ABDOMINAL TRAUMA : AN OVERVIEW

Dr S. Lal MSAssociate Professor

Department of SurgeryESI PGIMSR New Delhi

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

Epidemiology

• Peak incidence Abdominal Trauma

15 - 30yr•  More than 1.5 Lac people die every year as

a result of injuries by motor vehicle accident , fall, suicide and homicide

• Injury accounts for 10% of all deaths• Estimates indicate that by 2020, 8.4

million people will die yearly.• Prevalence: 13%

Types of Abdominal Trauma

1.Blunt Trauma

2.Penetrating Trauma

-Stab

-Gun shot Injury

M.V. Accidents involving high kinetic energy and acceleration or deceleration forces - 60%

Direct blow to abdomen - 15%

Fall- 6-9%

Blunt Trauma Abdomen (contd.)• Child Abuse• Domestic Violence • Iatrogenic injury

-Endoscopic /Laparoscopic surgical procedures

-Bag-mask ventilations

-Inadvertent esophageal intubation

-External cardiac compressions

-Heimlich manoeuvre

Penetrating Trauma

Penetrating abdominal trauma has a slightly higher mortality rate

Second most common cause of abdominal injury

Gunshot InjuryGunshot and stab wounds combine to cause 95% of penetrating abdominal injuries.

Prehospital Care• The goal of prehospital 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

Initial Assessment and Resuscitation

Primary survey

Identification & treatment of life threatening conditions

• Airway , with cervical spine precautions• Breathing • Circulation • Disability• Exposure

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

Secondary Survey• General &Systemic Examination-to identify

all occult injuries .• Special attention to Back, Axilla , Perineum • PR - sphincter tone ,bleeding ,perforation ,

high riding prostate• Foley’s catheter- monitor urine out put • Nasogastric tube

Secondary Survey(contd.)

AMPLE History

A: Allergy

M: Medications

P: Past medical history

L: Last meal

E: Event - What happened

Examination

• Laceration • Abrasion • Entry/Exit wounds • Involvement chest

& Head injury• Seat Belt Sign

Examination Cullen’s Sign:1918

Bluish discoloration around umbilicus

Diffusion of blood along periumbilical

tissues or falciform ligament

Hemoperitoneum

Severe pancreatitis

Examination

Grey-Turner’s Sign: (1877-1951)Bluish discoloration of the flanks

Retroperitoneal Hematoma

hemorrhagic pancreatitis.

Kehr’s sign (1862-1916).

Referred pain, Right shoulder

irritation of the diaphragm

(Splenic injury, free air,

intra-abdominal bleeding)

Examination

Balance’s SignDullness on percussion of the left upper quadrant

ruptured spleen

Labia and Scrotum : Pooling of blood from

abdominal and pelvic cavities.

ExaminationAuscultation :1. Bowel sounds in the

thoracic cavity (Diaphragmatic rupture)

2. Haemothorax

Palpation: -Mass

-Tenderness

-Signs of peritonitis

-# Ribs

-Chest & Pelvic compression test

Investigations

• FAST • X-Ray Chest & Abdomen• USG• CT Scan• Paracentasis• Diagnostic Peritoneal Lavage• Diagnostic Laparoscopy

Focused Assessment with Sonography in Trauma (FAST)

• First used in 1996 • Rapid , Accurate • Sensitivity 86- 99%• Can detect 100 mL of blood• Cost effective• Four different views- Pericardiac

Perihepatic

Perisplenic

Peripelvic space• Eliminates unnecessary CT scans • Helps in management plan

Plain X-Ray Chest & Abdomen

• Pneumotharax, Haemothorax • 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

USG

Advantage

• Easy & Early to Diagnose• Noninvasive • No Radiation Exposure

Resuscitation/Emergency room

Used in initial Evaluation

Low cost

Disadvantage

. Examiner Dependent• Obesity• Gas interposition• Low Sensitivity for free fluid

less 500 mL• False –Negative

retroperitoneal & Hallow viscus injury

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%

Diagnostic Peritoneal Lavage

• First described in 1965• Rapid & Accurate test used to identify intra-

abdominal injuries • Predictive value of greater than 90% • The RBC count for lavage fluid is >

1,00,000/cu m.m.• A WBC count > 500/cu m.m.• Test is highly sensitive to presence of

intraperitoneal blood • However specificity is low

Diagnostic Peritoneal Lavage

Indications

• Unexplained Shock • Altered sensorium (Head

injury , Drug)• General anesthesia for

extra-abdominal procedures

Contraindications• Clear indication for

Exploratory Laparotomy• Relative

-Previous Expl. Laparotomy

-Pregnancy

-Obesity

CT Scan•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%

CT Scan

Contraindication:• Clear indication for Laparotomy• Haemodynamically Unstable• Allergy to contrast media

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

Solid Organ Injuries

• Grading of injured solid organs such as Spleen, Liver &

Kidneys are on the basis of subcapsular

hematoma ,capsular tear, parenchymal lacerations &

avulsion of vascular pedicle

• Bleeds significantly and cause rapid blood loss

• Difficult to identify injury by physical exam

• Repeated assessment is required to make the diagnosis

• Slowly oozing blood into peritoneal cavity

SPLENIC INJURY

• Most common intra- abdominal organ to injured (40-55%)

• 20% of splenic injuries due to left lower rib fractures

• Commonly arterial hemorrhage

• Conservative management :

-Hemodynamic stability

- Negative abdominal examination

-Absence of contrast extravasation in CT

- Absence of other indication of Laprotomy

-Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm)

Monitoring

• Serial abdo. Examinations & Haematocrit are essential

• Success rate of conservative m/m is >80%

Splenic Injuries Operative ManagementCapsular 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%

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.

