Abdominal Trauma

Abdominal trauma accounts for 15% to 20% of all trauma deaths.

Although the liver is the most frequently injured abdominal organ, the spleen is
the most frequently injured intra-abdominal organ from sports accidents.
Death may occur as a consequence of massive hemorrhage and generally
results in early demise soon after the injury. Patients who survive the initial
traumatic insult are at risk for infection and suffermortality or morbidity
secondary to sepsis.

Etiology
Posttraumatic intra-abdominal injuries are common life-threatening
injuries.
The abdomen encompasses a relatively large area, extending from the
apex of the diaphragm to the level of the iliac crests. It contains a number of
organs and vascular structures that may be injured secondary. Any penetrating
injury below the level of nipple line – roughly the level of the apex of the
diaphragm – warrants evaluation for intra-abdominal injury.
Abdominal trauma is, traditionally, described, as either blunt or
penetrating trauma and the organs and structures injured may vary depending
on both the type and location of the trauma.
Patients with abdominal trauma require rapid assesment, stabilizationand
early surgical consultation when indicated to maximize the chances of a
successful outcome.
 Classification
There are different types of trauma .
The types are classified according to the mechanism of trauma.

1.Blunt Abdominal Trauma

Blunt injury is result from motor vehicle collisions, followed by falls from
heights, assaults and sports accidents. The liver and spleen are the most
commonly damaged organs.

Blunt forces exerted against the anterior abdominal wall can compress
abdominal viscera against the posterior thoracic cage or vertebral column,
crushing tissue.

An approppiate abdominal assesment also includes evaluation of the lumbar

spine, as intra-abdominal injuries have also been associated with trasnverse
lumbar spine fractures.

The presence of a “seat-belt sign“ significantly increases the likelihood of

intra-abdominal injury even in low pretest probability patients, suggesting that
that further modalities of evaluation (CT scan, laparotomy or laparoscopy).
 2.Penetrating Abdominal Injuries
Penetrating abdominal trauma are most commonly caused by knife or gun
wounds and the extent of injury is dependent on the location and velocity of the
inflicting agent.

A gunhot wound is associated whith high energy transfer and the extent of
intra abdominal injuries is difficult to predict. Are frequently associated with
massive tissue damage.

Stab wound can be inflicted by many objects other than knives, including
needles, garden forks, wire.

Prophylactic antibiotics are routinely given and tetanus status of the patient
should alway be adressed

2.A Gunshot wounds

Traditional teaching mandated that all gunshot wounds with an intra-

abdominal trajectory required exploratory laparotomy. Some authors have
described a less aggressive approach to a carefully selected subset of patients
with penetrating trauma to the abdomen including some low-velocity gunshot
wounds. Nonoperative management of gunshot wounds that penetrate the
peritoneum is controversial.
Patients presenting with hypotension despite crystalloid resuscitation will
need immediate exploratory laparotomy, antibiotics to cover
abdominal flora, and a tetanus booster.
For hemodynamically stable patients, once intraperitoneal invasion has been
ruled out, conservative management of wounds that are superficial and
tangential to the abdomen may be used.
Early surgical consultation is warranted in all cases of abdominal gunshot
wounds.
 2.B Stab wounds
In general, stab wounds are lower velocity events comparated to gunshot
wounds.
Stab wounds require appropriate resuscitation,tetanus booster when
indicated and prophylactic antibiotics id peritoneal violation is suspected.
 Patho-Phisiology
Blunt or penetrating trauma may lacerate or rupture intra-abdominal
structures. Blunt injury may alternatively cause only a hematoma in a solid
organ or the wall of a hollow viscus.
Laceration hemorrhage immediately. Hemorrhage due to low-grade
solid organ injury, minor vascular laceration, or hollow viscus laceration is
often low-volume, with minimal physiologic consequences. More serious
injuries may cause massive hemorrhage with shock, acidosis, and
coagulopathy; intervention is required. Hemorrhage is internal (except for
relatively small amounts of external hemorrhage due to body wall lacerations
resulting from penetrating trauma). Internal hemorrhage may be intraperitoneal
or retroperitoneal.
Laceration or rupture of a hollow viscus allows gastric, intestinal, or
bladder contents to enter the peritoneal cavity, causing peritonitis.
Complications
Delayed consequences of abdominal injury include

• Hematoma rupture
• Intra-abdominal abscess
• Bowel obstruction or ileus
• Biliary leakage and/or biloma
• Abdominal compartment syndrome.
 One or more of the intra-abdominal organs may be injured in abdominal
trauma. The characteristics in abdominal trauma. The characteristics of the
injury are determined in part by wich organ or organs are injuried.

