Abdominal packing 2. back to the ICU for resuscitation Correction of hypothermia, acidosis, coagulopathy 3. Definitive repair of injuries 4. Definitive closure of the abdomen
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430


Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

Resuscitation in the ICU IVF (crystalloid, not colloid) Transfusion ?1:1:1 PRBC/plt/FFP Recombinant activated factor VII Increased thromboembolic complications Rewarming if hypothermic Correction of metabolic abnormalities Low tidal volume ventilation recommended (4-6 ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

Open abdominal wounds and definitive closure40-70% can’t have primary closure after definitive repair. Temporary closure methods Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Abdominal Compartment Syndrome

Common problem with abdominal traumaDefinition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure± APP below 50 mm Hg Primary ACS: associated with injury/disease in abdomenSecondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment Syndrome

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

Abdominal Compartment Syndrome

Effects of elevated IAP Renal dysfunction Decreased cardiac output Increased airway pressures and decreased compliance Visceral hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment Syndrome

Management Surgical abdominal decompression Nonsurgical: paracentesis, NGT, sedation Staged approach to abdominal repair Temporary abdominal closure
Sugrue M. Curr Opin Crit Care 2005; 11:333-338
Bailey J. Crit Care 2000, 4:23–29

Conclusions

Watch out for implements and missiles violating the abdomen Laparotomy is mandatory if shock, evisceration, or peritonitis Diagnostic studies used to determine need for laparotomy in PAT and BAT FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood Damage Control is a principle of staged operative management with control and resuscitation prior to definitive repair Abdominal compartment syndrome is a common problem in abdominal trauma

THANK YOU

References
Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617 Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S421-30.Marx: Rosen’s Emergency Medicine, 7th ed. 2009 MosbySugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29