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TRAUMA
DR.R.SRIVATHSAN
PG-II
OUTLINE
Anatomic definition of abdomen
Mechanism of injury
Typical injury patterns
Assessment of abdominal trauma
Diagnostic algorithms
2
Abdominal trauma
Common site of injury for both blunt and
penetrating injuries
29% of polytraumapatient requires abdominal
exploration
Rapid, life-threatening bleeding can be hidden
in the abdomen
Unrecognized abdominal injuries in the multi-
system trauma patient
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Abdomen – anatomic
boundaries
External:
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Internal:
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Intraperitoneal and
retroperitoneal cavities
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Mechanisms and
Pathology
Blunt vs Penetrating
Often both occur simultaneously
Blunt injury is the most common mechanism
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Direct impact
Acceleration-deceleration:
differential movements of fixed and nonfixed
structures (e.g. liver and spleen lacerations
at sites of supporting ligaments)
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Key points
No correlation between size of contact area
and resultant injuries
Abdomen = Pandora’s box
A potential site of major blood loss with little
evident signs/symptoms.
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Assessment: History
Mechanism
Symptoms, Medications, drugs
MVC:
Speed
Type of collision (frontal, lateral, sideswipe, rear,
rollover)
Vehicle intrusion into passenger compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle
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Assessment: Physical
Exam
Inspection, auscultation, percussion,
palpation
Inspection: abrasions, contusions, lacerations,
deformity
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Diagnostic modalities
Labs:
- Complete Blood profile
- Coagulation profile
- Serum Amylase/Lipase
- Urine analysis
- Toxicology screen
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Radiological profile
Plain films:
- Chest XRay,
- Pelvic XRay
- Abdomen XRay
FAST
CT
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DPL - Procedure
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DPL
Standard criteria
10cc gross blood
RBC > 100,000/mm2
WBC > 500/mm2
Amylase > 175 IU/dL
Bile, bacteria, fiber or food.
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Indications:
- Equivocal physical examination
- Unexplained shock or hypotension
- Altered sensorium (closed head injury, drugs,
etc.)
- General anesthesia for extra-abdominal
procedures
- Cord injury
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Contraindications :
Clear indication for exploratory laparotomy
Relative contraindications:
- Previous exploratory laparotomy
- Pregnancy
- Obesity
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DPL
Highly sensitive to intraperitoneal blood,
but low specificity
Diaphragm
Retroperitoneal hematomas
Renal, pancreatic, duodenal
Minor intestinal
Extraperitoneal bladder injuries
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Focused Assessment with
Sonography for Trauma (FAST)
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FAST: Strengths and
Strengths Limitations Limitations
Does not typically identify
Rapid (~2 mins)
source of bleeding, or detect
Portable injuries that do not cause
Inexpensive hemoperitoneum
Requires extensive training
Technically simple, easy to assess parenchyma
to train (studies show reliably
competence can be Limited in detecting <250 cc
achieved after ~30 intraperitoneal fluid
studies) Particularly poor at detecting
Can be performed bowel and mesentery
damage (44% sensitivity)
serially
Difficult to assess
Useful for guiding triage retroperitoneum
decisions in trauma Limited by habitus in obese
patients patients
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FAST: Accuracy
For identifying hemoperitoneum in blunt abdominal
trauma:
Sensitivity 76 - 90%
Specificity 95 - 100%
The larger the hemoperitoneum, the higher the
sensitivity. So sensitivity increases for clinically
significant hemoperitoneum.
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CT Scan
Hemodynamically stable patient
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Indications and Contraindications
for Abdominal Computed
Tomography
Indications
Blunt trauma
Hemodynamic stability
Normal or unreliable physical examination
Mechanism: Duodenal and pancreatic trauma
Contraindications
Clear indication for exploratory laparotomy
Hemodynamic instability
Agitation 27
Advantages
Adequate assessment of the retroperitoneum
Nonoperative management of solid organ injuries
Assessment of renal perfusion
Noninvasive
High specificity
Disadvantages
Specialized personnel
Hardware
Duration: Helical versus conventional
Hollow viscus injuries
Cost
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Laparoscopy
Role still being defined
Good for diaphragm injury evaluation
Cons
Invasive
Expensive
Missed small bowel, splenic, retroperitoneal
injuries
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ROLE OF DIAGNOSTIC
LAPAROSCOPY
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Diagnosis
Test of choice dependent on hemodynamic
stability and severity of associated injuries.
Stable blunt trauma FAST or CT
Unstable blunt trauma FAST or DPL
Stab wounds without peritoneal signs,
evisceration, or hypotension wound
exploration or DPL.
Gun shot wounds surgical exploration.
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EAST Algorithm:
Unstable
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Initial hemostasis
Rapid mobilisation of injured lobe with
bimanual compression
Perihepatic packing
Pringle maneuver
Failure of pringle maneuver – major hepatic
venous involvement
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In the event of continued bleeding a vascular
clamp can be placed around porta hepatis-
hepatoduodenal lig.
