Management

Of Abdominal
Trauma
BY : CHONG LIH YIN
 Index
1. classification of abdominal injury
2. Pathophysiology of abdominal injury -PAT, BAT
3. Primary Survery
4. Secondary Survey- Physical examination,Lab Test
5. Imaging –Plain radiography , FAST scan, CT
6. Other diagnosis method -DPL,LWE,,Laparascopy, Exploratory Laparatomy
7. Management of BAT and PAT
8. Specific Organ injury
9. -Spleen , Diaphragm, stomach , small intestine, Colorectal injury,
10. Damage control resuscitation
11. Abdominal compartment syndrome
12. Reference
Abdominal Trauma
Blunt Abdominal Trauma
◦ Greater mortality than PAT (more difficult to diagnose, commonly associated with
trauma to multiple organs/systems)
◦ Most commonly injured organs?
- spleen > liver, intestine is the most likely hollow viscus.
◦ Most common causes?
- MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%)
Penetrating Abdominal Trauma
◦ Stabbing 3x more common than firearm wounds
◦ Gun shot wound cause 90% of the deaths
◦ Most commonly injured organs?
- small intestine > colon > liver
Pathophysiology of injury
Penetrating Abdominal Trauma
Stab Wounds
◦ Knives, ice picks, pens, coat
hangers, broken bottles
◦ Liver, small bowel, spleen
Gunshot wounds
◦ small bowel, colon and liver
◦ Often multiple organ injuries,
bowel perforations

Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury
Blunt Abdominal Trauma
• Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal
pressures
• Crushing effect
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
◦ “seat belt sign” = highly correlated with intraperitoneal injury

Rosen’s Emergency Medicine, 7th ed. 2009

Primary Survey –ATLS approach
ABCDE pattern: Airway, Breathing, Circulation, Disability (neurologic status), and
Exposure.
A - intubation may be required if patient is shocked, hypotensive or unconscious or in need
for ventilation. *with cervical precaution.

B - watch for hemothorax in both blunt and penetrating thoracoabdominal injuries.

C - start with 2 L crystalloid (If active bleeding you must find source and stop the bleeding)
D – May seen associated with thorocolumbar #
E - Watch for other injury
 First : recognize presence of shock or intraabdominal
Recognize
bleeding

Resuscitation Second : start resuscitative measures for

shock/bleeding

Diagnostic and Abdomen?

Third : determine if abdomen is source for shock
or bleeding
treatment
priorities Laparatomy ?
Fourth: determine if emergency laparatomy is
needed

Fifth: complete secondary survery,ab,and radiograph

Survey studies to determine if “occult” abdominal injury is
present.

Reassessment Sixth : conduct frequent reassessments.

 History for all trauma patients:
-Not necessary making an accurate diagnosis
S.A.M.P.L.E
S: Symptoms:
Secondary pain,vomiting,hematuria,hematochezia,dyspnea,respiratory
Survey History distress…
A: Allergies
M : Medications
L : Last meals
E : Events (mechanism of injury)
 Inspection : abrasions, contusion,
lacerations, deformity, entrance and exit
wounds to determine path of injury…
(grey Turner, Kehr, Balance,Cullen,seat belt
sign)
Physical Palpation: elicits superficial , deep , or
rebound tenderness; involuntary muscle
Examination duarding
Percussion : subtle signs of peritonitis;
tympany in gastric dilatation or free air;
dullness with hemoperitoneum.
Auscultation : bowel sounds may be
decrease ( late finding).
 Physical examination
Grey-Turner sign : bluid discoloration of
lower flanks, lower back; associated with
retroperitoneal bleeding of
pancrease,kidney or pelvic fracture.
Cullen sign : bluish discoloration around
umbilicus, indicates peritoneal bleeding,
often pancreatic hemorrhage.
Kehr sign: shoulder pain while supine
;caused by diaphragmatic irritation(splenic
injury, free air, intra-abdominal bleeding)
Balance sign : dull percussion in LUQ.Sign
In the trauma patient, a ‘normal’ physical exam of the of splenic injury; blood accumulation in
abdomen doesn’t equate to much. You NEED to do further
testing.
subcapsular or extracapsular spleen
 -Hematocrit – below 30% increases the likelihood of intra-
abdominal injury.
-Leukocyte count – In BAT, the white blood cell (WBC) count is
nonspecific and of little value. Catecholamine release due to
trauma can cause demargination and may elevate the WBC to
12,000 to 20,000/mm3 with a moderate left shift. Solid or hollow
viscus injury can cause comparable elevations
-Pancreatic enzymes – Normal serum amylase and lipase
Laboratory tests concentrations cannot exclude significant pancreatic injury . And
- limited while elevated concentrations raise the possibility of pancreatic
injury,
-Liver function tests – Hepatic injury is associated with
elevations in liver transaminase concentrations
-Urinalysis – Gross hematuria suggests serious renal injury and
mandates further investigation
-Base deficit and lactate - Base deficit less than -6 was
associated with intra-abdominal hemorrhage and the need for
laparotomy and blood transfusion
Plain films generally have NO ROLE
What else do we have?
in acute abdominal trauma

