Abdominal Trauma
Most found on secondary survey
High percentage require surgery
Contrasts with Thoracic Trauma
External Abdominal Anatomy
Nipples to pubic symphysis
Anterior axillary line bilaterally
Level of umbilicus = aortic bifurcation into common iliacs and height of transverse colon
Flank: anterior axillary line to posterior axillary line
Back: posterior axillary line to posterior axillary line
Internal Abdominal Anatomy
Peritoneal cavity
Pelvis
Retroperitoneal cavity
- Zone (exploration for hematomas in blunt/penetrating)
- Zone 1 - midline: great vessels (usually mandatory/mandatory)
- Zone 2 - Lateral: Kidneys, ureters, adrenals (selective/selective)
- Zone 3 - Pelvis (avoid/selective)
Mechanisms of Abd. Trauma
Blunt
1. Compression:
- Direct blow to viscera --> organ rupture --> bleeding, contamination
- Direct blow to viscera --> rib fracture --> organ rupture --> bleeding, contamination
2. Deceleration
- Differential movement of fixed and non-fixed structures --> tearing --> bleeding, contamination
Penetrating
1. Direct trauma to organs --> bleeding, contamination
2. Blast effect if high velocity injury
Spleen, Liver – most commonly injured organs in blunt trauma due vascularity and proximity to ribs
Small Intestine, Large Intestine, Liver – most commonly injured organs in penetrating trauma due to surface area
Assessment of Abd. Trauma
Inspection
- Abrasions/contusions
- Lacerations/penetrating wounds
- Don’t forget to look at back/flanks
- Seat belt sign
- Account for odd number of holes
Seat Belt Sign
11% of all MVCs / 21% if belted
~25% chance of serious intra-abdominal injury due to significant deceleration injury
But Belted = Lower mortality than unbelted (1% vs. 5 %)
~5x increased risk of solid organ injury (3 to 17%)
~10x increased risk of HVI (1 to 10%)
CT normal in 13% of small intestine injuries
Seat Belt Sign & Chance Fxs
Thoracolumbar Flexion-Distraction Injuries
Lumbar 2-4 most common
2-5% Incidence with SB Sign
~ 25% Cord Injury Rate
~ 90% incidence of significant injury if seen with unexplained free fluid
Listen
Not very useful
Feel
Palpation - tenderness, guarding, rebound, soft VRS rigid, distended?
Percussion
Peritoneal Signs = Acute Abdomen
- Guarding
- Rebound Tenderness
- Percussion Guarding
Celiotomy
Complete assessment of acute abdomen
Treatment – Basic Approach
Penetrating Abdominal trauma or Acute abdomen --> OR
Blunt abdominal trauma with:
Equivocal abdominal exam and hemodynamic instability --> FAST Exam or DPL
Equivocal abdominal exam and normal vital signs --> CT scan or observation
Diagnostic Peritoneal Lavage
Traditional parameters
- > 5cc gross blood
- > 100,000 RBCs
- > 500 WBCs
- Fecal matter
- Amylase > serum level
DPA alone role?
? Penetration: >10,000 - DISPROVEN, NO LONGER USED
? Contamination in setting of hemoperitoneum: WBC > RBC / 150 - MIGHT STILL BE USEFULL
DPL - Technique
- NG/Foley
- Just inferior to umbilicus (superior with pelvic hematoma)
- Percutaneous Technique Superior
Quicker w/ equivalent accuracy
Exceptions: adhesions/dilated bowel
- Aspirate first
- Infuse fluid, then allow fluid to drain to dependent drainage
- Keep "sump" effect (always keep 200 mL in bag)
- Minimum of 600 cc for accurate DPL
Focused Abdominal Sonography for Trauma
Supplanted DPL
Advantages:
- Non-invasive
- Rapid
- Potential for serial exams
Disadvantage:
- Significant learning curve
Ultrasound
- Problems
- Training
- Equipment
- Sensitivity
- User dependent!!!! (rec 800 mL fluid for 75% people to call positive)
Expeditious Intervention
139 Consecutive HD stable pts w peritonitis after Abd GSW
10% had > 1.5 l hemoperitoneum
Review of 243 pts from Pennslyvania Trauma Registry:
- 0 < SBP < 90
- No comorbidities
- No other system AIS > 2
1% Increased Mortality for each 3-9 minutes of Celiotomy delay up to 90 minutes.
Typtical
Penetrating trauma w/ peritoneal signs --> OR
Blunt trauma, hemodynamic instability, equivocal exam --> FAST
Hemodynamically stable patient, equivocal exam --> CT
VS.
