Abdominal trauma

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Background

  • >35% of blunt trauma patients thought to have a "benign abdomen" end up needing surgery
  • Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen
    • Not appropriate for flank or back wounds
  • Knife
    • Benign initial exam in 20% of patients
    • Liver most commonly injured in stab wounds
  • GSW virtually all have intra-abdominal injury requiring surgery
    • Small bowel most commonly injured

Classes of hemorrhagic shock[1]

Class I II III IV
Blood Loss (mL) <750 750-1000 1500-2000 >2000
Blood Loss (%) <15 15-30 30-40 >40
Pulse rate (per min) <100 100-120 120-140 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure (mmHg) Normal or Increased Decreased Decreased Decreased
Respiratory Rate (per min) 14-20 20-30 30-40 >35
Urine Output (mL/hr) >30 20-30 Negligible
Mental Status Slightly Anxious Mildly Anxious Anxious, Confused Confused, Lethargic
Fluids Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood

Clinical Features

Solid Organ Injuries

  • Signs/symptoms due to blood loss
    • May bleed slowly / delayed onset of shock
    • Spleen most likely solid organ injured

Hollow visceral injuries

  • Signs/symptoms due to blood loss and peritoneal contamination
  • Seat belt sign, peritoneal signs
  • Free air on CXR
  • Lap Belt Injuries often with Chance fracture

Retroperitoneal Injuries

  • Signs/symptoms may be subtle or completely absent initially
  • Duodenal rupture is often contained within the retroperitoneum
  • Pancreatic rupture may be initially asymptomatic / negative CT /negative lipase
  • Grey-Turner sign: flank brusing, often associated with pancreatitis or pancreatic hemorrhage
  • Cullen’s sign: subcutaneous bruising and edema, often seen with AAA or pancreatic injury

Diaphragmatic Injuries

  • Symptoms
    • shortness of breath, Kehr Sign: shoulder pain from diaphragm or peritoneal irritation)
  • Generally related to degree of displacement of abdominal viscera into thorax
  • CXR: NGT curled in chest, abdominal organ herniation, thoracic aorta rupture

Differential Diagnosis

Abdominal Trauma

Evaluation

Imaging

  • Ultrasound (FAST)
    • Indicated for hemodynamically unstable trauma patients
    • Sensitivity increases with serial exams
      • A prudent evaluation involves serial abdominal exams with two FAST examinations performed at least 6 hours apart
    • Cannot reliably evaluate retroperitoneum / hollow viscous injury
    • Lower sensitivity in the setting of pelvic fractures
  • CT
    • Consider triple-contrast (IV, PO, PR) if concern for GI trauma or penetrating flank or back trauma

ATLS Blunt Abdominal Trauma Algorithm

  • Unstable
    • FAST to search for free fluid (vs. DPL if unavailable)
      • Positive: Exploratory laparotomy
      • Negative: CT scan
  • Stable
    • CT scan
      • Exploratory laparotomy, angiographic embolization, conservative management as indicated

Management

Nonoperative management is the norm in children but not necessarily in adults

Indications for laparotomy


Blunt Penetrating
Absolute Anterior abdominal injury with hypotension Injury to abdomen, back, and flank with hypotension
Abdominal wall disruption Abdominal tenderness
Peritonitis GI evisceration
Free air under diaphragm on chest radiograph High suspicion for transabdominal trajectory after gunshot wound
Positive FAST or DPL in hemodynamically unstable patient CT-diagnosed injury requiring surgery (i.e., ureter or pancreas)
CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury)
Relative Positive FAST or DPL in hemodynamically stable patient
Solid visceral injury in stable patient
Hemoperitoneum on CT without clear source

Disposition

Stable

  • CT scan of the abdomen and pelvis
    • FAST neg, responding to IVFs, normotensive
  • Penetrating
    • Knife: If local wound exploration shows no violation of ant fascia, suture lac and discharged
    • If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation
  • Angioembolization for hemodynamically stable patients with suspected bleed

Unstable

  • IR vs Surgery
    • isolated bleed for angioembolization
    • polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy

See Also

References

  • Shah, Essential Emergency Trauma, pgs 143-148
  • Bailitz J, Bokhari F, Scaletta TA, Schaider J. Emergent Management of Trauma. New York: The McGraw-Hill Company, 2011: pg 193.
  1. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 9. 2012. Ch 3:62-81