Abdominal trauma
Background
- Typically divided into penetrating and abdominal trauma
- Gun shot wounds that penetrate the peritoneum virtually all have intra-abdominal injury requiring surgery
- Small bowel most commonly injured
Classes of hemorrhagic shock[1]
Class | I | II | III | IV |
---|---|---|---|---|
Approximate blood loss | <15% | 15-30% | 30-40% | >40% |
Heart rate | ↔ | ↔/↑ | ↑ | ↑↑ |
Blood pressure | ↔ | ↔ | ↔/↓ | ↓ |
Pulse Pressure (mmHg) | ↔ | ↓ | ↓ | ↓ |
Respiratory Rate (per min) | ↔ | ↔ | ↔/↑ | ↑ |
Urine Output (mL/hr) | ↔ | ↔ | ↓ | ↓↓ |
Glasgow coma scale score | ↔ | ↔ | ↓ | ↓ |
Base deficit^ | 0 to -2 mEq/L | -2 to -6 mEq/L | -6 to -10 mEq/L | -10 or less mEq/L |
Need for blood products | Monitor | Possible | Yes | Massive transfusion protocol |
^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.
Clinical Features
- Typically, abdominal pain after trauma (blunt or penetrating)
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
ATLS Blunt Abdominal Trauma Algorithm
- Unstable
- Stable
- CT scan
- Exploratory laparotomy, angiographic embolization, conservative management as indicated
- CT scan
Imaging Tests
- Ultrasound (FAST)
- Indicated only for hemodynamically unstable trauma patients
- Otherwise CT is indicated for primary imaging
- Ultrasound cannot reliably evaluate retroperitoneum / hollow viscous injury
- Ultrasound has lower sensitivity in the setting of pelvic fractures
- If CT is not available (e.g. low resource area, multiple casualty) can consider serial FAST exams, which increases sensitivity
- For example, serial abdominal exams with two FAST examinations performed at least 6 hours apart
- Otherwise CT is indicated for primary imaging
- Indicated only for hemodynamically unstable trauma patients
- CT
- CT with IV contrast only is typical standard
- May consider triple-contrast (IV, PO, PR) if specific concern for viscous perforation, although delay to imaging typically prohibits this as the initial study
- CT with IV contrast only is typical standard
Management
Nonoperative management is the norm in children, but not necessarily in adults.
- ATLS algorithm for severe trauma
- Vascular access
- Consider blood transfusion (and massive transfusion protocol) + TXA
- Surgery consult (surgery vs. IR)
- polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy
- isolated bleed for angioembolization
Indications for laparotomy
- Blunt
- Anterior abdominal injury with hypotension
- Abdominal wall disruption
- Peritonitis
- Free air under diaphragm on chest radiograph
- Positive FAST or DPL in hemodynamically unstable patient
- CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury)
- Penetrating
- Injury to abdomen, back, and flank with hypotension
- Abdominal tenderness
- GI evisceration
- High suspicion for transabdominal trajectory after gunshot wound
- CT-diagnosed injury requiring surgery (i.e., ureter or pancreas)
Disposition
Discharge
- CT scan of the abdomen and pelvis negative, normotensive
- Penetrating
- Knife: If local wound exploration shows no violation of anterior fascia, suture laceration and discharge
- If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation
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.
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
Videos
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