Assessment of Abdominal Trauma

Dr Ali Ahmed Dhaif M.D.,IMRCS, CABS

Injury and Abdominal Trauma

Globally, traumatic injury accounts for 10% of all deaths Trauma is now listed as the leading cause of death in persons between the age of 144

Peak incidence 14-30 years

One in ten deaths in trauma are due to abdominal injuries

Mechanism in Blunt Abdominal Trauma ( BAT )

Compression

Direct blow or compression against a fixed object

Commonly cause tears and subcapsular hematomas to solid viscera Less commonly, transiently increase intraluminal pressure and lead to rupture

Deceleration

Stretching and linear shearing between a fixed and free object

Hepatic tears along the ligamentum teres, intimal injuries, mesenteric tears

Initial Assessment

Initially, Evaluation and Resuscitation occur simultaneously Detailed History may be impossible

AMPLE
Allergies Medications Past medical history Last intake Events leading to presentation

Initial Assessment: Description of mechanism

Predicts injury patterns and helps avoid pitfalls

Type of collision (frontal, lateral, sideswipe, rear, rollover) and speed Damage to vehicle and whether prolonged extrication was required Ejection from vehicle and/or co occupant death Types of restraints The presence of alcohol or drug use

Initial Assessment: Physical Exam

RESCUSITATION continues as PE is completed

Airway, with cervical spine precautions Breathing Circulation Disability Exposure

Keep entire patient in mind

PE: The Secondary Survey

Initial exam of abdomen in blunt trauma is difficult and often unreliable

Powell et al reported that clinical eval alone has an accuracy rate of only 65% for detecting presence or absence of intraperitoneal blood Pain, tenderness, GI hemorrhage, evidence of peritoneal irritation

Most reliable signs and symptoms

Extremely difficult to assess the abdomen in cases of neurological dysfunction

Head or spinal cord injury Substance abuse

Adjuncts to the Abdominal Exam

Evaluate for pelvic instability

Potential for urinary tract injury as well as pelvic or retroperitoneal hematoma

Perform rectal exam to identify potential injury or bleed (controversial utility) NG tube for abdominal distention to decompress stomach Foley catheter placement after assessment for GU injury

The Workup: Laboratory Studies

Commonly recommended studies

Serum glucose CBC Serum chemistries Serum amylase Urinalysis Coagulation studies Blood type and match Blood ethanol, urine drug screens and a urine pregnancy test

Blood Type, screen and crossmatch

Screen and type blood from all trauma patients with suspected blunt abdominal injury

Initial crossmatch on a minimum of 4 units

If clear evidence of abdominal injury And/or hemodynamic instability

Until crossmatch blood available use O-negative or type specific blood

An indication for immediate transfusion is hemodynamic instability despite administration of 2 L of fluid to adult patients

Diagnostic Adjuncts

Plain films FAST ( focused abdominal sonography for trauma) CT studies DPL

Plain Radiographs

Generally of lower priority, limited value but can demonstrate important findings
CXR may aid in diagnosis of abdominal injuries such as ruptured hemidiaphragm, pneumoperitoneum, free air Pelvic or chest x ray may demonstrate fractures of the T and L spines

Transverse fractures of vertebral bodies suggests a higher likelihood of blunt injury to the bowel

FAST (focused assessment with sonography for trauma)

Used to evaluate for abdominal injury in blunt trauma since the 1970s Bedside ultrasound is rapid, portable, and noninvasive Interpreted as positive if fluid found in any of the 4 acoustic windows

Pericardiac, Perihepatic, Perisplenic, Pelvic

FAST: Accuracy

For identifying hemoperitoneum in blunt abdominal trauma

Sensitivity 76-90% Specificity 95-100%

FAST: Strengths and Limitations

Strengths

Limiations

Rapid (~ 2 min ) Portable Relatively inexpensive Technically simple, easy to train ( studies show competence can be achieved after ~ 30 studies Can be performed serially

Does not typically ID source of bleeding, or detect injuries that do not cause hemoperitoneum Limited in detection of intraperitoneal fluid (<250 mL) Poor at detecting bowel and mesenteric damage Difficult to assess retroperitoneum Limited by body habitus in the obese

Diagnostic Peritoneal Lavage

98% sensitive for intraperitoneal bleeding ( ATLS) Open or closed (Seldinger); usually infraumbilical

Supraumbilical in pregnancy and pelvic fracture

Free aspiration of blood, GI contents, or bile in hemodynamically unstable patient requires laparotomy

The Role of DPL

DPL regarded by many authors as obsolete

FAST has replaced DPL as investigation of choice in the hemodynamically unstable patient

It retains a role as a second line investigation tool and an adjunct to FAST

If fluid is found, DPL can help figure out what it is and where it is coming from but cannot ID the exact source

The Abdomen and Pelvic CT

CT scan remains the criterion standard for the detection of solid organ injuries CT scans unlike FAST examinations or DPL, have capacity to determine the source of hemorrhage Provide excellent imaging of the pancreas, duodenum, and GU system and can quantitate the amount of blood present in the abdominal cavity

Does FAST replace CT?

