Abdominal trauma Done by Areej AlHadidi Bayan Abu

Abdominal trauma Done by : Areej Al-Hadidi & Bayan Abu Alia

introduction • Abdominal injuries are present in 7– 10% of trauma patients. These injuries, if unrecognized, can cause preventable deaths. • Death usually result from hemorrhage and sepsis • The abdomen extends from the diaphragm to the pelvic floor, corresponding to the space between the nipples and the inguinal creases on the anterior aspect of the torso. Can be divided into : • Anterior abdomen • Thoracoabdomen • Flank • Back • intraperitoneal contents • Retroperitoneal space contents • Pelvic cavity contents

M. C : RTA / Fall gunshot

What is the difference between blunt trauma and penetrating trauma ?

Mechanisms of injury • Blunt abdominal trauma can be explained by : direct blow - compression and crushing injuries to abdominal viscera - such force deform solid and hollow organs and can cause rupture with secondary hemorrhage - contamination by visceral contents and associated peritonitis rapid deceleration ( shearing injuries) differential movement of fixed and non fixed parts of the body example: laceration injury to liver and spleen both are movable organs at the sites of their fixed supporting ligaments • In patients who sustain blunt trauma the organs most frequently injured spleen (40%-55%) ( this is from the book) but recently the most common organ injured in both blunt and penetrating trauma is the liver ) liver ( 35%-45%) small bowel (5%-10%) Retroperitoneal hematoma(15% )

Penetrating trauma • stab wounds and low velocity gunshot wounds cause tissue damage by lacerating and cutting • High velocity gunshot wounds transfer more kinetic energy to abdominal viscera • Stab wounds traverse adjacent abdominal structures and most commonly involve the liver (40%) small bowel(30%) diaphragm(20%) and colon (15%) • gunshot wounds may cause additional intra-abdominal injuries based upon the trajectory, cavitation , effect, and possible bullet fragmentation

• Patients who have suffered abdominal trauma can generally be classified into the following categories based on their physiological condition after initial resuscitation: ●hemodynamically ‘normal’ – investigation can be completed before treatment is planned; ● hemodynamically ‘stable’ – investigation is more limited. It is aimed at establishing whether the patient can be managed non-operatively, whether angioembolization can be used or whether surgery is required; ● hemodynamically ‘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 intraabdominal 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

Cont, , • 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.

Presentations - Depend on a few factors; size, site, organ involve, blunt or penetrating - Visible truncal injury including chest or abdomen - Abdominal pain - Bleeding - Piercing object - Evisceration - Shock Penetrating trauma is usually diagnosed by clinical findings while blunt is more likely to be missed due to less obvious findings

Presentation of penetrating trauma One third do not penetrate the abdominal cavity One third penetrate the abdominal cavity but don’t cause any significant intra abdominal injury One third do cause significant abdominal damage

Presentation of Blunt trauma In awake unimpaired patient without abdominal complaints Hospital admission+ seril abdominal examination (Rare) Unstable patient with multiple injury FAST exam may be useful Unstable patient with abdominal injury Immediate celiotomy Stable patient with multiple injuries Abdomen may harbor occult organ involvement >> Ct scan is necessary

Assessment History 1. AMPLE: A: Allergy/Airway M: Medications P: Past medical history L: Last meal E: Event - What happened? 2. Mechanism a. MVA - Speed - Type of collision (frontal, lateral, sideswipe, rear, rollover) - Types of restraints - Vehicle intrusion into passenger compartment - Deployment of air bag - Patient's position in vehicle - Fatality at the scene b. Gun Shots - # number of shots heard - Type of gun used - Position of pt when shot - Distance

Cont, , • So that’s why understanding the mechanism of injury is crucial specially in blunt trauma since it’s easier to miss. • Blunt abdominal trauma is very common in RTAs where: • There have been fatalities. • Any casualty has been ejected from the vehicle. • The closing speed is >50 mph(>80 km/h). • Patients who have been involved in a RTA should be asked: speed of the vehicle// type of collision (e. g. , frontal impact, lateral impact, sideswipe, rollover) • deployment of air bags, patient’s position in the vehicle, and status of passengers.

Cont, , • When assessing a patient who has sustained penetrating trauma: – type of weapon (e. g. , knife, handgun, rifle, or shotgun). – number of stab wounds or shots sustained. – the amount of external bleeding from the patient noted at the scene. – distance from weapon and bullets caliber. • For patients injured by falling: the height of the fall is important to determine due to the potential for deceleration injury from greater heights.

