abdominal trauma

1. Abdominal trauma
PRESENTED BY:
Dr Louza Alnqodi, R3

2. outlines
• Background
• Clinical assessment of pt with blunt ,
penetrating abdominal injuries
• Diagnostic tools
• Clinical approach
• Conclusion.

3. R1
• Which of the following does not cause a
falsely +ve DPL?
*Abdominal wall hematoma
*inadequate homeostasis
*pelvic #
*retroperitoneal injury

4. R1
• Which of the following does not cause a
falsely +ve DPL?
*Abdominal wall hematoma
*inadequate haemostasis
*pelvic #
retroperitoneal injury

5. R2
• Criteria for a +ve DPL include all of the
following except:
*initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
wound.
*presence of bile, bacteria or meat/vegetable fibers

6. R2
• Criteria for a +ve DPL include all of the
following except:
initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
wound.
*presence of bile, bacteria or meat/vegetable fibers

7. R3
During the evaluation of a trauma patient, an
upright CXR showed gastric bubble shifted to
the rt .
No free air is present. What is the main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury

8. R3
During the evaluation of a trauma patient, an
upright CXR showed gastric bubble shifted to
the rt .
No free air is present. What is the main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury

9. R4
• All of the following are clinical indicators' for urgent
laprotomy in pt presenting with abdominal stab
wounds except which one?
• *bowel protrusion or evisceration
• *evidence of diaphragmatic injury
• *indeterminate local wound exploration
• Peritoneal irritation on physical examination
• Significant GI bleeding

10. R4
• All of the following are clinical indicators' for urgent
laprotomy in pt presenting with abdominal stab
wounds except which one?
• *bowel protrusion or evisceration
• *evidence of diaphragmatic injury
• *indeterminate local wound exploration
• Peritoneal irritation on physical examination
• Significant GI bleeding

11. R5
• A 25 yr old male presents with a stab wound to the
upper abdomen. Vital signs are stable. The
abdomen is not distended, soft, non-tender. Bowel
sounds are present. Upright CXR does not
demonstrate a Penumothorax or free air under
diaphragm. What should the next step be?
*evaluation of the peritoneal entry by local wound exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.

12. R5
• A 25 yr old male presents with a stab wound to the upper
abdomen. Vital signs are stable. The abdomen is not
distended, soft, non-tender. Bowel sounds are present.
Upright CXR does not demonstrate a Penumothorax or free
air under diaphragm. What should the next step be?
*evaluation of the peritoneal entry by local wound exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.

13. anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
 Pelvic cavity contents

14. o Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal
ligaments and symphysis pubis.
o flank:
anterior and posterior axillary line ;sixth intercostal
to iliac crest
o Back:
posterior axillary line; tip of scapula to iliac crest

15. • Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small
bowel, sigmoid colon
• Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending
and descending colons
• Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia

16. mechanism
• Blunt trauma:
MVC
Seatbelt injury
fall from ht
crash injury
sport injury
 Penetrating injuries.

17. Blunt abdominal injuries carry a greater risk of
morbidity and mortality than peneterating
abdominal injuries.

18. • associated with severe trauma to multiple
intraperitoneal organs and extra-abdominal systems
• altered mental status, intoxication
• Peritoneal signs are often subtle and may be
obscured by other painful injuries
•
Up to 20% of patients with hemoperitoneum have
benign abdominal exams on initial presentation.

19. Blunt injury
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%

20. Splenic rupture is the most common visceral injury with blunt
abdominal trauma. Which of the following statements
regarding splenic rupture is FALSE?
• CT scan may confirm injury, but should not delay laparotomy
in unstable patients.
• Twenty percent of patients with left lower rib fractures have
associated splenic injury.
• Focused Assessment with Sonography for Trauma is useful if
performed by experienced users.
• Signs of peritonitis (involuntary guarding, rigidity, rebound)
are nearly always present.

21. Splenic rupture is the most common visceral injury with blunt
abdominal trauma. Which of the following statements
regarding splenic rupture is FALSE?
• CT scan may confirm injury, but should not delay laparotomy
in unstable patients.
• Twenty percent of patients with left lower rib fractures have
associated splenic injury.
• Focused Assessment with Sonography for Trauma is useful if
performed by experienced users.
• Signs of peritonitis (involuntary guarding, rigidity, rebound)
are nearly always present.

