Blunt abdominal trauma

The other modality that may be used in the trau-ma room to rapidly diagnose significant intra-ab-
dominal hemorrhage is US. In trained hands sensi-tivity of US for significant intra-abdominal
blood ap-proaches that of DPL, and US offers the added ad-vantage of non-invasiveness, and
repeatability. Assurgeons grow more comfortable in using and inter-preting US, it will likely
replace DPL in these situa-tions.
HEMODYNAMICALLY STABLE PATIENT
There continues to be controversy regarding the def-inition of hemodynamic stability after
trauma. Allcommonly used measures of circulatory adequacy(heart rate, blood pressure, base
excess, serum lac-tate, urine output) suffer from limitations. For prac-tical purposes a blunt
trauma patient may be consid-ered hemodynamically stable if after up to two lit-ers of
crystalloid infusion the patient is maintaininga systolic blood pressure >90 mmHg (>100
mmHgfor older patients), does not have a base deficit, (oris normalizing the base deficit), and is
making >50 mlof urine every hour. The evaluation of such patientshas two aims. First is to
rapidly identify patients whowill need operative therapy, and second is to triagepatients to
optimum level of care observation in theICU, observation in a regular hospital bed, and dis-
charge without admission.PE is the simplest form of evaluation. However itis suitable only for
neurologically intact mentallyalert patients. Also it entails admitting virtually allpatients for
repeated examination, and takes up sig-nificant time and personnel resources to be
effective.Even if all these limitations are acceptable, the lengthof time patients should be
observed is not clear. Al-though the large majority of patients with significantinjury requiring
intervention will be diagnosed with-in 24 hours of observation, a small number will bemissed, as
they may not demonstrate signs of injuryin this timeframe (e.g. a patient with a small
colonicperforation with minimal soilage, or a mesenteric in- jury with devascularized bowel).
DPL is highly sen-sitive for significant abdominal injury, but is inva-sive, nonspecific, and
results in an unacceptably highincidence of non-therapeutic laparotomy. US may bea good
screening modality, as it is noninvasive andits sensitivity approaches that of DPL. However
UScan miss a small amount of fluid in the peritoneum,which may be the only finding in a patient
with sig-nificant bowel injury. Further all three modalities donot address the second aim of
evaluation triage. Of the currently available modalities the one that comesclosest to meeting
the two aims of evaluation in a sta- ble patient is CT. A contrast enhanced CT can notonly
diagnose specific injuries, it can grade solid or-gan injury thus facilitating the decision making
proc-ess regarding the optimum level of care for a givenpatient. In a large prospective multi-
institutionalstudy of over 2000 patients it was shown that patientsevaluated by CT after blunt
trauma could safely bedischarged from the emergency department if the CTwas completely
normal and the patients did not haveany other indication for hospital admission (8). Theauthors
of this study however caution that such highaccuracy can only be achieved if helical (or
spiral)technology is utilized.In summary, all patients with significant blunttrauma that are
hemodynamically stable need tohave their abdomen evaluated for injury. Most cent-ers,
including the authors, use contrast enhanced hel-ical CT for this purpose. CT can identify
patients thatrequire operative intervention, and triage patients toobservations in either a regular
hospital bed or in theintensive care unit, or to discharge from the traumaroom. An alternative
approach may be to subject allpatients to US. If the US does not show any fluid,the patient is
admitted for observation, and if the USshows abdominal fluid, suggesting significant ab-dominal
injury, the patient undergoes CT for diag-nosing the source of fluid, and managing accord-
ingly.INDICATIONS FOR LAPAROTOMY
AT INITIAL PRESENTATION
1. Hemodynamic instability with evidence of intra-abdominal bleeding (grossly positive DPL or
pos-itive FAST)2. Peritoneal signs3. Chest radiograph showing evidence of diaphrag-matic tear
AFTER DIAGNOSTIC TESTING
Diagnostic tests showing:1. active extravasation from a major abdominal ves-sel or a contained
hematoma adjacent to a majorvessel suggesting injury2. solid organ injury with active
extravasation3. pancreatic injury4. hollow viscus injury5. intraperitoneal bladder rupture
DURING HOSPITAL OBSERVATION
1. Patient with solid organ injury being managednon-operatively developing hemodynamic
insta- bility or requiring >2 units of packed cell transfu-sion related to the solid organ injury2.
Development of peritonitis3. Persistent urinary leakage or persistent hematuriafrom a fragmented
kidney4. Patient with negative initial evaluation but notimproving or showing clinical
deterioration, withno other explanationSPECIFIC ORGAN INJURIES
SOLID ORGANS LIVER AND SPLEEN
Liver and spleen are the two most common organsthat are injured following blunt abdominal
trauma.Non-operative management of these injuries hasevolved over the past two decades.
Currently all he-modynamically stable patients with liver and/or

