Ashraf 2017 abdominal trauma

1. Blunt Abdominal Trauma
By
Ashraf M. Abdelkader
Associate Professor General Surgery
Banha University , EGYPT
Consultant General Surgery
KSH in Unizah , KSA

2. Background Anatomy
 Abdominal wall
 Anterior abdomen
 Flank
 Back
2

3.  Abdominal cavity
 Intra-peritoneal Space Contents
 Retroperitoneal Space Contents
 Pelvic Cavity Contents

4. Introduction
 Abdominal trauma is regularly encountered in the emergency
department.
 One of the leading cause of death and disability.
 Identification of serious intra-abdominal injuries is often
challenging.
 Many injuries may not manifest during the initial assessment and
treatment period

5. Epidemiology
 Peak incidence Abdominal Trauma 15 - 30yr
 Males > females
 Abdominal Injuries accounts for 10% of all deaths
 Estimates indicate that by 2020, 8.4 million people will die yearly.
 Abdominal trauma are major causes of morbidity and mortality.
 Combination injuries from bombs and explosive devices are on
the increase

6. Types of Abdominal Trauma
1.Blunt Trauma
2.Penetrating Trauma
-Stab
-Gun shot Injury

8. MECHANISMS OF INJURY
 CRUSHING
- Direct application of a blunt force to the abdomen
 SHEARING
- Sudden decelerations apply a shearing force across organs with fixed attachments
 BURSTING
- Raised intraluminal pressure by abdominal compression accurately in hollow
organs can lead to rupture
 PENETRATION
- Penetrating injury occurs directly from the object causing the injury or from
kinetic energy released by the object. This can cause cavitation.

9. Blunt Trauma Abdomen
 RTA 75% of all blunt trauma abdominal injuries
 Direct blow 15%
 Fall down 5-6%
 Child Abuse
 Domestic Violence

10. - More common in elderly due to less resilience.
- Blunt injuries causes solid organ trauma (spleen, liver and
kidneys) more often than hollow viscera.
- Multi organ injury and multiple system injury are also more
common in blunt injury than in other types.
Blunt Trauma Abdomen ( cont.)

11. PRESENTATION
 Varies widely from hemodynamic stability with minimal
abdominal signs to complete cardiovascular collapse
and may change from one to the other with alarming
rapidity

12. 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%
Bladder 5.7% Biliary Tract 1.1%
* Rosen: Emergency Medicine (1998)

13. Prehospital Care
 The goal of pre-hospital is to deliver the pt to hospital
for definitive care as rapidly as possible. ‘Scoop and
Run’
 Maintain airway & start I V line
 Care of spinal cord
 Communicate to medical control
 Rapid transport of patient to trauma centre

14. Initial Assessment and Resuscitation
Primary survey
Identification & treatment of life threatening conditions
 Airway , with cervical spine precautions
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability +Neurologic Evaluation
 Exposure / Environmental Control

15. Emergency Care
 I V fluids
 Control external bleeding
 Dressing of wounds
 Protect eviscerated organs with a sterile dressing
 Stabilize an impaled object in place
 Give high flow oxygen
 Immobilize the patient with a fractured pelvis
 Keep the patient warm
 Analgesics

16. Secondary Survey
 AMPLE History
 A: Allergy(e.g. penicillin or aspirin)
 M: Medications(e.g. a beta-blocker or warfarin)
 P: Past medical history (e.g. previous surgery or
anaesthetic mishap)
 L: Last meal(i.e. drink versus major meal)
 E: Event - What happened
- To know injury mechanism (mode of injury) – to
anticipate injury patterns and raise the index of suspicion for
occult injury

17.  MVC: What happened
 Speed
 Type of collision (frontal, lateral, sideswipe, rear,
rollover)
 Vehicle intrusion into passenger compartment
 Types of restraints
 Deployment of air bag
 Patient's position in vehicle

18. PHYSICAL EXAMINATION
 General &Systemic Examination-to identify all occult injuries .
 Special attention to Back, Axilla , Perineum

19. Abdominal Examination
Inspection :
abdominal distension
 Distension
 Laceration
 Abrasion
 Seat Belt Sign

20. Examination
Cullen’s Sign:1918
Bluish discoloration around umbilicus
Diffusion of blood along periumbilical
tissues or falciform ligament
Hemoperitoneum
Severe pancreatitis

21. Examination
Grey-Turner’s Sign: (1877-1951)
Bluish discoloration of the flanks
Retroperitoneal Hematoma
hemorrhagic pancreatitis.
Kehr’s sign (1862-1916).
Referred pain, Lt. shoulder
irritation of the diaphragm
(Splenic injury, free air,
intra-abdominal bleeding)

