The Initial Assessment and

Evaluation of Abdominal Trauma

Tanya L. Zakrison
Trauma & Acute Care Surgery
St. Michaels Hospital
Sept. 20th, 2011
 Objectives
How to recognize the trauma patient with an
abdominal injury
Anatomy
How to manage the patient with an abdominal
injury in the initial stage
Damage control resuscitation
How to evaluate the abdomen
Different modalities & whole body pan scan
Guidelines
European & EAST
 Case 1 - Blunt Abdominal Trauma
45F, high-speed MVC
Seat-belt sign, HD normal

How would you approach this patient?

How would that change if the pt. is HD abnormal?

What if the patient also had a pelvic fracture?

Case 2 - Penetrating Abdominal Trauma
23M, stab wound to anterior abdomen, HD
normal

How would you approach this patient? GSW?

How would that change if the patient is HD

abnormal?

What if the patient was stabbed in the flank? The

back? The thoracoabdominal area? Cardiac box?
 ATLS Approach
A intubation may be required if hypotensive
B watch H/PTX in both blunt and penetrating
TAA injuries
C start with 2 L crystalloid, may need to
activate MTP MUST FIND & STOP THE
BLEEDING
D may see associated thoracolumbar #s with
BAT
E watch for SBS, other injuries
What is Hemodynamic Normality?

Base deficit
lactate
 Shock?
Rapid responder (20%)
Transient responder (30%)
Non-responder (>30%)
Hypotension in the field
ATLS - 2L warmed crystalloid
(3:1)
Blood products as needed
Tranexamic acid (anti-
fibrinolytic)
Follow urine output
The Lethal Triad of Death
 More Complicated Than Anticipated
Acute Coagulopathy of Trauma Shock

25% of trauma patients present coagulopathic

 Damage Control Resuscitation
Permissive hypotension
1:1:1 resuscitation (pRBCs, platelets, FFP)
Damage control surgery
Stop the bleeding (pack)
Control the contamination
Definitive surgical anatomical restoration later
Initial Resuscitation The Bottom Line?
Identify what is bleeding: Very little to do in the
4 & on the floor trauma bay prior to OR if
1. Chest HD abnormal:
1. CXR Intubate
2. Intraperitoneal abdomen
CXR
1. FAST
3. Retroperitoneal Group & screen
abdomen
1. PXR, CT scan
4. Extremities (femur #s)
If crashing:
1. XRs Bilateral chest tubes
Then stop it:
OR If dying:
Angioembolization ED thoracotomy
Tourniquet
Reduction & stabilization Get to OR ASAP
Initial Management of the Bleeding Patient
European Guidelines; CC 2007
Recommendation 1:
That time elapsed between injury and operation be minimized
for pts. In need of urgent surgical control (grade1A)
Recommendation 2:
That a grading system be used to assess the clinical extent of
hemorrhage (ACS COT)
Recommendation 3:
pts. presenting in hemorrhagic shock AND an identified source
of bleeding undergo an immediate bleeding control procedure
UNLESS initial resuscitation measures are successful
Recommendation 4:
pts. with an unidentified source of bleeding in hemorrhagic
shock should undergo immediate further assessment
Recommendation 5:
Trauma pts. should be resuscitated initially with crystalloid to a
BP of 80-100 mmHg in the absence of TBI
 Tanyas guidelines:

Find what is bleeding

then stop it
Patient in Extremis = ED Thoracotomy
 The Abdomen
Thoracoabdominal area
Transverse nipple line to costal
margin
Anterior abdomen
Costal margin to groin crease
to anterior axillary lines
bilaterally
Flank area
Anterior axillary line to
posterior axillary line, costal
margin to iliac crests
Back
Medial to posterior axillary
lines, tip of scapula to iliac
crests
Torso
All the above
 Cardiac Box

