Abdominal trauma: Difference between revisions

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==Background==
== Background ==
*>35% of blunt trauma pts thought to have a "benign abdomen" end up needing surgery
 
*Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen
*>35% of blunt trauma pts thought to have a "benign abdomen" end up needing surgery  
**Not appropriate for flank or back wounds
*Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen  
**Not appropriate for flank or back wounds  
*Pts w/ transabdominal GSW virtually all have intra-abdominal injury requiring surgery
*Pts w/ transabdominal GSW virtually all have intra-abdominal injury requiring surgery


==Diagnosis==
== Diagnosis ==
*Solid Organ Injuries
 
**S/s due to blood loss
*Solid Organ Injuries  
***May bleed slowly / delayed onset of shock
**S/s due to blood loss  
*Hollow visceral injuries
***May bleed slowly / delayed onset of shock  
**S/s due to blood loss and peritoneal contamination
*Hollow visceral injuries  
*Retroperitoneal Injuries
**S/s due to blood loss and peritoneal contamination  
**S/s may be suble or completely absent initially
*Retroperitoneal Injuries  
**Duodenal rupture is often contained w/in the retroperitoneum
**S/s may be suble or completely absent initially  
**Pancreatic rupture may be initally asymptomatic / negative CT /negative lipase
**Duodenal rupture is often contained w/in the retroperitoneum  
*Diaphragmatic Injuries
**Pancreatic rupture may be initally asymptomatic / negative CT /negative lipase  
*Diaphragmatic Injuries  
**Symptoms generally related to degree of displacement of abdominal viscera into thorax
**Symptoms generally related to degree of displacement of abdominal viscera into thorax


==Work-Up==
== Work-Up ==
===Imaging===
*Ultrasound (FAST)
**Sensitivity increases w/ serial exams
**Cannot reliably evaluate retroperitoneum / hollow viscous injury
*CT
**Consider triple-contrast study (PO, PR, and IV) for penetrating trauma
===
 
 
 
==DDx==
 
 
==Treatment==
 
Accordingly, nonoperative management of even very severe injuries is the norm in children but not necessarily in adults
 
Table 260-6 American Association for the Surgery of Trauma Liver Injury Scale
 
Several large series have documented successful nonoperative treatment in >90% of patients who are hemodynamically stable at presentation.18,19 Low-grade injuries (grades I–III) can almost always able to be managed without surgery. Higher-grade injuries commonly fail nonoperative therapy.
 
atients who become unstable should undergo prompt laparotomy. Angiographic embolization is a useful adjunct. Patients with a large amount of hemoperitoneum or a vascular injury (contrast blush) on CT are good candidates for early angiography. Selected patients with juxta–vena caval injuries may also be candidates for hepatic vein stenting. These decisions should always be made with surgical consultation.
 
he spleen is the most commonly injured visceral organ in blunt trauma in both adults and children.20 Nonoperative management of splenic injuries in adults has a failure rate of approximately 10% to 15%.21 This relatively high failure rate has prompted some authors to advocate limiting nonoperative management to patients <55 years of age and those with a CT injury grade no higher than III
 
Table 260-7 American Association for the Surgery of Trauma Spleen Injury Scale
 
 
 
 
 
 
 
 
 
 


=== Imaging  ===


*Ultrasound (FAST)
**Sensitivity increases w/ serial exams
**Cannot reliably evaluate retroperitoneum / hollow viscous injury
*CT
**Consider triple-contrast study (PO, PR, and IV) for penetrating trauma


== Treatment  ==


*Nonoperative management is the norm in children but not necessarily in adults
*Indications for laparotomy


{| width="500" border="1" cellpadding="1" cellspacing="1"
|-
| <br>
| 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
|
|}


<br>


==Disposition==
== Liver Injury  ==


All patients with hypotension, abdominal wall disruption, or peritonitis need surgical exploration
*Nonoperative management is successful in &gt;90% of pts who are hemodynamically stable
*Low-grade injuries (grades I–III) can almost always be managed without surgery
**Higher-grade injuries commonly fail nonoperative therapy.
*Consider angiographic embolization if:
**Large amount of hemoperitoneum
**Vascular injury (contrast blush) on CT


presence of extraluminal, intra-abdominal, or retroperitoneal air on plain radiograph or CT should prompt surgical exploration. Finally, organ-specific injury seen on CT will often require exploration
== Splenic Injury  ==


Table 260-5 Indications for Laparotomy
*Most commonly injured visceral organ in blunt trauma
*Nonoperative management of splenic injuries has failure rate of 10-15%
**Same advocate nonoperative management only if &lt;55yr and CT injury grade &lt; IV


== Disposition  ==


If local wound exploration demonstrates no violation of the anterior fascia, the patient can safely be discharged.
*Penetrating
**If local wound exploration shows no violation of ant fascia pt can be discharged  
**If CT shows a subcutaneous trajectory or minimal retroperitoneal violation pt can be d/c'd home after period of observation


If CT clearly demonstrates a subcutaneous trajectory or minimal retroperitoneal violation, the patient can safely be discharged home after a period of observation.
== See Also  ==


==See Also==
== Source  ==


==Source==
Tintinalli  
Tintinalli


[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 19:13, 19 July 2011

Background

  • >35% of blunt trauma pts 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
  • Pts w/ transabdominal GSW virtually all have intra-abdominal injury requiring surgery

Diagnosis

  • Solid Organ Injuries
    • S/s due to blood loss
      • May bleed slowly / delayed onset of shock
  • Hollow visceral injuries
    • S/s due to blood loss and peritoneal contamination
  • Retroperitoneal Injuries
    • S/s may be suble or completely absent initially
    • Duodenal rupture is often contained w/in the retroperitoneum
    • Pancreatic rupture may be initally asymptomatic / negative CT /negative lipase
  • Diaphragmatic Injuries
    • Symptoms generally related to degree of displacement of abdominal viscera into thorax

Work-Up

Imaging

  • Ultrasound (FAST)
    • Sensitivity increases w/ serial exams
    • Cannot reliably evaluate retroperitoneum / hollow viscous injury
  • CT
    • Consider triple-contrast study (PO, PR, and IV) for penetrating trauma

Treatment

  • 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


Liver Injury

  • Nonoperative management is successful in >90% of pts who are hemodynamically stable
  • Low-grade injuries (grades I–III) can almost always be managed without surgery
    • Higher-grade injuries commonly fail nonoperative therapy.
  • Consider angiographic embolization if:
    • Large amount of hemoperitoneum
    • Vascular injury (contrast blush) on CT

Splenic Injury

  • Most commonly injured visceral organ in blunt trauma
  • Nonoperative management of splenic injuries has failure rate of 10-15%
    • Same advocate nonoperative management only if <55yr and CT injury grade < IV

Disposition

  • Penetrating
    • If local wound exploration shows no violation of ant fascia pt can be discharged
    • If CT shows a subcutaneous trajectory or minimal retroperitoneal violation pt can be d/c'd home after period of observation

See Also

Source

Tintinalli

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