• FAST ultrasound
• Diagnostic Peritoneal Tap
• CT Scan, contrast study
•/ Local wound exploration
• Angiography
• Urethrocystography
• IVU

Imaging in Abdominal Trauma

 Plain radiograph
Findings on chest radiograph that suggest intra-
abdominal injury include:
Lower rib fracture

•Diaphragmatic hernia
•Free air under the diaphragm
 (FAST) Focused assessment with
sonography for trauma
- To diagnosed free intraperitoneal fluid.
- evaluate solid organ hematoma
- Four areas:
1. Pericardium (subxiphoid)
2. Perihepatic &hepatorenal space (morrison’s pouch)
3. Perisplenic
2 1 3
4. Pelvis (pouch of Douglas /rectovesical pouch)
Sensitivity 60-95% for detecting 100ml -500 ml of fluid
E-fast(extended)
-add thoracic windows to look for pneumothorax. Sensitivity
59%,specificity,specificity up to (99% for pneumothorax. )

4
FAST Ultrasound
Advantages Disadvantages
• Sensitivity at detecting 100cc fluid is 60- • -Injury to solid parenchyma, the retroperitoneum,
or the diaphragm is not well seen.
95%
• -Uncooperative patients, obesity, bowel gas, and
• Portable(bedside),fast(<5 min) and subcutaneous air interfere with image quality.
ability to repeat • -Low sensitivity in comparison to CT, particularly for
• No radiation or contrast non-hypotensive patients. Cannot reliably exclude
clinically significant injuries
• Noninvasive • -Blood cannot be distinguished from ascites or
• Rapid results, hemodynamically unstable urine.
patient that unable to go for CT scan • -Subcapsular injuries cannot be detected.
• -Insensitive for detecting bowel injury
• Less expensive
• -Limited in detecting<200cc intraperitoneal fluid
Pericardium
(subxiphoid)
FAST-Morrison’s pouch (hepato-renal space)

Rosen’s Emergency Medicine, 7th ed. 2009

FAST Perisplenic view
FAST-Retrovesicle (Pouch of Douglas)

Rosen’s Emergency Medicine, 7th ed. 2009

trauma.org
CT Imaging
◦ Accurate for solid visceral lesions and intraperitoneal hemorrhage
◦ guide nonoperative management of solid organ damage
◦ IV not oral contrast
◦ Disadvantages : insensitive for injury of the pancreas, diaphragm, small
bowel, and mesentery

Rosen’s Emergency Medicine, 7th ed. 2009

 Diagnostic Peritoneal Taps
DPA - The recovery of 10 cc of frank blood (or more) from the peritoneum
is a strong predictor (90% PPV in blunt trauma) of intraperitoneal injury,
and the procedure is then terminated.

DPL - If aspiration findings are negative, lavage is conducted in which the

peritoneal cavity is washed with saline. RBC count exceeding 100,000/cc
is considered positive and generally specific for injury. Sensitivity 90%.
Diagnositic Peritoneal ‘Lavage’
Is actually a 2 Step Process.

Step 1. DPA (closed).