22. Seatbelt injuries
Unrestrained front and rear seat passengers are at
unequivocally greater risk of intra-abdominal injury
than their restrained counterparts.
The three-point shoulder-lap belt is the most effective
restraining system and is associated with the lowest
incidence of abdominal injuries.
However, abdominal injuries are still ascribed to
shoulder-lap and lap-belt systems.

23. pathogensis
o compression of bowel between the belt and the
vertebral column.
o an acute short closed-loop obstruction occurs along
with perforation secondary to the sudden generation
of high intraluminal pressures.

24. Clinically, two symptom patterns emerge.
 ~1/4 of pt develop evidence of a hemoperitoneum secondary
to mesenteric lacerations.
 In the remainder, the intestinal injury most commonly
involves the jejunum contusion or perforation.
 Rare cases of acute abdominal aortic dissection with
incomplete or complete occlusion have also been described,
and injuries to the lumbar spine are not uncommon.

25. Penetrating abdominal trauma

26. Mechanism
• Stab wound
• gunshot

27. • Knives are not the sole implement used in stabbings.
• Ice picks, pens, coat hangers, screwdrivers, and broken
bottles.
• most commonly in the upper quadrants, the left
more commonly than the right.

28. Stab wound
 multiple in 20% of cases
 involve the chest in up to 10% of cases.
 Most stab wounds do not cause an
intraperitoneal injury
 the incidence varies with the direction of entry
into the peritoneal cavity
 The liver, followed by the small bowel, is the
organ most often damaged by stab wounds.

29. Gunshot Wounds
• handguns, rifles, and shotgun
• 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 .

30. Missile velocities :
low (slower than 1100ft/sec)
medium (1100-2000ft/sec)
high (faster than 2000-2500ft/sec)

31. • type I wounds: long range (>7 yards) , a penetration
of subcutaneous tissue and deep fascia only.
• Type II wounds: distance of 3 to 7 yards and may
create a large number of perforated structures.
• Type III wounds occur at point-blank range (<3 yards)
and involve a massive destruction of tissue

32.
 multiple organ injuries are sustained, notably
perforations to bowel .
 greatest for small bowel, followed by the
colon and then the liver.

33. Missiles effects
• Extensive tissue damage
• external contaminants tend to be dragged into the
wound.
• the closure of the tract immediately after the bullet's
passage may lead to an underestimation of tissue
damage.
• high-velocity bullets can fragment internally

34. • Small bowel injury is the most common injury
resulting from ___ abdominal trauma.
• penetrating
• blunt

35. • Small bowel injury is the most common injury
resulting from ___ abdominal trauma.
• penetrating
• blunt

36. CLINICAL ASSESSMENT OF PT WITH
ABDOMINAL TRAUMA .

37. history
• Primary goal is to identify that an injury exists, not necessarily
making an accurate diagnosis.
• The patient's history may be unobtainable, elusive, or
temporarily abandoned while resuscitative measures are
carried out.
• History from prehospital care team or transferring hospital :
the vital signs, physical assessment, prehospital course, and
response to therapy should be obtained
• Mechanism of injury is an important factor in developing a
high index of suspicion; thus a detailed history is helpful if
available.

38. • Details about accident
• Damage to car
• Velocity
• Steering wheel damage
• Type of seatbelts used
• Air bags deployed
• All patients involved in deceleration injuries and
bicycle injuries should be suspected of having
intraabdominal injury

39. In penetrating trauma:
• # of shots or stabs
• Type of weapon
• Distance b/w firearm and victim

40. examination
 Overall, the accuracy of the physical examination
in patients with blunt abdominal trauma is 55% to
65%.
 Although the presence of physical findings makes
intraperitoneal injury more likely, their absence does
not preclude serious pathology, and none is
exclusively diagnostic of a specific injury.

41. • Hypotension in the acute stage results from
hemorrhage that is most often from a solid visceral
or vascular injury.
• hypotension with significant multiple blunt trauma
and is unexplained, one should assume the presence
of intraperitoneal hemorrhage until it is excluded.

42. • In conscious, alert pt, look for:
• Abdo tenderness,90%
• Peritoneal irritation
• Penetrating: wounds (log roll pt)
• Ecchymosis, Cullen and Gray-Turner signs

43. • Rectal exam is important; assess for blood and
palpable bony fragments and position of the
prostate. High riding prostate suggests posterior
urethral tears.
• Urethral disruption should be considered when blood
is noted at the meatus.
• Vaginal exam for bleeding – may suggest bony
fragments causing laceration. Implications of
bleeding during pregnancy should be considered.