22. Examination
Labia and Scrotum : Pooling of blood from
abdominal and pelvic cavities.

23. Examination
Palpation: - Tenderness - Mass
- Signs of peritonitis
- # Ribs
- Chest & Pelvic compression test
Percussion : Dullness/ shifting dullness / hyper-resonance
Auscultation :
1. +/- ve bowel sounds
2.. Bowel sounds in the thoracic cavity
(Diaphragmatic rupture)

24. Rectal findings
 Check for gross blood - pelvic fracture
 Determine prostate position – high riding prostate –
urethral injury
 Assess sphincter tone – neurologic status.
NB.
Foley’s catheter- monitor urine out put
Nasogastric tube

25. INVESTIGATIONS
Aim
To identify To decide When
(those with injury) (which ones (how quickly
need laparotomy) this must be
undertaken)

26. Investigations
 Laboratory tests
 FAST
 X-Ray Chest & Abdomen
 USG
 CT Scan
 Paracentasis
 Diagnostic Peritoneal Lavage
 Diagnostic Laparoscopy

27. Laboratory tests
 Complete haemogram with hematocrit,
 ABG
 Renal function tests
 Urine analysis –
+ ve of hematuria – genito urinary injury
- ve of hematuria – does not rule out it
 Serum amylase / lipase or liver enzymes - se -suspicion of
intraabdominal injuries

28. Focused Assessment with Sonography in
Trauma (FAST)
 First used in 1996
 Rapid , Accurate
 Sensitivity 86- 99%
 Can detect 100 mL of blood
 Cost effective
 Eliminates unnecessary CT scans
 Helps in management plan
 Four different views- Perihepatic
Perisplenic
Peripelvic space
Pericardiac

29. FAST Algorithm
FAST
+Ve
Unstable
patient
OT
Stable
patient
CT
-Ve
Stable
patient
Observ.
Unstable
patient
DPL
+Ve
OT
-Ve
The abdomen is not the Couse
of shock

30. Plain X-Ray Chest & Abdomen
 Pneumothorax, Hemothorax
 Free air under diaphragm
 Nasogastric tube, bowel loops in the chest
 Elevation of the both /Single diaphragm
 Lower Ribs # -Liver /Spleen Injury
 Ground Glass Appearance –
Massive Hemoperitoneum
 Obliteration of Psoas Shadow –Retroperitoneal
Bleeding
 #vertebra

31. Paracentasis
 Four quadrant aspiration of abdomen.
 A Positive tap – blood , air , bile stained fluid.
 Negative tap doesn’t rule out injury.
 False negatives are as high as 22-60%

32. Diagnostic Peritoneal Lavage
 First described in 1965
 Rapid & Accurate test used to
identify intra-abdominal injuries
 Predictive value of greater than
90%
 Test is highly sensitive to
presence of intraperitoneal
blood
 However specificity is low
Criteria for positive DPL:
- Gross bloody tap
- >1,00,000 RBCs per mm
- > 500 white blood cells per
mm
- Elevated amylase level
- Presence of bile or bacteria or
faeces

33. Diagnostic Peritoneal Lavage
Indications
• Unexplained Shock
• Altered sensorium (Head injury , Drug)

34. • Absolute :
 Peritonites
 Injured diaphragme
 Extraluminal air by x-ray
 Significant intraabdominal
injury by CT scan
 Intraperitoneal perforation of
the bladder by cystography
CONTRAINDICATIONS
• Relative :
 Previous abdominal
operations (because of
adhesions)
 Morbid obesity
 Gravid Uterus
 Advanced cirrhosis
(because of portal
hypertension and the risk
of bleeding)
 Preexisting coagulopathy

35. What About DPL?
 Can be performed if –ve FAST in blunt abdominal
trauma.
 If DPL +ve then emergency laparotomy.
 If DPL -ve then seek and treat other sources.
Perform serial abdominal exams.
Perform serial FAST exams.
If patient stabilizes, then CT.