Mediastinum

Thoracoabdominal area
 The Abdomen is More Than Just the
Abdomen
Abdomen: Thorax
Intraperitoneal cavity (thoracoabdominal
Clinical exam injuries)
FAST CXR
DPL Heart & Great Vessels
CT scan (cardiac box injuries)
Exploratory laparoscopy
Cardiac FAST
Exploratory laparotomy
CXR
Retroperitoneal cavity &
pelvis Diaphragm & Bladder
Pelvic xray (innocent bystanders)
CT scan Diagnostic laparoscopy
Exploratory laparotomy CT cystogram
Blunt Abdominal Trauma
 Why investigate?
Unlike penetrating trauma, diagnosis of BAT by
clinical exam is unreliable, esp. decreased LOC
Late diagnosis of missed injuries leads to
increased mortality rates
Large prospective study- 10% of patients with no
clinical signs of injury had injuries found on CT
Consensus guidelines suggest that the threshold
for investigation of BAT should be very low
EAST, 2002
Tools Available For Abdominal Trauma
Physical exam
X-Rays
Ultrasound (FAST)
Computerized Tomography (CT)
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory laparotomy
Tools Available For Abdominal Trauma
Physical exam bad for blunt, good for
penetrating (serial physical exams)
X-Rays
Ultrasound (FAST) helpful if positive
Computerized Tomography (CT) not for HVI
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy for the diaphragm
Exploratory Laparotomy if needed
 What Are We Worried About?
Bleeding:
Liver
Spleen
Kidneys
Mesentery
Bowel:
Contamination
Bladder:
Intraperitoneal rupture
Diaphragm:
Mainly on the left side
 How to Investigate Blunt Abdominal
Trauma? BMJ 2008
Concealed or occult hemorrhage is the 2nd
most common cause of death after trauma
Missed abdominal injuries are a frequent
cause of morbidity and mortality
Appropriate and expeditious investigations are
important
Non-operative management of solid organ
injury now more common
 Physical Exam
Neither sensitive nor specific to rule out intra-
peritoneal hemorrhage (bleeding)
Excellent to watch for the development of
peritonitis (contamination)
Less than 24 hours, usually by 13 hours
A modality usually employed in penetrating
trauma
Very poor to detect bladder or diaphragmatic
injury
Seat Belt Sign Not Just the Abdomen
 Physical Exam Caveat
The Seat Belt Sign
Historically indicative of significant intra-abdominal
injury
Especially when accompanied by a Chance fracture (L2
flexion distraction fracture) (up to 30-50% pts.)
Can occur together or in isolation on the neck, chest or
abdomen
Indicative of carotid, thoracic or intraabdominal injuries
Hollow viscus injuries
Retroperitoneal injuries (duodenum and pancreas)
Solid organ (tearing of the falciform ligament)
Odds of intraabdominal injury increased 2.6x if SBS
present on passenger seated in the front seat Coimbra,
2009
Focused Assessment With Sonography
in Trauma (FAST)
Looks for free intra-abdominal fluid (assumed to be blood
or gastrointestinal content, may be other)
Also pericardial fluid
Non-invasive, no radiation, repeatable
Highly Sn (79-100%) and Sp (96-100%)
Moreso in hemodynamic pts. after BAT
Repeating FAST also increases Sn
May still need other imaging modalities with a negative
FAST
Can be performed with equal accuracy by surgeons
Use controversial in penetrating trauma of the abdomen
Only helpful if positive
VERY helpful for detecting intrapericardial blood
UABCDE
FAST
 Diagnostic Peritoneal Lavage (DPL)
Described in 1965, standard of care
Open or closed (Seldinger) approach
Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)
Lead to a non-therapeutic laparotomy rate of 36%
Laparotomy when:
10 cc gross blood
Enteric contents
1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3
High false positives with pelvic fractures
Do a supraumbilical approach
High Sn for hollow viscus injuries
Moreso than CT
Risk of visceral injury = 0.6%
Retroperitoneum cant be assessed
 Diagnostic Peritoneal Lavage
In real life:
Good tool if FAST equivocal
in the HD abnormal pt. in
the setting of a pelvic
fracture
FAST unavailable, pt. is HD
abnormal
 Computerized Tomography
Imaging modality of choice only in HD normal patients
Pts crumping in CT a performance indicator in trauma centres
Sn = 92-97%, Sp = 99% for bleeding
Active arterial contrast extravasation, blush or
pseudoaneyurysm
Even with AKI, or in the elderly
Only modality to directly detect retroperitoneal injury
Less accurate for HVI
Still need serial physical exams
If pelvic fluid is present in absence of solid organ injury
exploratory laparotomy is mandated, especially if moderate or
large amounts of free fluid Chen, 2009
3% males may have pelvic fluid 2dary to resuscitation
Poor test to diagnose diaphragmatic injury
 Computerized Tomography
Effect of whole-body CT during trauma
resuscitation on survival: a retrospective,
multicentre study
Huber-Wagner et al., Lancet 2009
Relative risk of mortality in blunt trauma reduced
by 25% according to TRISS
NNT = 17
Whole-body CT an independent predictor of
survival
Hypovolemic Shock Complex
 Indications for Laparotomy
Blunt Abdominal Trauma