➢ Splenic Injuries

• Is the most common cause of massive bleeding in blunt abdominal

trauma to a solid organ.
• Is the most commonly injured organ.
• Left upper quadrant pain and tenderness, often with radiation to left
shoulder.
• May cause significant hemodynamic instability because she have
ability to bleed profusely that means aruptured speen can be life-
threatening resulting in shock.
• CT scan is noninvasive and sensitive in stable patients; use FAST
examination or laparotomyfor unstable patients.
• Delayed rupture may occur.

Grades of laceration
Grade I: small laceration < 1cm and small subcapsular hematoma
Grade II: moderate laceration 1-3cm and moderate subcapsular hematoma
 Grade III: Subcapsular hematoma > 50% of surface area,
intraparenchymal hematoma ≥ 5 cm, any expanding or ruptured
hematoma
Laceration > 3 cm deep or involving a trabecular vessel.
Grade IV: laceration involving the hilum that devascularizes > 25% of
spleen
Grade V: destroyed spleen,completely shattered spleen.

➢ Liver Injuries

• Because of its size and location, the liver is the second most commonly
injuured organ in blunt abdominal trauma, accounting for approximately
8-25% of all intra-abdominal injuries.

• Like splenic injuries, liver injuries can include contusions,

laceration,hematoma,frectures and devascularization.

• Liver injuries present a serious risk for shock because the liver tissue is
delicate and has a large blood supply and capacity. The liver may be
lacerated of contused and a hematoma may develop.

• If severely injured, the liver may cause exanguination(bleeding to death),

requiring emergency surgery to stop the bleeding.

• CT scan is noninvasive and sensitive in stable patients; use FAST

examination or laparotomyfor unstable patients.
 ➢ Renal Injuries
• After the spleen and liver, the kidney are the third most commonly injured
solid organ in blunt abdominal trauma.

• Gross hematuria is tipically indicative of urologic injury. This could

include the kidneys, ureters, bladder, urethra, or external genitalia.

• Any hematuria microscopic or macroscopic should be followed up for

resolution.

• Bladder injuries are most commonly asossociated with pelvic fractures

and CT cystography is the imaging modality of choice.

Severity is assessed according to the depth of renal parenchymal damage

and involvement of the urinary collecting system and renal vessels.
 grade I
a)subcapsular hematoma or contusion, without laceration
grade II
b)superficial laceration ≤1 cm depth not involving the collecting system (no
evidence of urine extravasation)
c)perirenal hematoma confined within the perirenal fascia
grade III
d)laceration >1 cm not involving the collecting system (no evidence of urine
extravasation)
e)vascular injury or active bleeding confined within the perirenal fascia.
grade IV
f)laceration involving the collecting system with urinary extravasation
g)laceration of the renal pelvis and/or complete ureteropelvic disruption
h)vascular injury to segmental renal artery or vein
i)segmental infarctions without associated active bleeding (i.e. due to vessel
thrombosis)
j)active bleeding extending beyond the perirenal fascia (i.e. into the
retroperitoneum or peritoneum)
grade V
k)shattered kidney
l)avulsionof renal hilum or laceration of the main renal artery or vein:
devascularisation of a kidney due to hilar injury
m)devascularised kidney with active bleeding.

➢ Pancreatic injuries
• Uncommon and usually seen after blunt trauma
• Pacients may present with epigastric or back pain

• Serum pacreatic enzyme leves demonstrate only averange sensitivity and

specificity, lipase levels are more specific

• It occurs in both, penetrating and blunt trauma

• The pancreas may be lacerated, contused, transected or comminuted

• The pacreas may lacerated, contused, transected or comminuted

• ALL patiens with traumatic pancreatic injuries should be admitted.