Examination - Inspect the abdomen and flanks for Lacerations, contusions (eg, seat belt sign), and ecchymosis, abdominal Distension, piercing objects, entry and exits for gunshots - Palpate for tenderness and rigidity, rebound tenderness - Auscultate for presence/absence bowel sounds - Percuss to elicit subtle rebound tenderness - Assess pelvic stability - Examine gluteal regions and perinum, rectum, penile, vaginal

Diagnostic studies • Focused assessment with sonography for trauma (FAST) • CT scan –abdomen • CXR and pelvic X-ray • Diagnostic peritoneal lavage (DPL)”not commonly used anymore” • Local wound exploration

FAST(Focused assessment with sonography for trauma) • It is used to identify free fluid inside the peritoneal cavity as a source of significant hemorrhage. • Used bedside so it can be used in relatively unstable patients. • With specific equipment and in experienced hands, ultrasound has a sensitivity, specificity, and accuracy in detecting intraabdominal fluid comparable to DPL. • • Thus, ultrasound provides a rapid, noninvasive, accurate, and inexpensive means of diagnosing hemoperitoneum that can be repeated frequently There should be no attempt to determine the nature or extent of the specific injury

Cont, , • • can be performed at the same time as resuscitation. It is accurate at detecting >100 m. L 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 FAST a low sensitivity (29– 35%) for organ injury without haemoperitoneum. • FAST is also unreliable for excluding injury in penetrating trauma. (high false negative) • If there is doubt, the FAST examination can be repeated. • In case of previous surgery , there may be a lot of adhesion that affect the sensitivity of FAST

4 P s pericardium Perisplenic (LUQ) Morrison’s pouch Pouch of Douglas

Diagnostic peritoneal lavage (DPL) • Diagnostic peritoneal lavage (DPL) 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. • If the FAST exam is unavailable/ limited (eg, poor image quality) , DPL should be performed as alternative in hemodynamically unstable patient. • A cannula is inserted below the umbilicus, directed caudally and posteriorly. The cannula is aspirated for blood (>10 m. L is deemed as positive) and, following this, 1000 m. L of warmed Ringer’s lactate solution is allowed to run into the abdomen and is then drained out via the same route.

Cont, , • The presence of >100 000 red cells/μL or >500 white cells/μL is deemed positive (this is equivalent to 20 m. L of free blood in the abdominal cavity), as is the presence of vegetable fiber 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.

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CT scan • CT has become the ‘gold standard’ for the intra-abdominal diagnosis of injury in the stable patient. • The scan 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: ● 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. • Laparoscopy 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

Indications of Laparotomy - Signs of peritonitis. - Uncontrolled shock / hemorrhage. - Clinical deterioration during observation. -Evisceration - Hemoperitoneum findings after DPL / FAST. - Any knife injury –with visible viscera, clinical peritonitis, hemodynamic unstable, or developing fever/signs of sepsis. - Any gunshot wounds

• MRI can be used for a stable pregnant patient in need of intrabdominal imaging following penetrating injury

X-Ray It doesn’t use that much in trauma • Plain radiographs typically add little to the management of abdominal trauma. • If free peritoneal air is seen on upright chest or lateral decubiuts , then the peritoneal cavity has been violated , but this does not confirm hollow viscus injury. • In diaphragmatic rupture when can see part of the intestine inside the peritoneal cavity • if peritonitis signs but no peritontitis think of diaphragm rupture

Local wound exploration • With the use of local anesthesia , this procedure could be performed at the bedside in stable patients with stab wound to the abdomen to evaluate the depth and the tract of the injury. • if the anterior rectus fascia is not violated << no further investigation is needed << considered a deep laceration • If the fascia is violated <<needs further investigation << CT scan if stable to evaluate the degree of bowl or vascular injury.

Management Primary survey (ABCDE ) • Evaluation of vitals and resuscitation should be done concurrently • Any patient persistently hypotensive despite resuscitation , no obvious cause of blood loss -intrabdominal bleeding • In abdominal penetration and there is no signs of perforation , , admit the patient , keep him NPO for 8 -12 hours. . If no peritonitis , send him home

Abdominal compartment syndrome • Sustained elevation above 35 mm. Hg. • Organ dysfunction caused by intra-abdominal hypertension (e. g. falling renal perfusion, respiratory insufficiency) • ACS is a major cause of morbidity and mortality in the critically ill patient and its early recognition is essential. • Operative decompression is always indicated. • In all cases of abdominal trauma in which the development of ACS in the immediate postoperative phase is considered a risk, the abdomen should be left open and managed as for damage control surgery.

Take home messages • Abdominal trauma is often difficult to evaluate in the pre-hospital setting. • Death from Abdominal injury usually from hemorrhage and delayed surgical repair. • CT is gold standard to diagnose intra-abdominal injury in hemodynamically stable patient • liver is the most affected organ in blunt or penetrating • 85 % with hepatic blunt trauma are stable • When there is a chance of abdominal trauma , don`t delay transport !!