Pringle Maneuver
If bleeding continues…
B. It is coming from the portal vein or hepatic
artery
OR
E. It is coming from the retrohepatic vena
cava or hepatic veins
Schrock shunt: atrial-caval shunt can be life
saving.
Total hepatic isolation: vascular clamps at
hepatoduodenal ligament, descending
aorta at infra diaphragmatic region and
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Definitive
hemostasis
Surface ooze: cautery;argon beam laser;
parenchymal sutures; topical hemostatics
Deeper wounds: hepatotomy – finger fracture
tech
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Packing
Used when other
techniques fail in
controlling hemorrhage
Use in patients that are
hypothermic, acidotic,
coagulopathic
ICU for rewarming
Re-explore 48-72 hours
Intra-abd abscesses
<15%
Arteriography/embolizati
on useful adjunct
47
Splenic injury
Most frequently injured intra-abdominal organ
in blunt trauma.
Suspected in all c/o LUQ injury; L lower ribs
fracture
Splenic preservation when possible
OPSI (0.6% in children, 0.3% in adults)
More than 70% can be treated non-operatively
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Criteria for conservative
mng
Hemodynamic stability
Negative abdominal exam
Absence of extravasation of contrast on CT
Absence of bleeding diasthesis
Absence of other indications of laprotomy
Grade I - III
52
Monitoring in the ICU setup
NG tube
Strict bed rest
Serial abdominal examinations
Serial hematocrit
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Extravasation / Blush on CECT:
Stable: angiography and selective embolisation
Unstable: surgery
SURGERY : splenectomy / splenic salvage
surgery
Deep lacerations: horizontal absorbable mattress
sutures
Major laceration < 50% parenchyma :
segmental/partial splenic resection
Extensive injury of hilum/ central portion of
spleen : spleenectomy + autotransplantation
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Predictive factors for nonop success:
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Pancreatic Injury
Rare 10-12% of abdominal injuries, but
mortality 10-25%, mostly from associated
intra-abd injury
Most caused by penetrating trauma - 75%
associated with major vascular injury
Blunt trauma
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Pancreatic Injury
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GSW to Pancreatic Head
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PANCREAS INJURY SCALE
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Pancreatic Injury
Distal duct injury (Grade III)
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Complications after
Pancreatic Trauma
High complication rate 35-40%
Most common are pancreatic fistulas &
abscesses
Most fistulas close spontaneously if well
drained
Somatostatin / Octreotide to expedite
healing
Abscesses - surgical debridement &
drainage
Incidence of pancreatitis 8-18%
Pseudocysts are infrequent
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Gastric Injury
Mostly penetrating trauma.
<1% from blunt trauma
Including iatrogenic injury from CPR/ ET in
esophagus
NGT + aspirate for blood
Intraop evaluation includes good
visualisation of EG junction; ant gastric wall;
opening of gastrocolic ligament and
complete visualization of posterior wall
Most penetrating wounds treated by
debridement and primary closure in layers.
Evacuation of hematomas.
Major tissue loss may necessitate gastric
resection. 64
Gastric Injury
Post-op
complications
Bleeding, abscesses,
gastric fistula with
peritonitis,empyema
Recent meal
neutralization of
gastric acidity
65
Duodenal Injury
Incidence: 3 – 5%
Majority due to penetrating trauma.
Blunt injury usually secondary to steering
wheel blow to the epigastrium (difficult to
diagnose)
Retroperitoneal location is protective, but also
prevents early diagnosis.
Isolated injury to the duodenum is rare
Hyperamylasemia in 50% with blunt injury.
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Plain films of the abdomen
§ mild scoliosis
§ obliteration of the right psoas shadow
§ absence of air in the duodenal bulb
§ air in the retroperitoneum outlining the kidney
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Duodenal Injury
Gastrograffin UGI
or CT with contrast
Extravasation of
contrast
If CT eqivocal –
dilute barium UGI
May see retro-
peritoneal air on CT
DPL unreliable but
may be positive
from an associated
injury 69
Duodenal
Hematoma
The radiographic
finding of a duodenal
hematoma (coiled
spring or stacked coin
sign) is not an
indication for surgical
exploration
NGT until peristalsis
resumes.
Slow introduction of
food.
OR if obstruction
persists > 10 –15
days.
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Stacked coin sign
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Duodenal Injury
Appropriate repair depends
on injury severity and
elapsed time
80-85% can be primarily
repaired.
Duodenal decompression
advisable if injury >6 hours
old (transpyloric nasogastric
tube, tube jejunostomy, or
tube duodenostomy)
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Grade III injuries(major disruption of the
duodenal circumference ) : primary repair,
pyloric exclusion, and drainage or by Roux-en-
Y duodenojejunostomy.