40. CT Scan
 Replacing DPL.
 Gold Standard
 Haemodynamically Stable
 Provides excellent imaging of pancreas, duodenum and
Genitourinary system
 Standard for detection of solid organs injury.
 Determines the source and amount of bleeding
 Can reveal other associated injuries e.g. Vertebral & Pelvic # &
injury in the thoracic cavity .
 High Specificity-95%

42. CT Scan
Contraindication:
 Clear indication for Laparotomy
 Haemodynamically Unstable
 Allergy to contrast media

43. Diagnostic Modalities in Abdominal Trauma cont…..
DPL US CT SCAN
Sensitivity 100% 84% 89%**
Specificity 97% 88% 98%**
Accuracy 99% 86% 97%
* Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in
blunt abdominal trauma. J Trauma 29:242, 1999.
** Meyer D M, Thal E R, Weigelt J A, et al: The role of abdominal CT in the
evaluation of stab wounds to the back. J Trauma 29:1226, 1999.

44. DIAGNOSTIC LAPAROSCOPY
 Haemodynamically stable patients
 Inadequate/equivocal USG
 Mild hypotension or persistent tachycardia
 Persistent abdominal signs/symptoms
 It decreases non-therapeutic laparotomies
 Useful in penetrating injury
 Limitation :Retroperitoneal Injury

45. LAPAROSCOPY cont…
Disadvantages:
- Pneumoperitoneum may elevate ICP
- General anesthesia usually necessary
- Patient must be haemodynamically stable
Complications:
- Bleeding or injury
- Gas embolism

46. Management
of Abdominal Trauma

47. Blunt abdominal trauma
Haemodynamically
Stable
Shock due to other
causes
Haemodynamically
Unstable
LAPAROTOMY
FAST
DPL
Follow up
- ve + ve
CT
+ ve - ve
FAST

48. NON OPERATIVE MANAGEMENT OF
BLUNT ABDOMINAL INJURY
 Patient haemodynamically stable after initial resuscitation:
o Continuous patient monitoring for 48 hrs
o Surgical team immediately available
o Adequate ICU support and transfusion services available
o admission for observation, serial hematocrit measurement,
and repeat imaging

49. Laparotomy
Indications
Absolute criteria
• Peritonitis (gross blood, bile or faeces)
• Pneumoperitoneum or pneumoretroperitoneum
• Evidence of diaphragmatic defect
• Gross blood from stomach or rectum
• Abdominal distension with hypotension
• Positive diagnostic test for an injury requiring operative
repair

50. Thank You

51. Solid Organ Injuries
 Grading of injured solid organs such as Spleen, Liver
& Kidneys are on the basis of :
1- Subcapsular hematoma.
2- Capsular tear.
3- Parenchymal lacerations .
4- Avulsion of vascular pedicle.

52. Solid Organ Injuries
 Bleeds significantly and cause rapid blood loss
 Difficult to identify injury by physical exam
 Repeated assessment is required to make the diagnosis

53. SPLENIC INJURY
 Most common intra- abdominal organ to injured (40-
55%)
 20% of splenic injuries due to left lower rib fractures
 Commonly arterial hemorrhage

54. SPLENIC INJURY
 Conservative management :
(Success rate of conservative m/m is >80%)
 -Hemodynamic stability
 - Negative abdominal examination
 -Absence of contrast extravasation in CT
 - Absence of other indication of Laparotomy
 -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm)
 Monitoring
o Serial abdo. Examinations & Haematocrit are essential

55. Splenic Injuries
 Operative Management:
 Capsular tears (I)- Compression & topical haemostatic agent
 Deep Laceration (II)- Horizontal mattress suture
 or Splenorrhaphy
 Major Laceration not involving hilum (IV)-
 Partial Splenectomy
 Hillar injury (V)–Total Splenectomy
 Grade IV-V: almost invariably require operative intervention
 Success rate of Splenic salvage procedure is 40-60%

56. Liver injury
 Liver is the largest organ in abdomen
 2nd most common organ injured (35-45%) in BTA
 Driving and fighting responsible for 50% of deaths due
to liver injury
 Usually venous bleeding
 85% of all patients with blunt hepatic trauma are stable
 CT is the mainstay of diagnosis in stable pt.

57. Liver Injury
Non Operative management :
 Haemodynamically Stable
 No other intra-abdominal injury require surgery
 < 2 units of BT required
 Hemoperitoneum <500 ml on CT
 Grade I-III(subcapsular & intr-perenchymal hematoma)

58. Liver Injury
Operative management
 Packing
- Bleeding can be stopped by packing of abdomen
-Pack removed after 48 hr
-hemostatic agents
-34 % survival in packing only
 50% liver injury have stop bleeding spontaneously by
the time of surgery

59. Liver Injury
Operative Management(Contd.)
 Suturing: -Simple suture
-Deep mattress suture
 Laceration: -Mesh hepatorrhaphy
-Omental flap to cover the laceration
- Debridement
 Lobar Resection
 Liver Transplantation
 Ligate or repair damaged blood vessels & bile duct
 Mortality of liver injury is 10%