44. • The major findings with injury of the solid
abdominal organs are those of hemorrhagic shock.
Signs with solid organ injury include all of the
following EXCEPT:
• abdominal pain and tenderness
• early bacterial peritonitis
• development of rebound, guarding and rigidity
• hypotension and tachycardia
• palpable mass and radiographic mass effect (may result from
confined hemorrhage)

45. • The major findings with injury of the solid
abdominal organs are those of hemorrhagic shock.
Signs with solid organ injury include all of the
following EXCEPT:
• abdominal pain and tenderness
• early bacterial peritonitis
• development of rebound, guarding and rigidity
• hypotension and tachycardia
• palpable mass and radiographic mass effect (may result from
confined hemorrhage)

46. DIAGNOSTIC STRATEGIES
• Hct: can be a delayed sign, should do serial.
• WBC: ↑ in stress, peritoneal irritation
• Pancreatic enzymes: if normal, does NOT r/o
pancreatic injury
↑ amylase: EtOH, narcotics
↑amylase & ↑lipase: ischemia 2° hypotension
both non-specific & non-sensitive for pancreatic
injuries

47. • Are abdo x-rays useful in trauma?
Although plain abdominal films can demonstrate
numerous findings, their place in acute trauma is
limited. Because of spinal precautions, hemodynamic
instability, time consuming or patient discomfort.

49. Smaller diaphragmatic injuries are often missed, with
herniation occurring late as the negative intrathoracic
pressure gradually draws the mobile abdominal organs into
the chest. Early radiographic findings may be absent or
subtle and include all of the following EXCEPT :
• pleural effusion
• appearance of the nasogastric tube in the chest
• appearance of bowel loops in the chest
• elevation of the diaphragm
• blurring of the diaphragm

50. Smaller diaphragmatic injuries are often missed, with
herniation occurring late as the negative intrathoracic
pressure gradually draws the mobile abdominal organs into
the chest. Early radiographic findings may be absent or
subtle and include all of the following EXCEPT :
• pleural effusion
• appearance of the nasogastric tube in the chest
• appearance of bowel loops in the chest
• elevation of the diaphragm
• blurring of the diaphragm

51. Imaging
• CT
– Able to define organ injury
– Good for retroperitoneal &
vertebral column
– Non-invasive
– Not Operator dependant
– Not great for hollow viscus
– Stable patient
– Cost $$$
– Complications: IV or oral
contrast
• US
– Good for solid organs
– Portable
– Fast
– 100 cc detection blood
– Mediastinum evaluation
– No radiation
– No contrast need
– Not see well: solid
parenchymal, retroperitoneal,
diaphragm
– Problem if: obesity, gas
– Less sensitive than DPL for
hemoperitoneal
– Operator dependant

52. 20 y/o female patient involved in a low velocity MVA. Upon initial exam no
abnormalities noted, no complains.
The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT
Scan which showed Liver Laceration Grade III. This patient was treated non-
operatively.

56. Preferred Site of Diagnostic Peritoneal Lavage
• Standard adult :Infraumbilical midline C or SO
• Standard pediatric: Infraumbilical midline C or SO
• 2ed &3ed trimester pregnancy :Suprauterine FO
• Midline scarring :Left lower quadrant FO
• Pelvic fracture: Supraumbilical FO

57. DPL RBC Criteria (per mm3(
Positive Indeterminate
Blunt 100,000 20–100,000
Stab wound
Anterior abdomen 100,000 20,000–100,000
Flank 100,000 20,000–100,00
Back 100,000 20,000–100,000
Low chest 5000 1000-5000
Gunshot wound 5000 1000-5000

58. • List causes false negative DPL?
Catheter preperitoneal space
Fluid in compartment 2° adhesions
Diaphragmatic tear, so fluid goes into thoracic cavity
•

59. -sole absolute contraindication to DPL is the established
need for laparotomy.
Relative contraindications:
- prior abdominal surgery
- Infections
- Coagulopathy
- obesity
- second- or third-trimester pregnancy.