Grade IV injuries (involving the ampulla or
distal common bile duct) : primary repair of the
duodenum, repair of the common bile duct and
placement of a T-tube with a long
transpapillary limb or a choledochoenteric
anastomosis
If repair of the CBD is impossible, ligation and a
second intervention for a biliary enterostomy
Pancreaticoduodenectomy - grade V injuries
(massive disruption of the duodenum and
pancreatic head or massive devascularization 73
Duodenal injury
severity
74
COMPLICATIONS
Duodenal fistulas (5 – 15%) – conservative
mng
Abscess (10 – 20%) – percutaneous / open
drainage
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13% perforated
small bowel have a
normal CT scan
Suggestive findings
include free air, free
fluid without solid
organ injury,
thickening of small
bowel wall or
mesentery
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Penetrating injuries by
firearms should be
debrided.
Small tears closed
primarily.
Adjacent holes
connected and closed
transversely.
Extensive lacerations
and devascularization
require resection and
reanasatomosis.
Explore all mesenteric 79
Colon Injury
Second most frequent injured organ,
usually from penetrating trauma
Repair within 2 hours dramatically reduces
infectious complications.
Pre-operative antibiotics important adjunct.
PE blood per rectum, stab to flanks or back
CT with rectal contrast, XR-
pneumoperitoneum
WWI primary repair led to 60% mortality.
WWII colostomy led to 35% mortality.
80
Colon Injury
Primary repair criteria
Early diagnosis (within 4-6 hours)
Absence of prolonged shock/hypotension
Absence of gross contamination
Absence of associated colonic vascular injury
Less than 6 units blood transfusion
No requirement for use of mesh for closure
Extensive wounds
Right colon
81
Rectal Injury
Most from GSW
Other causes - foreign body, impalement,
pelvic fractures, and iatrogenic
Lower abdomen/buttock penetrating injury
should raise suspicion.
May be intra- or extraperitoneal
Rectal exam may reveal blood or laceration
Work-up includes anoscopy and rigid
sigmoidoscopy.
82
Rectal Injury
Extraperitoneal
injury
Primary closure
Diverting colostomy
Washout of rectal
stump
Wide presacral
drainage
Intraperitoneal
injury
Primary closure
Diverting colostomy
83
Complications
Sepsis
Pelvic abscess
Urinary/rectal fistulas
Rectal incontinence / stricture
Loss of sexual function
Urinary incontinence
84
Renal trauma
Classified as major and minor injuries (85%)
MC injured part of urinary tract
87
Surgical techniques
88
Complications of renal injuries :
- secondary hemorrhage, usually due to infection
(10 to 14 days after trauma)
-paralytic ileus (4 to 5 days) d/t retroperitoneal
hematoma
-hypertension as a result of the constricting effect
of reorganizing perirenal hematoma
-arterio-venous fistula;
-renal failure;
-renal atrophy;
-hydronephrosis;
-chronic pyelonephritis;
-renal calculi;
-renal artery stenosis.
89
Bladder injury
The majority of bladder injuries occur as a result of
blunt trauma, and the association of bladder
rupture and pelvic fractures is extremely high(75%)
Hematuria is the most frequent sign
Bladder rupture may be extraperitoneal or
intraperitoneal.
Extraperitoneal rupture usually results from
perforation by adjacent bony fragments.
Intraperitoneal rupture of the bladder results from
injuries located in the dome- full bladder sustains a
direct blow.
The diagnosis is made by cystography - a postvoid
film is necessary to identify lateral or posterior
90
Intraperitoneal injuries are repaired
primarily by three-layer closure +/-
Suprapubic cystostomy
Extraperitoneal rupture of the bladder:
primarily nonoperative –Foley’s catheter for
10 to 14 days
Severe pelvic fractures and massive
retroperitoneal bleeding : initially managed
nonoperatively. delayed repair of the
extraperitoneal rupture is performed
91
Complications of bladder rupture
Hemorrhage
Urinoma
Abscess formation
Sepsis.
92
Retroperitoneal
hematoma
Zone 1
Explore regardless of
mechanism.
Zone 2
Explore penetrating
trauma.
Observe blunt
trauma
(nonexpanding,
nonpulsatile, no
urologic indications)
Zone 3
Explore penetrating.
Observe blunt.
93
Damage Control
Abbreviated laparotomy and temporary
packing
Effort to blunt physiologic response to shock
and hemorrhage
Severe metabolic acidosis, coagulopathy, and
hypothermia
ICU resuscitation
Return to OR in 48-72 hours
94
Damage Control Surgery
Phase I
Rapid termination of operative procedure
Arrest of bleeding
Removal of contamination
Phase II
Correction of physiologic abnormalities
Acidosis, hypothermia, coagulopathy
Phase III
Definitive surgery
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Abdominal compartment
syndrome
End organ dysfunction secondary to
intraabdominal hypertension
Tense abdomen,
Elevated peak airway pressure
Inadequate ventilation
Inadequate oxygenation
Oliguria
Reversed with decompression
Bladder pressure >16mmHg
Full blown syndrome >35 mmHg
Worse with fascial closure
97
THANK
YOU
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