ABDOMINAL TRAUMA : AN OVERVIEW Dr S. Lal MS Associate Professor Department of Surgery ESI PGIMSR New Delhi
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.