60. Pancreatic Injury
 Rare 10-20% of all abdominal injury
 Crush , Direct blow to abdo & Seat belt injury
 Associated with abdo. Duodenal injury, Vascular injury &
liver injury
 Diagnosis – Difficult, High index of suspicion
 CECT Scan is helpful
 Serum amylase is a poor indicator
 Usually diagnose on Laparotomy
 Distal Pancreatic injury - Distal resection
 Pancreaticojejunostomy – Injury to Ampulla of Vater, Head
& Body of Pancreas

61. Renal Injury
 Clinically not suspected & frequently overlooked
 Mechanism: Blunt , Penetrating
# lower ribs or spinous process,
Crush abdominal
Pelvic injury
Direct blow to flank or back
Fall

62. Renal Injury
Diagnosis
1.History ,Clinical examination
2. Presentation :Shock, hematuria & pain
3. Urine: gross or microscopic hematuria
4.X-ray KUB
IVP
5. USG
6.CT Scan abdomen
7. Radionuclide Scan
NB: The degree of hematuria may not predict the severity of renal
injury

63. Renal Injury
Classification of Injury
 Grade I : Contusion or Subcapsular Hematoma
 Grade II: Non Expanding Hematoma, <1 cm deep ,no
extravasation
 Grade III: Laceration >1cm with urinary Extravasation
 Grade IV: Parenchymal Laceration deep to CM Junction
 Grade V: Renovascular injury

64. Management of Renal Injury
Conservatively: 85% of blunt renal trauma
Renal exploration :
Indication
 Deep cortico-medullary Laceration with extravasation
 Large perinephric Hematoma
 Renovascular injury
 Uncontrolled bleeding
Before Nephrectomy ,Contralateral Kidney should be assessed

65. Diaphragmatic Injury
 Incidence -0.8%-1.6% in BTA
 High index of suspicion required , may be missed.
 40 to 50% are diagnosed immediately
 Presentation may be delayed
 Imaging
Nasogastric tube seen in the thorax
Abdominal contents in the thorax
Elevated hemidiaphragm (>4 cm Lt vs Rt)
Distortion of diaphragmatic margin.
 Lt- 69% , Rt -24% B/L- 15%

66. Hollow Viscus Injuries
 Gastric Injury :
o Penetrating trauma MC
o Blunt trauma abdomen 1%
 Duodenum
o Isolated Duodenum injury rare Incidence - 3-5%
 Small Intestine& Colonic Injuries
o Commonly Injured in Penetrating injury
o Blunt Trauma -Incidence 5% -20%

67.  Bladder Injury
o Commonly in BTA
o 70% of bladder Injury are associated with pelvic fracture .
o Type 1.Extraperitoneal Rupture-by bony fragment
2. Intra-peritoneal Rupture- at dome

68. Vascular Injury
 Incidence 5-10%
 Highly lethal.
 Associated with extremely rapid rates of blood loss
 Exposure is difficult in Laparotomy
 Initial Control by digital pressure
 Heparinized saline (50U/ml) injected in both end of vessel
 Rx Lateral suture ,End to end Anastomosis &
Interposition graft
 Mortality rate is very high

69. Injury Prevention
1.Primary: Prevent an injury from its occurrence in the first place:
Educational activity such as anti-drink-driving campaigns , speed
limit rule
-Children should accompanied with parent
2.Secondary: Attempts to lesson the consequences of injury –
making road & safer car, anti-locking brakes, air bags , helmets,
seat belt
3. Tertiary: Minimize the effect of injury by health care by
individuals & system.

70. Injury Prevention (Contd.)
 Speed is a critical factor ; a 10% increase speed translate into a
40% rise in the case fatality rate.
 Use of seat belt reduces the risk of death or serious injury by
45%.
 Air Bags reduces the risk of fatal injury by 30% & deaths by 11
%.
 Children Below 12yrs should be properly restraints in the back
seat.
 Motorcycle experience death rate 35 time greater than car.

71. Summary
 Trauma is a massive & growing health burden
worldwide ,which increasingly afflicts the young &
productive age group.
 Repeated assessment is required to make the diagnosis
 Ultrasonography and peritoneal aspiration are rapid
methods of determining or excluding the presence of
Hemoperitoneum
 Conservative approach in Liver & Renal Injury
 Successful m/m of trauma requires integration of Pre-
hospital ,in-hospital ,& rehabilitative care.

72. Thank You