Absolute Indications:

1. Shock
2. Peritonitis
3. Blood out of NG tube or on rectal exam
4. Intraperitoneal bladder rupture
5. Diaphragmatic rupture
Initial Management of the Bleeding Patient
European Guidelines; CC 2007
Recommendation 6:
Early FAST for the detection of FF in patients with
suspected torso trauma
Recommendation 7:
Pts. with significant FF on FAST with hemodynamic
instability should undergo urgent surgery
Recommendation 8:
HD normal pts. with suspected head, chest and/or
abdominal bleeding following high-energy injuries should
undergo further assessment using CT
Recommendation 9:
Single Hct is not helpful; lactate or base deficit is helpful to
estimate and monitor the extent of bleeding and shock
 BAT & Pelvic #
May have ongoing bleeding from the
abdomen, pelvis (retroperitoneum) or both
FAST used for intraabdominal bleeding
PXR for pelvic fractures (APC, VS, LC)
Abdomen trumps pelvis (80-90% venous
bleeding)
Pelvic bleeding should subside with stabilization in
the majority of cases
Laparotomy done first if FAST positive
Open Book Pelvic Fracture
Pelvic Fracture has large potential
space for hemorrhage
Col (ret) Mark W. Bowyer MD

Close Pelvis Many Devices

Available to Close Pelvic Ring
Surgical consult Pelvic wrap
Intraperitoneal gross blood?

Yes No

Laparotomy Angiography

Control hemorrhage
Fixation device
Initial Management of the Bleeding Patient
European Guidelines; CC 2007
Recommendation 10:
Pts. in shock with pelvic ring fractures should undergo
immediate closure and stabilization
Recommendation 11:
If ongoing instability, proceed to early angioembolization or
surgical bleeding control such as packing
Recommendation 12:
Early bleeding control must be achieved by packing, direct
surgical bleeding control, the use of local hemostatic
procedures. If pt. is exsanguinating, aortic cross-clamping may
be employed as an adjunct
Recommendation 13:
Damage control surgery should be employed in the severely
injured pt. with signs of shock, ongoing bleeding and
coagulopathy
 EAST Guidelines Evaluation of Blunt
Abdominal Trauma, 2001
Level I:
Exploratory laparotomy is indicative for patients with a
positive DPL
CT is recommended for the evaluation of hemodynamically
stable patients with equivocal findings on physical
examination, associated neurologic injury, or multiple
extra-abdominal injuries. Under these circumstances,
patients with a negative CT should be admitted for
observation (i.e. contamination)
CT is the diagnostic modality of choice for non-operative
management of solid visceral injuries (i.e. bleeding)
In HD stable patients, DPL and CT are complementary
diagnostic modalities
 EAST Guidelines Evaluation of Blunt
Abdominal Trauma, 2001
Level II:
FAST may be considered as the initial diagnostic
modality to exclude hemoperitoneum
Exploratory laparotomy is indicated in HD unstable
patients with a positive FAST
If HD stable with a positive FAST, follow up CT permits
nonoperative management of select injuries
Surveillance studies (DPL, CT, repeat FAST) are
required in HD stable pts. With indeterminate FAST
results
 Tanyas Summary - BAT
In stable go to the OR for a laparotomy
If you are worried about contamination (HVI)
Fluid in the pelvis in absence of SOI
If you are worried about an intraperitoneal
bladder injury or large diaphragmatic injury
In unstable go to the OR for a laparotomy
If the bleeding is in the abdominal cavity
If the bleeding is in the pelvis for packing as still
ongoing after stabilizing
Penetrating Abdominal Trauma
 ATLS Approach
A intubation may be required if hypotensive
B watch H/PTX in both blunt and penetrating
TAA injuries
C start with 2 L crystalloid, may need to
activate MTP MUST FIND & STOP THE
BLEEDING
D may see associated thoracolumbar #s with
BAT
E watch for SBS, other injuries
 Penetrating Abdominal Trauma
Violation of peritoneum
Therefore risk of intra-
abdominal injury that
requires surgery
Caused by stab wounds
Caused by gun shot wounds
Caused by shot gun wounds
Caused by other
penetrating objects
How common are injuries that require
surgical repair?
Anterior abdominal stab wounds:
25-33% will need a laparotomy

