ABDOMINAL TRAUMA DR. Tamer N. Abdelbaki MD *Associate ...

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ABDOMINAL TRAUMA

DR. Tamer N. Abdelbaki MD

*Associate Professor of Hepatobiliary

&pancreatic surgery, university of Alexandria,

Egypt.

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I. TOPOGRAPHIC ANATOMY

Definitions:

- Thoracoabdominal area: Transverse nipple line to costal margin

- Anterior abdomen: Costal margin to groin crease to anterior axillary

lines bilaterally

- Flank area: Anterior axillary line to posterior axillary line, costal margin to

iliac

crests

- Back: Medial to posterior axillary lines, tip of scapula to iliac crests

- Torso: All the above

The Abdomen is More Than Just the Abdomen:

Intraperitoneal cavity

Retroperitoneal cavity & pelvis

thoracoabdominal injuries

cardiac box injuries(Heart & Great Vessels )

Diaphragm & Bladder (innocent bystanders)

II. CLASSIFICATION:

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(Causes, Mechanisms and Grading)

i.CAUSES:

- Penetrating Abdominal Trauma (PAT) Gun Shot Wounds (High velocity, Low velocity), 25%

Stab wounds , 75%

Stab Wounds Knives, ice picks, pens, coat hangers, broken bottles

Less often multiple organ injuries

Liver, small bowel, spleen

Direct effect.

Gunshot wounds Bullets and pellets

Often multiple organ injuries, bowel perforations

small bowel, colon and liver

Direct effect, kinetic energy( cavitation

- Blunt Abdominal Trauma (BAT) High energy transfer (MVA) , 75%

Low energy transfer (fall, fight), 25% RTA, Run over , falls, blows,

Multiple organ damage.

Most commonly injured organs: small intestine > colon > liver

Pressure effect→ burst injury, Crushing effect → crush injury, Acceleration &

deceleration effect → shear injury.

- Mixed Pattern Explosions

ii.PATHOGENESIS Of Injury: Stab Wounds

Knives, ice picks, pens, coat hangers, broken bottles

Less often multiple organ injuries

Liver, small bowel, spleen

Direct effect.

Gunshot wounds

Bullets and pellets

Often multiple organ injuries, bowel perforations

small bowel, colon and liver

Direct effect, kinetic energy( cavitation).

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iii.GRADING (AAST Concept) American association for surgery of Trauma

CT-BASED criteria: mainly relying on: presence of hematoma, laceration,

vascular injury and effect on collecting system.

Grading (Spleen)

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Grading (Liver)

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Grading (Kidney)

Grading (Pancreas)

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III. PRESENTATION:

A. PHYSICAL EXAM

Signs of intraperitoneal injury

➢ Hypovolemia

➢ Peritonism.

➢ Distention (pneumoperitoneum, gastric dilation, or ileus)

➢ subcutaneous emphysema

➢ Entrance and exit wounds to determine path of injury.

➢ Gastrointestinal hemorrhage: Mouth Or DRE

➢ Ecchymosis :

umbilicus (cullen's sign)

flanks(gray turner’s sign) :retroperitoneal hemorrhage

Back: retroperitoneal hemorrhage

Abdominal contusions – seat belt sign,

Cullen’s Sign & Gray turner’s sign

Seat Belt Sign

Be cautious!!!!

Clinical assessment is mandatory but is not enough.

➢ Silent presentation. (Blunt Trauma can be evolving)

➢ Limitation because of degree of consciousness, distracting

injury, spinal cord injury.

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B. INVESTIGATIONS

i. Laboratory Investigations

May have: ↓ Hct.,↑WBC, Lactate, CRP. LFTs, lipase.

ii. Imaging

Plain films:

fractures: nearby visceral damage, Subcutaneous Air

free intraperitoneal air, Retroperitoneal air

Foreign bodies and missiles

iii. FAST(Focused assessment with sonography for trauma): To diagnose free intraperitoneal blood after blunt trauma

4 areas:

Perihepatic & hepato-renal space (Morrison’s pouch)

Perisplenic

Pelvis (Pouch of Douglas/rectovesical pouch)

Pericardium (subxiphoid)

sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid

Extended FAST (E-FAST):

Add thoracic windows to look for pneumothorax.

FAST Advantages:

Portable, fast (<5 min),No radiation or contrast Less expensive

Disadvantages: Operator dependant, Limited by obesity,

substantial bowel gas, and subcut.air.

Not good for retroperitoneum, or diaphragmatic defects.

Not suitable for solid parenchymal damage,

Can’t distinguish blood from other fluid collection.

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FASTMorrison’s pouch (hepato-renal space)

FASTPerisplenic view

FAST Retrovesicle (Pouch of Douglas)

FAST Pericardium (subxiphoid)

iv. Imaging CT

• Advantages :

Accurate for solid organ lesions and intraperitoneal hemorrhage

guide non operative management of solid organ damage

• Disadvantages :

Expensive. Radiation and contrast exposure.

less sensitive for injury of the pancreas, diaphragm, and mesentery.

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v. 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

vi. Diagnostic Peritoneal Lavage (DPL)

1. attempt to aspirate free peritoneal blood

>10 mL positive for intraperitoneal injury

2. insert lavage catheter.

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

DPL Largely replaced by FAST and CT

Limited indications: 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

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IV. TREATMENT:

A. Management Algorithm (BAT):

Initial Resuscitation

Hemodynamically Stable Patient

FAST

-VE +VE

CT

-VE CT SOLID ORGAN

Manage According to the Grade

Conservative

Hollow Organ/Active Bleeding

Hemodynamically Unstable Patient

FAST

-VE+VE

LAPAROTOMY

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Non-Operative Management Criteria Reliable FAST Good quality CT scans Experienced radiologist Intensive care setting Hemodynamically stable Minor Grade Injury Absence of active hemorrhage Absence of peritoneal sign

Operative Management Criteria Lack of reliable FAST

Lack of good quality CT scans Lack of Experienced radiologist Lack of Intensive care setting Hemodynamically unstable High or increasing PRBCs transfusion req. High Grade Injury Active hemorrhage Peritonism

B.Management Algorithm (PAT):

- 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

- Laparoscopy

∙Most useful to evaluate penetrating wounds to thoraco-abdominal region in stable

patient; esp. for diaphragm injury: Sensitivity 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