◦ Patient supine
◦ Landmark is 2 finger widths below umbilicus
◦ Local freezing, puncture skin 30-degrees to the head
◦ Seldinger technique to introduce a DPL catheter
◦ Aspirate using 30cc syringe
 DPA
Advantages
◦ Highly accurate for hemoperitoneum (SENS 90-100%)
◦ Most sensitive test for hollow viscus injury
Disadvantages
◦ Invasive (complication rate 1-5%)
◦ Time consuming (20 minutes)
◦ False positives. Up to 25% non-therapeutic laparotomies
DPA
•If 10cc frank blood or more is aspirated, you are
done, patient needs to go to the OR.

If the DPA is negative, you proceed to Step 2…

Diagnostic Peritoneal Lavage
Step 2. DPL.
◦Hook up 1L of Ringer’s to the peritoneal catheter, and
squeeze into the abdomen.
◦Once infused, put the empty Ringer’s bag on the floor,
and let it back-fill via gravity
◦Send off 10cc for analysis, if 100,000 RBC/cc it is positive
 Is there still a role for DPA?
FAST has largely replaced DPA, likely due to
ease of use.
However, 2 areas where still is warranted:
◦ Hemodynamically unstable and an equivocal FAST
◦ No FAST available
“DPL is safe, sensitive, and reduces the use of
CT” (Journal of Trauma 2007)
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

Rosen’s Emergency Medicine, 7th ed. 2009

Laparoscopy
Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
esp for diaphragm injury: Sens 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
Exploratory laparatomy
Potential indications include the following:
Haemodynamic instability
 Evidence of Peritonitis to achieve control of haemorrhage and control of spillage
Traumatic diaphragmatic injury with herniation
 Severe solid organ injury (e.g. kidney and spleen)
 Infarction due to post traumatic occlusion of the blood supply
 Mesenteric tear/s
 Unexplained Moderate to large amounts of free fluid (200-≥500mls)
 Failed non-operative management
 Management
of BAT

• NOM: nonoperative management

• Abd CT: abdominal CT scan;
• DPT: diagnostic peritoneal tap;
• LAP: laparotomy
Management of penetrating abdominal trauma
Mandatory laparotomy
vs
Selective nonoperative management
Management of penetrating abdominal trauma
Mandatory laparotomy
◦ standard of care for abdominal stab wounds until 1960s, for GSWs until
recently
◦ Now thought unnecessary in 70% of abdominal stab wounds
◦ Increased complication rates, length of stay, costs
◦ Immediate laparotomy indicated for shock, evisceration, and peritonitis
Management of penetrating abdominal trauma
Selective management used to reduce unnecessary laparotomies
Diagnostic studies to determine if there is intraperitoneal injury
requiring operative repair
Strategy depends on abdominal region:
 Thoracoabdomen
Nipple line to costal margin
 Anterior abdomen
Xiphoid to pubis
 Flank and back
Posterior to anterior axillary line
Management of penetrating abdominal trauma
Thoracoabdomen
Big concern is diaphragmatic injury
◦ 7% of thoracoabdominal wounds
Diagnostic evaluation:
◦ CXR (hemothorax or pneumothorax)
◦ Diagnostic peritoneal lavage
◦ FAST
◦ Thoracoscopy

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Thoracoabdomen
Management of penetrating abdominal trauma
Anterior abdomen
◦ Only 50-70% of anterior stab wounds enter the abdomen
◦ of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?
 Management of penetrating abdominal trauma
Back/Flank
◦ Risk of retroperitoneal injury
◦ Intraperitoneal organ injury 15-
40%
◦ Difficulty evaluating
retroperitoneal organs with
exam and FAST
◦ In stable pts, CT scan is reliable
for excluding significant injury:

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
 Management of PAT
Anterior abdomen

laparoscopy (LPY), or serial physical examinations (SPEs)

Management of penetrating abdominal trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal penetration have injury requiring
operative management
Most centers proceed to lap if peritoneal entry is suspected
Expectant management rarely done
 Management of PAT
Gunshot wounds
-assess peritoneal entry by missile path,
LWE, CT, US, laparoscopy (all limited)

laparoscopy (LPY), or serial physical examinations (SPEs)