Posterior or flank stab wounds:

15% will need a laparotomy

Anterior gun shot wounds:

58-75% will need a laparotomy

Posterior gun shot wounds:

33% will need a laparotomy
 Indications for Laparotomy
Penetrating Abdominal Trauma

Absolute Indications:

1. Shock
2. Peritonitis
3. Evisceration
4. Weapon still in situ
5. Blood out of NG tube or on rectal exam
6. Gross hematuria
 Penetrating Abdominal Trauma
When to Operate in Stab Wounds?
1. Shock
PPV = 80% for
therapeutic laparotomy
2. Peritonitis
PPV = 85% for
therapeutic laparotomy
Local (50%)
Diffuse (81%)
3. Evisceration
PPV = 75% for
therapeutic laparotomy
Intestinal (100%)
Omental (76%)
 Stab Wounds
Anterior Abdominal Wall
Not all stab wounds to the anterior abdominal
wall (AAW) will have:
Violated the peritoneum
Caused intraabdominal injury requiring operative
repair

Up to 50% of stab wounds to the AAW will not

violate the peritoneum
Up to 50% that violate the peritoneum do not cause
injury requiring operative repair
 Stab Wounds
Anterior Abdominal Wall
1. Local Wound Exploration (LWE)
Sterile procedure with local anesthetic
2. Serial Physical Examinations (SPE)
Done by same clinician to assess for the
development of peritonitis
3. Focused Assessment with Sonography for
Trauma (FAST)
Not indicated in penetrating trauma
4. Diagnostic Peritoneal Lavage (DPL)
Not done in many centers
 Stab Wounds
Anterior Abdominal Wall
5. Computerized Tomography (CT)
Historically not used for anterior abdominal stab
wounds
More useful in penetrating injury to the flank and back
6. Diagnostic Laparoscopy
Used to rule out:
Peritoneal penetration
Diaphragmatic injury on left side
7. Exploratory Laparotomy
Still the gold standard in ruling out intra-abdominal
injury
 Pitfalls
1. DPL:
Cumbersome
Sensitivity poor for hollow viscus injury
Different criteria for positive tests in different centers
Positive test for RBCs does not equate to needing a
therapeutic laparotomy
Many solid organ injuries managed non-operatively now
2. FAST (Soffer, 2004):
Very limited role in penetrating abdominal trauma
Rarely changes management, even if positive (1.7%)
 Pitfalls
3. Diagnostic laparoscopy:
Only identifies peritoneal violation
Not sensitive for hollow viscus or retroperitoneal
injury
Automatic conversion to laparotomy will still
result in a high non-therapeutic rate
Still largely reserved to rule out diaphragmatic
injury with left thoracoabdominal SWs
30% will have an injury to the diaphragm
Caution: 10% develop a tension pneumothorax
intraoperatively if no chest tube in place
Non-Operative Management of Stab Wounds
EAST 2010
1. Hemodynamically stable
2. No peritonitis or diffuse abdominal pain
3. In a center with surgical expertise
4. Patient is evaluable*

*Evaluable: absence of brain or spinal cord

injury, intoxication or need for sedation or
anesthesia

20% of patients selected for NOM will fail

(Clarke et al., 2010)
 Stab Wounds Flank and Back
Laparotomy used to be standard of care
Phillips, 1986
CT first reported for SWs to flank & back
Fletcher, 1989
Non-operative management with 3CT in 76% of
patients with SWs to flank & back
Jurkovich et al, 2009
Triple contrast CT scan has replaced DPL
Evaluates retroperitoneum as DPL cannot
Now mandatory laparotomy replaced with triple
contrast CT scan for stab wounds to flank and
back
Some centers advocate IV contrast only is necessary
 Thoracoabdominal Stab Wounds
Historically, 33% of patients with left
thoracoabdominal stab wounds with have a
diaphragmatic injury
Murray, 1998
Prospective study of left throacoabdominal SWs
Diaphragmatic injury in 26% of patients who had no
indication for laparotomy
Patients with left thoracoabdominal stab wounds may
be observed for 12 hours