Liver Injury

• 50% liver injury have stop bleeding

spontaneously by the time of surgery

Non Operative m/m

• 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)

Liver Injury Operative m/m

• Packing

- Bleeding can be stopped by packing of abdomen

-Pack removed after 48 hr

-haemostatic agents

-34 % survival in packing only

• 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%

Liver Injury Operative Management(Contd.)

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

Pancreatic Injury

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

MVA

Renal Injury

Diagnosis

1.History ,Clinical examination

2. Presentation :Shock, hematuria & pain3. Urine: gross or microscopic hematuria

Renal Injury

Diagnosis (contd.)

5.X-ray KUB IVP 7. USG 6.CT Scan abdomen

8. Radionuclide Scan

The degree of hematuria may not predict the

severity of renal injury

m

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

Management of Renal Injury

About 85% of blunt renal trauma can be manage by conservatively

Renal Contusion : Conservatively

Renal exploration : Indication• Deep cortico-medullary Laceration with

extravasation • Large perinephric Hematoma• Renovascular injury • Uncontrolled bleeding

Before Nephrectomy ,Contralateral Kidney

should be assessed

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%

Diaphragm Rupture /Hernia

• S Lal, Y Kailasia , S Chouhan , APS Gaharwar, GP Shrivastava . Delayed presentation of post traumatic diaphragmatic hernia. JSCR 2011. 7:6

Diaphragm Rupture /Hernia

S Lal, Y Kailasia, S Chouhan, APS Gaharwar, GP Shrivastava. Delayed presentation of post traumatic diaphragmatic hernia. JSCR 2011. 7:6

Hollow Viscus Injuries Gastric Injury : Penetrating trauma MC

Blunt trauma abdomen 1%

Causes

Penetrating Injury

-Crushing Against the Spine

-CPR

-Vigorous Ventilation with ET Tube in the Esophagus

-Heimlich Maneuver

Diagnosis : X-Ray chest & Abdomen

CT scan

Diagnostic Peritoneal Lavage

During Surgical Exploration

T/t : Expl. Laparotomy with Primary Repair

Hollow Viscus Injuries (Contd.) DuodenumIsolated Duodenum injury rare Incidence - 3-5% Cause :Penetrating injury: mc Steering wheel injury Assault Fall Associated with other intra-abdominal injury Diagnosis:Plan X-ray –Free air in abdomen -Intraoperative diagnosis

Rx : Primary Repair 80% case Roux-en –Y duodenojejunostomy 20%

Hollow Viscus Injuries

Small Intestine& Colonic InjuriesCommonly Injured in Penetrating injury

Blunt Trauma -Incidence 5% -20%Mechanism : -Crush Injury -At Fixed point DJ & IC Junction

Rx : Exploratory Laprotomy

Bladder Injury

• Commonly in BTA

• 70% of bladder Injury are associated with pelvic fracture .

• Hematuria

Type 1.Extraperitoneal Rupture-by bony fragment

• 2. Intraperitoneal Rupture- at dome

when blow in distended bladder

• Diagnosis -1. Clinical 2. Cystography

T/t 1. Intraperitoneal –trans-peritoneal - closure +SPC

2:Extraperitoneal Rupture : Foley’s catheter -10 -14 days

Ureteral Injury• Uncommon• Mostly occur after penetrating trauma• Associated with concomitant intra-abdominal or

genitourinary injury• Diagnosis

-IVP

-15-20% Retrograde ureteroscopy

- At the time of Laparotomy• Operative procedure

Proximal & mid ureter -End to end Anastomosis over DJ Stent

Distal –Ureteric Reimplantaion

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

Trauma in Pregnancy• Incidence- 10-20%

• Causes: 1.Domestic violence

2.Sexual Assault 3. Accident

• Third trimester- mc- balance & coordination disturbed

• Multidisciplinary team- Obstetrician, surgeon, and neonatologist

• Peritoneal sign are delayed

• “Supine hypotensive syndrome” > 20 weeks’ gestation.

COMPLICATIONS

• Fetal Injury & Death –fetoplacental injury, maternal shock,

• Placental Abruption

• Rupture of Uterus

Penetrating abdominal trauma

•Gunshot•Stab wound

Penetrating Abdominal Trauma

• Patients with deep penetrating injuries always require surgery• Common Organs –Small int.(29%) liver(28%) Colon(23%)

EAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

Penetrating Abdominal Trauma(Contd.)

• Multiple in 20% of cases • Most stab wounds do not cause an

intraperitoneal injury• A complete Laparotomy is

mandatory

Penetrating Abdominal Trauma(Contd.)

Abdominal Evisceration

Stab wound to right lower quadrant with caecal evisceration.  No colon injury at laparotomy

Penetrating Abdominal Trauma(Contd.)

Abdominal Evisceration

• Never try to replace organs

• Cover with moist gauze, then sterile dressing.

• Transport immediately

Gunshot Injury

• Handguns, Rifles, and Shotgun• More dangerous than penetrating injury

• The degree of injury depends . Amount of kinetic energy imparted by the bullet to the

victim Mass of the bullet and the square of its velocity Distance .• Injury multiple organ

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.

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.

Summary

• Injuries are Preventable• 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

Prehospital ,in-hospital ,& rehabilitative care.