Specific Organ Injury
-Treatment of an organ injury is Specific organ
similar whether the injury trauma:
mechanism is penetrating or 1. peritoneal
blunt 2. retroperitoneal
-An exception to the rule is a
3. diaphragm
retroperitoneal hematoma
-explore all retroperitoneal
hematoma caused by
penetrating injury.
 Splenic Injury - Grading System(AAST)
I - Hematoma, subcapsular <10% SA
Capsular Laceration <1cm
II - Hematoma, subcapsular 10-50% SA; intraparenchymal <5cm
Capsular Laceration 1-3cm
III - Hematoma, subcapsular >50% SA; intraparenchymal >5cm
Capsular Laceration >3cm (or parenchymal depth)
IV - Hematoma ruptured into parenchyma
Hilar Injury devascularizing spleen >25%
V - Vascular hilar injury devascularing spleen 100%, or
‘Shattered’
WSES classification
Minor spleen injuries:
WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and penetrating lesions.
Moderate spleen injuries:
WSES class II includes hemodynamically stable AAST-OIS grade III blunt and penetrating lesions.
WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating
lesions.
Severe spleen injuries:
WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and penetrating
lesions.
 Diaphragmatic injury
Its possible in injuries to the thoracoabdominal region
Can be due to blunt(>85%) or penetrating injury and is larger in the blunt
Possible cardiac injury if the penetrating wound is more central
The weakest point of diaphragm is the left posteriorlateral(80%)
Often missed in multitrauma
In isolated injury it may go unnoticed and there is often a delay between the injury and the diagnosis
Patients present with non specific symptoms and may complain of chest pain,abdominal pain,dyspnea
,tachypnea and cough
Rupture with herniation is diagnosed by CXR or CT but without herniation is difficult to diagnose
Thoracoscopy or laparascopy is diagnostic
Treatment
Once identified must be repaired because it will not close spontaneously regardless the size.
Early diagnosis needs abdominal approach using the interrupted nonabsorbable suture and
the large defect(>25cm2) may need nonabsorbable mesh.
In the event of a gross contamination, endogenous tissue can be utilized for a definitive repair
as latissimus dorsi flap, tensor fascia lata or omentum.
There are some who advocate using biologic tissue grafts, such as AlloDerm(human acellular
tissue matrix).The durability of such a repair is questionable.
Place chest tube on the surgery side at the time of repair
 Stomach
More common in penetrating trauma than blunt &
its about 10% of penetrating injuries of the abdomen
• FAST examination:-
Diagnosis:
unreliable
Physical exam: • DPL: WBC, RBC < Gross
-epigastric tenderness, contamination
• CT scan:
-peritoneal signs,
pneumoperitoneum
-bloody gastric aspirate. • Laparoscopy:-operator
Plain radiography in <50%: dependent
-free air under diaphragm
 Stomach treatment is according to the
severity
administer preop abx
Hematoma is evacuated ,hemostasis and closure with nonabsorbable suture.
Small perforation can be closed in one or two layered
Large injuries near the greater curvature can be closed by suture or GIA stapler
Certain defects may be closed using a TA stapler
A pyloric wound may be converted to pyloroplasty
Destructive wound may need proximal or distal gastrectomy
In rare cases a total gastrectomy and Roux-en –y esophagojejunostomy are necessary for severe
cases.
 Small intestine
The small bowel is the mc injured intraabdominal organ in penetrating
tauma, a blunt trauma cause is less common,but not rare(10%)
Small isolated perforation probably result from blowout of pseudoclosed
loops(seatbelt related injuries)
Larger perforation, complete disruptions and injuries associated with
large mesenteric hematoma or laceration are caused by direct blows or
shearing injury or contusion
Perforation from blunt injury is the mc at the ligament of triez,ileocecal
valve,midjejunum or in the areas of adhesion
Small intestinee
• CT has a significant false negative rate in the diagnosis of small-
bowel injury.
• CT findings in small-bowel injury include:
Fluid collections without solid viscus injury
Bowel wall thickening
 Mesenteric infiltration
Free intraperitoneal air
 Oral contrast extravasation
Colon and rectum
-Diagnosis
• Peritoneal signs or free intraperitoneal air.
• At laparotomy, small injuries in the wall of the colon can be missed so explore all blood staining
or hematomas of the colonic wall.
• Consider proctoscopy or proctosigmoidescopy in :
- Gross blood on PR in the presence of a pelvic fracture
- Penetrating abdominal, buttock, thigh or pelvic wound.
- Any patient with a major pelvic fracture if the patient is stable.
• The location of the injury can be important in planning the operation. Even if the hole cannot be
visualized on proctoscopy, assume the patient has a colorectal injury, if there is intraluminal blood.
• In hemodynamically unstable patients, proceed with laparotomy first.
 Current operative options include :