 ➢ Diaphragnatic Injuries
➢ Rupture may be secondary to blunt or penetrating forces
➢ Diaphragmatic rupture occurs predominantly on the left side because the
right hemidiaphragm is better protect by the liver
➢ Ct scan is more sensitive, but still miss diaphragmatic injuries
➢ The delayed diagnosis of diagragmatic injury can lead to potential
herniation and strangulation of visceral abdominal contents.

➢ The presence of abdominal contents in the torax may not be obvious on

initial chest X-ray and insertion of nasogastric tube may facilitate the
diagnosis.
 ➢ GASTROINTESTINAL TRACT INJURIES

• May occur with blunt and penetrating injuries

• Peritoneal signs may be delayed
• May be missed on initial plain X-rays, ultrasound, and CT scan
• May have delayed presentation (e.g., duodenal hematomas)
• Strongly consider the diagnosis in patients with free fluid on CT scan but
no specific solid organ injury identified.
Both penetrating and blunt injuries can cause gastrointestinal tract (GIT)
injuries. Injuries to the GIT may be clinically subtle and are more common with
penetrating than blunt trauma. GIT injuries occur in 30% of stab wounds and in
80% of gunshot wounds to the abdomen.
In blunt trauma, an abdominal wall bruise or "seat-belt sign" should raise the
level of suspicion since the finding is associated with a GIT injury in up to 21%
of cases. GIT injuries may be missed on FAST examination or CT scan.
The finding of free fluid in the abdomen on CT scan without a specific solid
organ injury is highly suspicious of a hollow viscus injury.
 Evaluation
The evaluation of any trauma patient begins with evaluating the airway,
accessing the breathing and managing the circulation.

A. Airway
Administer high-flow oxygen, and intubate the patient if necessary.
Maintain cervical spine immobilization until potential injury is ruled out.

B. Breathing
Auscultate for breath sounds. Inspect for asymmetry of chest wall
movement, open wounds, or flail segments. Palpate the chest wall carefully as
palpable crepitus may indicate a pneumothorax or rib fractures. Pulse oximetry
and capnography may be useful. Rapidly perform needle decompression or tube
thoracostomy if tension pneumothorax is suspected.

C. Circulation
Stop gross external hemorrhage with direct pressure. Assess pulses,
capillary refill, and blood pressure. Obtain intravenous access with at least two
large-bore (≥=16-gauge) catheters. If peripheral intravenous access is
inadequate, place a central venous catheter. Fluid resuscitation is
an area of controversy (see below). The FAST examination is important at this
stage of the evaluation, especially in hemodynamically unstable patients.

D. Disability
Complete a brief, focused neurologic examination to document the patient's
baseline. The examination should include an assessment of pupillary size and
reactivity, a determination of the patient's Glasgow Coma Scale score, and
notation of any focal neurologic deficits such as
nilateral weakness or poor muscle tone. Ideally, perform the examination
before administering pain medications, sedatives, or paralytics.

E. Exposure
Completely undress the patient although be careful to prevent or recognize
and correct associated hypothermia. Begin a more thorough secondary survey,
including logrolling the patient and examining all skin folds, the back, and
axillae for occult penetrating injuries. Identify any puncture wounds and
document their location. To help identify the trajectory of bullets, place a
radiopaque marker (e.g., paper clip) at the wound site prior to obtaining X-rays.

Do not remove impaled foreign bodies because they may be providing

hemostasis from a vascular injury.
Foreign body removal should be performed with surgical consultation in a
more controlled setting.
Any penetrating injury below the level of the nipple line warrants
evaluation for intra-abdominal binjury. In patients in motor vehicle collisions,
look for ecchymosis or erythema in the area of the clavicles or across the
abdomen. The classic "seat-belt sign" or linear bruising across the lower
abdomen is a marker for intra-abdominal injury.
 Examine the abdomen for any tenderness, distention,
rigidity, or guarding.
It is often difficult to assess bowel sounds at this stage of the examination.
Evaluate the pelvis for anteroposterior or lateral instability with gentle
pressure; this does not require much force and should not be repeatedly
performed.
Examine the genitalia and look for blood at the urethral meatus, especially
in males. Perform digital rectal examination in any patient with abdominal
trauma.