Exceptions
Selected Stab Wounds
Free Fluid without Solid Organ Injury
Tangential GSWs
Delayed GSWs
Stab wounds – up to 30% of stab wound wounds which penetrate peritoneum don’t cause significant injury
Back and Flank - are protected by heavier muscle layers. 85% of back stab wounds can be managed non-op.
Anterior Stab Wounds
Anterior abdominal stab wounds --> hemodynamically unstable, peritonitis, evisceration ? --> Yes: OR, No: local wound exploration/FAST --> Negative: D/C, Positive/equivocal: admit for obs w/ vitals q4h, serial abdominal exams, q8H cbc --> peritonitis or hemodynamic instability --> yes: OR, no -->significant drop in hemoglobin (>3g/dL), significant leukocytosis --> yes: CT, DPL or OR, no: Feed and D/C
Based on one study:
Test: Sensitive, Specific, Positive Predictive Value, Negative Predictive Value
FAST: 36, 96, 67, 86
CT: 89, 82, 53, 97 (other papers usually say lower)
Local Wound Exploration: 100, 22, 22, 100
DPL: 67, 100, 100, 89
SCA: 100, 96, 82, 100
If you follow the above protocol, cut down on CT scans, cut down on non-therapeutic laparotomies
Some data shows delay in OR specifically in stab wounds excluding peritoneal signs, evisceration or shock does not effect outcome, it's more related to the severity of the injury
Related Issue with Blunt Trauma:
Fluid on CT in absence of solid organ injury
Occurs in 2-8% of blunt trauma cases
~ 25% incidence of significant injury (ie bowel perforation)
Mortality of SB lac increases with delay in intervention
One study shows incidence of fluid on CT in absence of solid organ injury = 2% (28 / 1367) HD Stable Blunt Trauma Pts
78% Intra-abd injury, 64% “Significant Injury”
~ 90-100% significant injury rate c concurrent Seat Belt Sign or Chance Fx
HDS blunt abdominal trauma patient --> ABCs --> CXR, PXR, secondary survey --> CT A/P -->No solid injury, free fluid only -->
Alert patient -->
PE positive --> laparotomy
PE negative --> observe (30% chance of still having to go to OR)
Altered mental status -->
DPL positive --> laparotomy
DPL Negative --> observe
Positive seatbelt sign or chance fx --> laparotomy
Contamination in setting of hemoperitoneum: WBC/RBC > 1/150
TAKE HOME POINT: Delay should be avoided in all hollow viscus injuries but appears better tolerated with stab wounds than blunt injury
LAC & some other centers having some success with non-op management of selected GSWs: no peritonitis or high velocity GSW, HDS, reliable exam
Other options for GSWs: local exploration, modified DPL, CT, Laparoscopy
2010 EAST Guidelines:.Penetrating Abdominal Trauma
- Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1)
- Patients who are hemodynamically stable with an unreliable clinical examination should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1)
- A routine laparotomy is not indicated in hemodynamically stable patient swith abdominal SWs without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2)
- A routine laparotomy is not indicated in hemodynamically stable patients with abdominal GSWs if the wounds are tangential and there are no peritoneal signs (level 2)
- Serial physical examination is reliable in detecting siginificant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2)
- In patients selected for initial NOM, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2)
- Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3)
- The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3)
- Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2)
Trauma Laparotomy
Wide Draping
Overview: access and exposure --> temporary bleeding control --> exploration --> decide between definitive repair vs. damage control
Time is Critical
Exploratory Laparotomy
1. RUQ (Diaphragm, Liver, Biliary Triad, Hepatic Flexure)
2. LUQ (TC, Splenic Flexure, Spleen, Stomach)
3. Zone 1 Supramesocolic
4. Zone 1 Inframesocolic
5. Run SB
6. RLQ (Appendix, R Colon, R Zone 2)
7. Pelvis
8. LLQ (Rectum, L Colon, L Zone 2)
9. Additional Exposures prn - kocher, R or L medial visceral rotation
Common Missed Injury Sites - Esophagogastric junction, Ligament of treitz, mesenteric border of small bowel, posterior wall of transverse colon, extraperitoneal rectum
Damage Control
Indications
1. Injury patterns indicating the need for bail out
- Combined major vascular and hollow viscus injuries
- Penetrating injury to the "surgical soul" (chapter 8)
- High grade liver injury
- Pelvic fracture with an expanding pelvic hematoma
- Injuries requiring surgery in other cavities (chest, head, neck)
2. Hostile physiology
- Triad of death: acidosis, hypothermia, coagulopathy
- Intraoperative cues: edema of the bowel, midgut distention, dusky serosal surfaces, tissues cold to the touch, non-compliant swollen abdominal wall, diffuse oozing from surgical incisions
Priorities
Stop the Bleeding
Control Contamination
Restore Perfusion
Don’t burn bridges