If no need for laparotomy by that time, may repair

diaphragm using laparoscopic techniques
 CT Scan for Anterior Abdominal Wall
Stab Wounds
Not well defined, evolving modality
Does not add much to serial physical exams
Poor test for:
Hollow viscus injuries
Diaphragm injuries
Use if:
1. High suspicion of solid organ injury (liver, spleen,
kidney) based on wound location (R or LUQ)
2. Positive FAST exam
3. Hematuria
 While selective management of anterior
abdominal stab wounds is appropriate...

Selective management of anterior abdominal

GSWs is still controversial

But this can reduce the rate of nontherapeutic

laparotomy from 30-50% to 5-10%
Non Operative Management of Gun Shot
Wounds Guidelines (EAST) 2010

1. Hemodynamically stable
2. Tangential wound
3. No peritoneal signs

4. Consider only if patient is evaluable

5. Exception if GSW to RUQ

Non Operative Management of Gun Shot Wounds to
Right Upper Quadrant (Non-Tangential) - Guidelines

Absolute indications:
1. Hemodynamically stable
2. Patient is evaluable*
3. Minimal to no abdominal
tenderness

* Evaluable: absence of
brain or spinal cord injury,
intoxication or need for
sedation or anesthesia
 EAST Guidelines 2010
Patients with GSWs who are selected for initial
non-operative management should have other
diagnostic tests

This should be an abdominal pelvic CT scan to

facilitate initial management decisions
 Is a Non-Therapeutic Laparotomy Bad?

Ventral incisional hernia rate 5 - 20%

Lowe et al., 1972

245 pts. with negative or non-therapeutic laparotomies after mainly
penetrating trauma
20.4% complication rate (evisceration in 4 pts.)
1.6% mortality rate related to unnecessary laparotomy
Demetriades, 1993
11% of non-therapeutic laparotomies with major complications
LOS = 4.1 days if no complications vs. 21.2 days if complicated
Renz & Feliciano, 1995
Complications in 41.3% of 254 pts. with laparotomies for trauma
Velmahos et al, 2001
$ 9.5 million saving with NOM over 8 years, 1856 pts. with GSW
 How long to observe?
Patients with penetrating abdominal injuries
selected for NOM should be observed for 24
hours
They may be discharged after 24 hours in the
presence of a reliable physical exam and minimal
to no tenderness
The majority of asymptomatic patients who failed
NOM after SWs did so within 12 hours Alzamel et al,
2005
24 hours still recommended by most centers
Inaba & Demetriades,2007
Summary Stab Wounds to Abdomen

Non-operative management if no:

Shock, peritonitis, evisceration & patient
evaluable
LWE as per clinician preference
May discharge patient home if no fascial violation
Serial physical exams by same clinician X 24
hours
Watch for peritonitis, discharge home if minimal
or no pain
 Summary Stab Wounds to Abdomen

CT scan if
SW to R or LUQ to rule out solid organ injury
SW to flank or back as CT may rule out peritoneal
violation
May send home after or..
May observe patient after CT for 24 hours nonetheless
Delayed laparoscopy after 12 hours of observation if
TAA SW to left upper quadrant to identify and repair any
diaphragmatic injury
 Summary GSW to Abdomen
Non-operative management if no:
Shock, peritonitis, evisceration & evaluable
All patients undergo CT scanning
Anterior abdomen, flank or back
If GSW tangential (no peritoneal breach) & no
peritoneal signs, patient may be discharged home
If solid organ injury, may manage non-operatively
Consider repeat imaging in 7 days to manage
asymptomatic complications in 50%
If hollow viscus injury, proceed with laparotomy
If no apparent injury, observe for 24 hours
Summary Penetrating Abdominal
Trauma
Low threshold to operate
Dont forget trauma to thoracic structures if
TAA
FAST only helpful with bleeding if positive
Always do a pericardial FAST if close to the box
CT only helpful with bleeding
Less so with HVI
Serial physical exams helpful in all
 Thank you!
zakrisont@smh.ca