Symptoms and signs

• Pain
• Tenderness
• Gastrointestinal haemorrhage
• Hypovolemia
• Evidence of peritoneal irritation.

Abdominal pain typically is present; however, pain is often mild and thus
easily obscured by other, more painful injuries (eg, fractures) and by altered
sensorium (eg, due to head injury, substance abuse, shock).
Pain from splenic injuries sometimes radiates to the left shoulder. Pain from
a small intestinal perforation typically is minimal initially but steadily worsens
over the first few hours. Patients with renal injury may notice hematuria.
On examination, vital signs may show evidence of hypovolemia
(tachycardia) or shock eg, dusky color, diaphoresis, altered sensorium,
hypotension.
Bradicardia may indicate the presence od free intraperitoneal blood in a
patient with blunt abdominal injuries.

Inspection

Penetrating injuries by definition cause a break in the skin, but clinicians

must be sure to inspect the back, buttocks, flank, and lower chest in addition to
the abdomen, particularly when firearms or explosive devices are involved.
Cutaneous lesions are often small, with minimal bleeding, although
occasionally wounds are large, sometimes accompanied by evisceration.
 Blunt trauma may cause ecchymosis (eg, the transverse, linear ecchymosis
termed seat belt sign), but this finding has poor sensitivity and specificity.
The seat belt sign is particularly associated with an increased risk of
gastrointestinal and pancreatic injuries.
Cullen's sign periumbilical ecchymosis and Grey Turner sign are most
freqently associated with retroperitoneal haemorrhage.

Abdominal distention after trauma typically indicates severe hemorrhage (2

to 3 L), but distention may not be apparent even in patients who have lost
several units of blood.

Auscultation

Abdominal bruit may indicate underlying vascular disease of traumatic

arteriovenous fistula.

Percussion
Percussion tenderness constitua a peritoneal sign.
Tenderness indicates further evaluation and probaly surgical referral is
required.

Palpation

Abdominal tenderness is often present. This sign is very unreliable because

abdominal wall contusions can be tender and many patients with intra-
abdominal injury have equivocal examinations if they are distracted by other
injuries or have altered sensorium or if their injuries are mainly retroperitoneal.

Although not very sensitive, when detected, peritoneal signs (eg,

guarding, rebound) strongly suggest the presence of intraperitoneal blood
and/or intestinal contents.

Rectal examination may show gross blood due to a penetrating colonic

lesion, and there may be blood at the urethral meatus or perineal hematoma due
to genitourinary tract injury. Although these findings are quite specific, they are
not very sensitive.

Diagnosis
In the hemodynamically UNSTABLE patient a rapid evaluation for
hemoperitoneum can be accomplished be means of diagnostic peritoneal lavage
(DPL) or the focused assesment with sonography for trauma FAST .

FAST – FOCUSED ABDOMINAL SONOGRAPHY FOR TRAUMA

Ultrasonography has emerged as the primary initial diagnostic examination

of the abdomen in multisystem blunt trauma patients .
The FAST examination has high specificity 99% to detect hemoperitoneum
and can detect as little as 250 ml of blood in the pritoneal cavity.

First the FAST examination evaluates intraperitoneal blood and poorly

visualizes blood in the retroperitoneum.

Important if the FAST is negativ does a mean that there is no bleeding or

injuries.

Unlike CT, the FAST examination is rapid, can be performed at bedside in

the emergency department and is easy reapeatable.
 If the pacient is hemodynamically unstable with a positive FAST
examination, they should GO DIRECTLY FOR EXPLORATORY
LAPAROTOMY.
 CT SCAN
Hemodynamically stable trauma patient, computer tomography
scanning is an execellent diagnostic modality that is easy to perform.

Contraindications to CT scanning in trauma include hemodynamic

instability or clear indication for exploratory laparotomy.

CT is able to detect 79% of hollow viscous injuries so people have

negative scan are often observed and rechecked if they deteriorate.