56
A. K. Malhotra, R. R. Ivatury, R. Latifi
spleen injuries detected by CT are managed non-op-eratively (9, 10). Patients who on CT scan
demon-strate active extravasation of intravenous contrastand yet are stable may either be
managed by imme-diate angiography with selective embolization of the bleeding vessel, or
undergo urgent laparotomy. Thedecision to go for surgery or control by interventionalradiology
is usually based on the locally availableexpertise and resources. In the absence of active con-trast
extravasation, patients with these injuries aremanaged by observation in the intensive care
unit.Any such patient developing hemodynamic instabil-ity or requiring >2 units of packed cell
transfusiondue to the solid organ injury should undergo urgentlaparotomy.
PANCREAS
Pancreatic injuries are often detected at surgery asthese patients usually have associated injuries
thatrequire laparotomy. Isolated injuries of the pancreashowever can be difficult to detect.
Enzyme elevationis fairly sensitive, but nonspecific. CT done in the ear-ly post trauma period
may fail to show injury. If theinitial CT does not show injury and the index of sus-picion, based
on mechanism or persistent enzyme el-evation, is high, the CT can be repeated. In such sit-
uations the technique should be modified to get thinsections through the pancreas and to time the
scanso that data acquisition is done when the intravenouscontrast is within the organ. Patients
with CT show-ing injury need laparotomy for drainage with orwithout resection. Alternatively
MR pancreatogra-phy, where available, offers a noninvasive way toevaluate the pancreatic duct.
Major ductal injury isan indication for laparotomy, while if the injury doesnot involve the major
ducts, the patient maybe man-aged non-operatively.
HOLLOW VISCUS
Hollow viscus injury is the third most common in- jury seen after blunt abdominal trauma. Delay
in op-erative therapy following such injuries can lead tosignificant morbidity and mortality.
Patients withperitoneal signs, either at initial presentation or dur-ing observation in the hospital,
should undergolaparotomy without delay. Although CT has tradi-tionally been considered poor
in the diagnosis of these injuries, the current helical scanners have in-creased the accuracy
considerably. Individual find-ings of bowel or mesenteric injury unexplained in-traperitoneal
free fluid; pneumoperitoneum; bowelwall thickening; mesenteric fat streaking;
mesenterichematoma; extravasation of luminal or vascular con-trast are nonspecific, but they
can raise suspicionof hollow viscus injury, and prompt further tests orlaparotomy. In a recent
report the number of CT find-ings was found to directly correlate with presence of injury (11). In
that report the authors suggest doinga DPL for a single CT finding, and proceeding
withlaparotomy if more than one finding is present.
DIAPHRAGM
All diaphragm injuries should be operatively re-paired. If repair is not done in the acute setting
thesepatients may present years later with chronic dia-phragmatic hernias and respiratory
compromise, orstrangulation. Larger ruptures are easily detected bychest radiography. Smaller
injuries can be missed.None of the available diagnostic modalities are re-liable in detecting such
injuries. The newer genera-tion helical scanners may show some subtle signssuch as thickening
of the hemidiaphragm. In theabsence of a reliable diagnostic test, the surgeon hasto maintain a
high index of suspicion based on thehistory more common with a mechanism involv-ing a
crushing force to the upper abdomen or chest.If the index of suspicion is high, laparoscopy
may be utilized to not only diagnose the injury, but re-pair it also. In rare cases exploratory
laparotomymay be necessary to establish the diagnosis and re-pair the injury.
URINARY TRACT
Majority of renal injuries following blunt traumadoes not require laparotomy. Laparotomy and
repairis indicated if there is urinary extravasation that ispersistent over 4872 hours. In most
patients present-ing with gross hematuria, the hematuria usually re-solves. In cases where the
hematuria does not re-solve, and the imaging studies suggest renal frag-mentation, laparotomy
may be required to removewhole or part of the kidney. The warm ischemia timefor the kidney is
four to six hours, and hence at-tempts at revascularization after traumatic avulsionor thrombosis
of the renal artery are usually futile.In rare instances when the diagnosis has been madeearly, the
patient is hemodynamically stable, and itis important to preserve renal parenchyma
(solitarykidney, borderline renal function), laparotomy forrevascularization may be
justified.Blunt ureteric injury is rare and usually occurswith other major injuries that require
laparotomy.Intraperitoneal rupture of the bladder is usually seenin association with a pelvic
fracture or when therehas been a blow to the lower abdomen with a dis-tended bladder. In
conscious patients peritonealsigns are present. CT scan usually shows free intra-peritoneal fluid.
Injury may be confirmed by retro-grade or CT cystography. Once the diagnosis ismade,
laparotomy is indicated to repair the bladder.
REPRODUCTIVE ORGANS
Injuries to the intra-abdominal reproductive organsare rarely isolated in the non-gravid patient,
and arefound during laparotomy for other reasons.
ABDOMINAL VESSELS
Injuries to the major abdominal vessels usually causehemodynamic instability, and are found at
laparot-omy. In some instances the bleeding may havestopped, and a pseudoaneurysm is detected
on CT

57
Blunt abdominal trauma
scan. If the pseudoaneurysm involves any major ves-sel, immediate laparotomy is indicated to
repair thevessel and prevent exsanguinating hemorrhage.CONCLUSIONSBlunt trauma accounts
for large majority of civiliantrauma. Prompt evaluation of the abdomen is neces-sary to minimize
preventable morbidity and mortal-ity. Unstable patients with evidence of intra-abdom-inal
hemorrhage (by US or grossly positive DPL)should undergo laparotomy immediately. Of
themultiple modalities available for evaluating stablepatients, contrast enhanced CT provides the
mostuseful information for deciding which patient needsoperative therapy, observation in the
intensive careunit or hospital, or can be safely discharged from theemergency
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