Abdominal trauma

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

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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

Disposition

All patients with hypotension, abdominal wall disruption, or peritonitis need surgical exploration

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

Table 260-5 Indications for Laparotomy

If local wound exploration demonstrates no violation of the anterior fascia, the patient can safely be discharged.

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

Source

Tintinalli