People with abdominal trauma frequently need CT SCAN for other

truma for example head or chest CT, in this cases abdominal CT scan can be
performed at same time without wasting time in patient care.
 Other Diagnostic Modalities

1. Laboratory Evaluation
Initial laboratory evaluation should include hemoglobin and hematocrit and
platelet count to establish a baseline, and a blood-type and screen in case
transfusion of packed red cells is needed.
A lactate level may be obtained and, if elevated, is an excellent indicator of
shock. Base deficit is another indicator of shock.
The role of amylase in abdominal trauma is uncertain.
Examination of the urine may reveal gross hematuria, which suggests
significant injury to the
urogenital tract .

2. Plain radiography—Almost all major trauma patients require plain

X-rays of the chest, pelvis, and cervical spine. Although rarely used today
because of the ubiquity of computed tomography (CT) scanning.

3. Diagnostic peritoneal lavage—Although DPL has largely been

replaced by ultrasonography, it is still used occasionally. The main concern
regarding DPL is that it is overly sensitive for intra-abdominal blood, which has
lead to a high rate of negative or nontherapeutic laparotomies.
Recent literature however, has advocated the use of DPL in conjunction
with CT scanning or laparoscopy, particularly in low-velocity penetrating
trauma (i.e., stab wounds), to decrease the number of nontherapeutic
laparotomies. If DPL is considered, it should be performed only after
consultation with the trauma surgeon, who should perform this diagnostic study
in most cases.

TREATMENT
A. Fluid Resuscitation
The concept of acute fluid resuscitation has evolved and may represent an
area of some controversy. Animal and human studies have demonstrated
deleterious effects of aggressive fluid resuscitation, particularly if penetrating
trauma is present. Rapid infusion of large amounts of crystalloids may disrupt
the formation of the soft clot and dilute the clotting factors, leading to
increased bleeding. The results are less clear in the setting of blunt trauma.
Also, blood pressurealone is not the best indicator of the level of shock.
Attempts to make the patient normotensive are not recommended. A more
reasonable goal may be to obtain systolic blood pressure of 80-90
mmHg or a mean arterial pressure of 70 mm& Hg and a shock index less than 1
/2 Hr(heart rate)/SBP(systolic blood pressure)
Crystalloids remain first-line fluids,followed by infusions of packed red
blood cells. Other blood products may be indicated on an individual basis.
Synthetic hemoglobin preparations are under evaluation. Similarly, activated
factor VII has been preliminarily reported to reverse the coagulopathy
associated with massive transfusion in the severely traumatized patient and may
be another option for resuscitation in the future.
The use of 1 g of tranexamic acid TXA is demonstrated an overall
reduction in mortality of 1.5%in pacient.
Analgesia – tritated narcotic analgesia is tha initial approach to pain
management in trauma. Intravenous is the most effective route. Admister as per
local protocols and tritate to effect. Analgesia should be administered prior to
any wound or fractured can be particularly painful.
Consider phophylactic antiemetic administration, especially if transfer and
retrieval is likely.
Prevent hypothermia – it is important to maintain normothermia. Ensure
the pacient does not lose excess heat due to exposure or wounds. Make sure all
wounds are covered. Use warmed IV fluids, cover the pacient with extra warm
blankets as wll as keeping the room warm.
Tetanus immuisation should be updated in the case of significant or
contaminated wounds.Tetanus immunoglobulin should be given to patients who
have not received a complete primary immunisation.
Antibiotics – Routine IV antibiotic administration is not recommended in
major trauma, is indicated in pacient with penetrating abdominal injury
requiring surgical management.

B. Indications for Emergency Laparotomy

Most patients with penetrating abdominal injuries will also require
laparotomy given the high incidence of intra-abdominal injury once the fascia
has been violated.
Hemodynamically unstable patients sustaining blunt or penetrating trauma
with a positive screening test (such as focused assessment with sonography for
trauma [FAST] examination or diagnostic peritoneal lavage [DPL]) require
laparotomy to control hemorrhage and evaluate for intra-abdominal injuries.
Initially stable blunt trauma patients with identified abdominal injuries should
be carefully observed so that if they become hemodynamically unstable they
can rapidly receive operative intervention.
Patients with obvious diaphragmatic injury noted on chest X-ray require
emergency laparotomy.