-Primary repair of the injury,

Colon and
rectum -.Resection and anastomosis, and

-Colostomy..
 Colon and rectum
The guidelines for primary repair include :
• Minimal fecal spillage, If a primary repair cannot be
• No shock (defined as systolic blood pressure <90 mmHg), performed safely for anatomic
• Minimal associated intraabdominal injuries, reasons (bowel wall edema,
• <8-hour delay in diagnosis and treatment, and vascular compromise), a
• <1-L blood transfusion. colostomy may be a safer
option.

Traditional contraindications to primary repair include :

• Patients with shock, underlying disease, significant associated injuries, or peritonitis
• Extensive intraperitoneal spillage of feces,
• Multisegmental or extensive colonic injury requiring resection, and
• Major loss of the abdominal wall or mesh repair of the abdominal wall; Colon and rectum
Treatment is operative
Rectum -intraperitoneal or extraperitoneal
1.Often, intraperitoneal rectal injuries can be managed as in colonic injury (primarily repaired).
2.Treat extraperitoneal rectal tears by diverting sigmoid colostomy. Acceptable options include:
• Hartmann resection with end colostomy,
• End colostomy with a mucus fistula, or
• Loop colostomy with a stapled distal end.
3.If the defect is not readily identified on proctoscopy…..
4.Presacral drainage and irrigation of the distal rectal stump…..
5.If a colostomy is necessary in a patient with a pelvic fracture requiring fixation……
6.Perioperative broad-spectrum antibiotics should be administered for colon and rectal wounds
 It’s an alternative resuscitation approach to hemmorhagic
shock which involves:

1. rapid control of surgical bleeding

Damage 2. Early and increased use of RBC, plasma and platelets in

a 1:1:1 ratio.
control
Resuscitation 3. limitation of excessive crystalloid use

-can be applied to unstable

patient who are with life 4. prevention and treatment of
threatening hemorrhage & hypothermia,hypocalcemia and acidosis.
going to need massive
transfusion. 5. Permissive hypotension. (hypotensive resuscitation
strategies).
Indication of
damage control
resuscitation
Approach
Before:
ER->OR ->death
Now:
ER->OR->DCS->ICU->OR->ICU
Major complication of abdominal trauma-
Abdominal Compartment Syndrome
Common problem with abdominal trauma
Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg,
with single or multiple organ system failure
◦ ± APP below 50 mm Hg
Primary ACS: associated with injury/disease in abdomen
Secondary (“medical”) ACS: due to problems outside the abdomen
(eg sepsis, capillary leak)

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

 Abdominal Compartment Syndrome
Effects of elevated IAP
◦Renal dysfunction
◦Decreased cardiac output
◦Increased airway
pressures and decreased
compliance
◦Visceral hypoperfusion

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
 Abdominal Compartment Syndrome
Management
◦ Surgical abdominal decompression
◦ Nonsurgical: paracentesis, NGT,
sedation
◦ Staged approach to abdominal
repair
◦ Temporary abdominal closure
 Conclusions
Watch out for implements and missiles violating the abdomen
Laparotomy is mandatory if shock, evisceration, or peritonitis
Diagnostic studies used to determine need for laparotomy in PAT and BAT
FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal
blood
Damage Control is a principle of staged operative management with control
and resuscitation prior to definitive repair
Abdominal compartment syndrome is a common problem in abdominal
trauma
Reference
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care
2010;16:609-617
https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0151-4#
http://www.aast.org/library/traumatools/injuryscoringscales.aspx#pancreas
https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-abdominal-trauma-
in-
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