Abdominal trauma
Revision as of 21:31, 21 July 2016 by Neil.m.young (talk | contribs) (Text replacement - "==Diagnosis==" to "==Evaluation==")
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
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
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Evaluation
Imaging
- Ultrasound (FAST)
- Sensitivity increases with serial exams
- Cannot reliably evaluate retroperitoneum / hollow viscous injury
- CT
- Consider triple-contrast (IV, PO, PR) if concern for GI trauma
Template:ATLS abdominal trauma diagnosis algorithm
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
- 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.