C. Surgical Consultation
Seek surgical consultation early in the management of patients with
abdominal trauma, especially if the patient is hemodynamically unstable.

Emergency Pre-Hospital Care

Pre-Hospital care focuses on rapidly evaluating life-threatening problems,
initianting resuscitative measures, and initianting prompt transport to a
definitive care site.
 The injuried patient is at risk for progressive deterioration from
continued bleeding and requires rapid transport to a trauma center or the closest
approppiate facility with approppiate stabilization procedures performed en
rooute.
Hence, securing the airway, placing large-bore IV fluid must take
place en route, unless transport is delayed.
Use endotracheal intubation to secure the airway of any patient who is
unable to maintain the airway or who has potencial airway threats.
Secure the airway in conjunction with in-line cervical immobilization
in any pacient who may suffered cervical trauma. Provide artificial ventilation
by using a high fraction of inspired oxygen(FIO2) for pacient who exhibit
compromise breathing respiration.
 Maintain oxygen saturation(SaO2) atmore than 90%-92%.
Initiate volume resuscitation with crystalloid solution, however never
delay patient transport while IV line are inserted. En, route administer a fluid
bolus or lactated Ringer or normal saline solution to pacients with evidence of
shock.
Titrate IV fluid therapy to patient's clinical response. Because overagressive
volume resuscitation may lead to recurrent to increased hemorrhage, IV fluids
should be titrated to a systolic blood pressure of 90-100 mmHg. This practice
should provide the mean blood pressure necesary to maintain perfusion of the
vital organs.
Acquire expeditious and complete spinal immobilization on patients with
multisystem injuries and on patients with mechanism of injury that has potential
for spinal cord trauma.

In emergency department

Upon the patient’s arrival in the emergency department (ED) or trauma

center, a rapid primary survey should be performed to identify immediate life-
threatening problems.
The first priority is reassessment of the airway. Protection of the cervical
spine with in-line immobilization is absolutely mandatory.
If intubation is indicated, attempt nasotracheal of endotracheal intubation.
If possible, perform and record a brief neurorological examination prior to
neuromuscular blockade and intubation.
If intubation is unsuccessful, perform cricothyroidotomy.
After an airway has been established, adequate ventilatory exchange is
assessed by auscultation of both lung fields.
Pacients who display apnea or hypoventilation require respiratory support ,
as do those pacients with tachypnea.

The next priority in the primary survey is an assessment of the circulatory

status of the pacient.
Circulatory collapse in a pacient with blunt abdominal trauma is unsually
caused by hypovolemia from hemorrhage
 Identification of hypovolemia and signs of shock necessitate vigorous
resuscitation and attempts to identify the source of blood loss.
Effective volume resuscitation is accomplished by controlling external
hemorrhage and infusing warmed crystalloid solution via 2 large bore(18-
gauge) peripheral iv lines.
Use central lines for pacients in whom percutaneous peripheral acces
cannot be established. Administer a rapid bolus os crystalloid.

Hemodynamic instability despite the admistration of 2L of fluid to adult

pacients indicates on going blood loss and is an indication for immediate blood
transfusion. Administer type 0, Rh-negative blood is cross-marched or type
blood in not avaible.
Upon the patient’s arrival in the emergency department (ED) or trauma center, a rapid primary survey
should be performed to identify immediate life-threatening problems. The first priority is reassessment of
the airway. Protection of the cervical spine with in-line immobilization is absolutely mandatory. If
intubation is indicated, attempt nasotracheal (ie, if no contraindications) or endotracheal intubation. If
possible, perform and record a brief neurologic examinataaagjkk.fjh.hrigo'reiular blockade and intubation.
If intubation is unsuccessful, perfoeo below).

After the primary survey and initial resuscitation have begun,

complete the secondary survey. Perform a thorough head-to-toe examination,
paying attention to evidence of mechanism of injury and potentially injured
areas.
 BIBLIOGRAPHY

• CURRENT Diagnosis and Treatment Emergency Medicine 8th

Edition

• Section III Trauma Emercencies

• Tintinalli’s Emergency Medicine a Comprehensive Study Guide

• European Resuscitation Council

• Advanced Trauma Life Support