60. CLINICAL APPROCHES TO PT WITH:
o BLUNT ABDOMINAL TRAUMA
o STAB WOUND
o GUNSHOT
o ABDOMINAL WITH PELVIC TRAUMA.

62. Clinical Indications for Laparotomy after Blunt
Trauma
Manifestation Pitfall
Unstable vital signs with
strongly suspected
abdominal injury
Alternate sources shock
Unequivocal peritoneal
irritation
Unreliable
Pneumoperitoneum Insensitive; may be due to
cardiopulmonary source or invasive
procedures (diagnostic peritoneal
lavage, laparoscopy)
Evidence of diaphragmatic
injury
Nonspecific
Significant gastrointestinal
bleeding
Uncommon, unknown accuracy

63. Approach to abdominal stab
wound.
• Step I: Clinical Indications for Laparotomy.
• Step II: Peritoneal Violation.
• Step III: Injury Requiring Laparotomy.

65. Clinical Indications for Laparotomy Following
Penetrating Trauma
Manifestation Premise Pitfall
Hemodynamic
instability
Major solid visceral or
vascular injury
Thorax or mediastinum,
causal or contributory
Peritoneal signs Intraperitoneal injury Unreliable, especially
immediately post-injury
Evisceration Additional bowel, other injury No injury in one fourth to one
third of stab wound cases
Diaphragmatic injury Diaphragm Rare clinical, radiographic
findings
Gastrointestinal
hemorrhage
Proximal gut Uncommon, unknown
accuracy
Implement in situ Vascular impalement Comorbid disease or
pregnancy creates high
operative risk
Intraperitoneal air Hollow viscus perforation Insensitive; may be caused by
intraperitoneal entry only or
be due to cardiopulmonary
source

66. Peritoneal Violation.
• 1. Evisceration
• 2. Intraperitoneal air
• 3. Local wound exploration
• 4. Ultrasonography
• 5. Laparoscopy

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

68. • Eviscerated omentum is easily mistaken for subcutaneous
fat, so care must be taken in the examination of open
abdominal injuries. Which of the following statements
regarding abdominal evisceration treatment is FALSE?
• Cover eviscerated organs with moist gauze or petrolatum
gauze (to prevent desiccation) for replacement at laparotomy.
• Return all eviscerated organs to the peritoneal cavity.
• Only organs with vascular compromise should be promptly
returned to the abdominal cavity.

69. • Eviscerated omentum is easily mistaken for subcutaneous
fat, so care must be taken in the examination of open
abdominal injuries. Which of the following statements
regarding abdominal evisceration treatment is FALSE?
• Cover eviscerated organs with moist gauze or petrolatum
gauze (to prevent desiccation) for replacement at laparotomy.
• Return all eviscerated organs to the peritoneal cavity.
• Only organs with vascular compromise should be promptly
returned to the abdominal cavity.

70. • In the abdominal stab wound victim without clear indications for
exploration (obvious peritoneal penetration, unexplained hypotension, or
signs of peritoneal irritation), local wound exploration with local
anesthesia should be performed; laparotomy should be performed if the
__ is penetrated.
• rectus abdominis muscle
• posterior rectus sheath
• transversalis fascia.

71. 25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar
entered at the level of the epigastrium and exited through the left posterior thoracic wall.
Abdominal stab wound, with hepatic
lesion grade II.

72. Implements in situ
• implements in situ of the torso in the operating room.
 to ensure expeditious control of hemorrhage
 the implement reside within a vascular space or highly vascularized
organ.
• exceptions to this practice exist:
 situations in which emergency department resuscitation is impeded by
the presence of the implement
 the patient is at high risk of significant morbidity from nontherapeutic
laparotomy because of severe comorbid conditions or pregnancy.

74. •What is your approach to pelvic#?

75. conculsion
• The accuracy of physical examination is limited in cases of
blunt and penetrating trauma. It is less reliable by distracting
injury, altered sensorium (e.g., head trauma, alcohol or drug
intoxication, mental retardation), and spinal cord injury.
• The choice of diagnostic studies for abdominal trauma is
based on clinical need first and foremost, as well as study
availability and the trustworthiness of that study in a
respective center

76. • Ultrasonography and peritoneal aspiration are rapid methods
of determining or excluding the presence of hemoperitoneum
in the critically ill blunt or penetrating trauma patient.
• Clinical indications for laparotomy are more dependable in
and more frequently applicable to cases of penetrating
trauma than cases of blunt trauma.

77. THANK YOU