Only at the extremes Unstable patient, (+) FAST OR Stable patient, low force injury, (-) FAST consider observing patient and doing serial FAST exams

Spleen Injury

Most commonly injured organ 25% of blunt abdominal injuries Signs and symptoms often subtle

Left lower rib fractures

Non operative management in hemodynamically stable patients

Immunologic function has promoted salvage of the spleen rather than splenectomy

Spleen Injury

Non-operative management attempted in 60-80%

85-94% successful 2/3 will fail nonoperative mgmt within the first 24 hours

Salvage rates decrease with injury severity

Hepatic Injury

Relatively fixed position

Suspect in right lower chest injuries, rib fractures 710

2nd most common organ injured 15-20% of blunt abdominal injuries Responsible for 50% of deaths Non-operative management in hemodynamically stable patients

Hepatic Injury

Grade of Injury does not necessarily predict non operative failures Failure rates approximately 2% If stable with ongoing bleeding angiographic embolization

Pancreas Injury

Isolated injury to this organ is uncommon

More frequently associated with liver injury

Normal in up to 40% of patients

Missed injuries do occur

Mechanism most often crush and transection Delayed serum amylase elevations are much more sensitive Significant injury carries grave prognosis

Bowel and Mesenteric Injury

Occurs in 5% of abdominal trauma Mechanisms of injury

Compression increasing the intraluminal pressure in the bowel or by compressing fluid-filled bowel against solid structures Deceleration stretching and tearing of bowel loops at points of fixation

Difficult to diagnose

Seatbelt sign present in 21%

Bowel Injuries

Most Common Sites of Injury

Jejunum, ileum > colon, duodenum ( 2nd and 3rd portions )

Requires emergent operative management

Undiagnosed injuries lead to fatal peritonitis or hemorrhage Atypical for peritonitis to be present early on

CT in Bowel and Mesentery Injury

CT is currently best imaging tool

DPL is more sensitive (for bowel injury) but invasive minimal role in mesentery injury

CT sensitivity
94% for bowel injury 96% for mesentery injury

Diaphragmatic Injury

Diaphragm rupture rarely occurs as an isolated injury

Pelvic fracture Splenic rupture Liver laceration Thoracic aorta injury

Only 40-50% are diagnosed immediately

Diaphragm Rupture

Uncommon fewer than 5%

80-90% occur due to MVC

Left lateral impact 3x more likely than frontal impact

Mechanism

80-90% occur on the left

Penetrating Abdominal Injury

Implies either a GSW or stab wound has penetrated the abdominal cavity
GSWs associated with high incidence of injury and typically require laparotomy Stab wounds associated with lower incidence and may be expectantly managed

Relevant Anatomy

Thoracoabdominal area: Nipples to 12th rib, between anterior axillary lines Abdomen: Nipples to anus between anterior axillary lines Flank: Between ipsilateral anterior and posterior axillary lines Back: Below the tip of the scapula, between posterior axillary lines

Penetrating Trauma: 3 Categories

Presentation

Injury Type

Pulseless Hemodynamically Unstable Hemodynamically Stable

Major Vascular Injury Vascular and/or solid organ injury and/or hemorrhage from other sites Hollow viscus injury, vs renal or pancreatic injury

The Pulseless Patient

The pulseless patient with witnessed signs of life within 5 minutes prior to arrival
Need immediate laparotomy in the OR ED thoracotomy is an option if no OR is available

A surgeon must be available if you are preparing to open the chest cavity and cross clamp the aorta This procedure has a very low functional survivor yield

The Hemodynamically Unstable Patient

These patients must be taken to the OR

No further investigations should be undertaken if the patient is unstable

For questions regarding whether abdomen is source or site of bleed

FAST, DPL can be undertaken

Penetrating Abdominal Injuries in the Unstable Patient

Decision to perform laparotomy may be complicated by

Multiple gunshot/stab wound to more than 1 cavity The wounds are at or cross junctional zones such as the costal margin There is evidence of the possibility of cardiac tamponade

The Hemodynamically Stable Patient

Patients with clinical signs of peritonitis or with evisceration of bowel should be taken immediately to the OR The goal in the stable patient with penetrating wounds
Identify injuries Avoid unnecessary laparotomy

Options for Management

Serial Physical Examinations Local Wound Exploration Diagnostic Peritoneal Lavage Ultrasound ( FAST) CT Laparoscopy Laparotomy

Local Wound Exploration

Sensitivity and Specificity 71% and 77% Wound is extended under local anesthesia and tracked through tissue layers
Can be done in OR or ED Invasive with rare complications Penetration of the anterior fascia is considered a + LWE + LWE leads to laparotomy or other studies

FAST

Role of FAST in penetrating trauma has not been fully evaluated Ultrasound as yet cannot detect the small amounts of fluid associated with hollow viscus injury A positive FAST indicates peritoneal penetration but does not discriminate between injuries requiring intervention A negative FAST does not exclude signficant injury

CT Scan

Most studies recommend a multislice scanner with triple contrast protocol

IV, oral and rectal

CT gives best assessment of retroperitoneal structures

Laparoscopy

Technology still in infancy and is user dependent

In most studies, laparoscopy has a significant false negative, primarily due to missed bowel injuries Limited in evaluating for retroperitoneal injuries

It is the diagnostic method of choice for suspected diaphragmatic injuries

Laparotomy

Still has a role in resource limited environments and occasionally in cases of multi-cavitary injuries In most cases the non therapeutic lap rate will be unacceptably high

A negative lap has complications of 12-40% with hospital stays of 4-9 days

Special Situations: Flank or Back Wounds

Flank or Back Wounds

Associated with retroperitoneal injuries including the colon, kidney and lumbar vessels

Pancreas, aorta and inferior vena cava are less likely to be injured but must be considered

Injury to the colon is the most frequently missed

Serial PEs should be extended to 72 hours if colon injury is suspected

Special Situations: Wound to Buttock or Perineum

Buttock / Perineum wounds

Most dangerous occult injury in this area is to the rectum Any penetrating injury to the gluteal region carries this risk

DRE is inadequate and full proctoscopy and sigmoidoscopy should be performed

Thank You