Abdominal

trauma
:PRESENTED BY
Dr Louza Alnqodi, R3

outlines
Background
Clinical assessment of pt with blunt ,
penetrating abdominal injuries
Diagnostic tools
Clinical approach
Conclusion.

R1
Which of the following does not
cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate homeostasis
*pelvic #
*retroperitoneal injury

R1
Which of the following does not
cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate haemostasis
*pelvic #
retroperitoneal injury

R2
Criteria for a +ve DPL include all
of the following except:
*initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low
chest wound.
*presence of bile, bacteria or meat/vegetable
fibers

R2
Criteria for a +ve DPL include all
of the following except:
initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low
chest wound.
*presence of bile, bacteria or meat/vegetable
fibers

R3
During the evaluation of a trauma
patient, an upright CXR showed
gastric bubble shifted to the rt .
No free air is present. What is the
main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury

R3
During the evaluation of a trauma
patient, an upright CXR showed
gastric bubble shifted to the rt .
No free air is present. What is the
main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury

R4
All of the following are clinical
indicators' for urgent laprotomy in pt
presenting with abdominal stab
wounds except which one?

*bowel protrusion or evisceration

*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding

R4
All of the following are clinical
indicators' for urgent laprotomy in pt
presenting with abdominal stab
wounds except which one?

*bowel protrusion or evisceration

*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding

R5
A 25 yr old male presents with a stab
wound to the upper abdomen. Vital signs
are stable. The abdomen is not distended,
soft, non-tender. Bowel sounds are present.
Upright CXR does not demonstrate a
Penumothorax or free air under diaphragm.
What should the next step be?
*evaluation of the peritoneal entry by local wound
exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.

R5
A 25 yr old male presents with a stab wound to
the upper abdomen. Vital signs are stable. The
abdomen is not distended, soft, non-tender.
Bowel sounds are present. Upright CXR does not
demonstrate a Penumothorax or free air under
diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound

exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.

anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
Pelvic cavity contents

o Anterior abdomen:
trans-nipple line, , anterior axillary lines,
inguinal ligaments and symphysis pubis .

o flank:
anterior and posterior axillary line ;sixth
intercostal to iliac crest

o Back:
posterior axillary line; tip of scapula to iliac
crest

 Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse
colon; lower-small bowel, sigmoid colon

Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys,
ureters,ascending and descending colons

Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia

mechanism
Blunt trauma:
MVC
Seatbelt injury
fall from ht
crash injury
sport injury

Penetrating injuries.

Blunt abdominal injuries carry a

greater risk of morbidity and
mortality than peneterating
abdominal injuries.

 associated with severe trauma to multiple

intraperitoneal organs and extra-abdominal
systems
altered mental status, intoxication
Peritoneal signs are often subtle and may be
obscured by other painful injuries

Up to 20% of patients with hemoperitoneum have

benign abdominal exams on initial presentation.

Blunt injury
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%

Splenic rupture is the most common visceral injury

with blunt abdominal trauma. Which of the following
statements regarding splenic rupture is FALSE?

CT scan may confirm injury, but should not delay

laparotomy in unstable patients.
Twenty percent of patients with left lower rib fractures
have associated splenic injury.
Focused Assessment with Sonography for Trauma is useful
if performed by experienced users.
Signs of peritonitis (involuntary guarding, rigidity, rebound)
are nearly always present.

Splenic rupture is the most common visceral injury

with blunt abdominal trauma. Which of the following
statements regarding splenic rupture is FALSE?

CT scan may confirm injury, but should not delay

laparotomy in unstable patients.
Twenty percent of patients with left lower rib fractures
have associated splenic injury.
Focused Assessment with Sonography for Trauma is useful
if performed by experienced users.
Signs of peritonitis (involuntary guarding, rigidity, rebound)
are nearly always present.

Seatbelt injuries
Unrestrained front and rear seat passengers are
at unequivocally greater risk of intra-abdominal
injury than their restrained counterparts.
The three-point shoulder-lap belt is the most
effective restraining system and is associated
with the lowest incidence of abdominal injuries.
However, abdominal injuries are still ascribed to
shoulder-lap and lap-belt systems.

pathogensis
o

compression of bowel between the belt

and the vertebral column.

o an acute short closed-loop obstruction

occurs along with perforation secondary to
the sudden generation of high intraluminal
pressures.

Clinically, two symptom patterns emerge.

~1/4 of pt develop evidence of a hemoperitoneum
secondary to mesenteric lacerations.
In the remainder, the intestinal injury most commonly
involves the jejunum contusion or perforation.
Rare cases of acute abdominal aortic dissection with
incomplete or complete occlusion have also been
described, and injuries to the lumbar spine are not
uncommon.

Penetrating abdominal
trauma

Mechanism

Stab wound
gunshot

 Knives are not the sole implement used in

stabbings.

Ice picks, pens, coat hangers, screwdrivers, and

broken bottles.

most commonly in the upper quadrants,

the left more commonly than the right.

Stab wound
multiple in 20% of cases
involve the chest in up to 10% of cases.
Most stab wounds do not cause an
intraperitoneal injury
the incidence varies with the direction of
entry into the peritoneal cavity
The liver, followed by the small bowel, is
the organ most often damaged by stab
wounds.

Gunshot Wounds
handguns, rifles, and shotgun

the degree of injury depends .

amount of kinetic energy imparted by the
bullet to the victim
mass of the bullet and the square of its
velocity
Distance .

Missile velocities :
low (slower than 1100ft/sec)
medium (1100-2000ft/sec)
high (faster than 2000-2500ft/sec)

 type I wounds: long range (>7 yards) , a

penetration of subcutaneous tissue and deep
fascia only.
Type II wounds: distance of 3 to 7 yards and may
create a large number of perforated structures.
Type III wounds occur at point-blank range (<3
yards) and involve a massive destruction of
tissue

 multiple organ injuries are

sustained, notably perforations to
bowel .
greatest for small bowel, followed by
the colon and then the liver.

Missiles effects
Extensive tissue damage
external contaminants tend to be dragged
into the wound.
the closure of the tract immediately after
the bullet's passage may lead to an
underestimation of tissue damage.
high-velocity bullets can fragment
internally

 Small bowel injury is the most

common injury resulting from ___
abdominal trauma.
penetrating
blunt

 Small bowel injury is the most

common injury resulting from ___
abdominal trauma.
penetrating
blunt

CLINICAL ASSESSMENT OF PT
WITH ABDOMINAL TRAUMA .

history
Primary goal is to identify that an injury exists, not
necessarily making an accurate diagnosis.
The patient's history may be unobtainable, elusive,
or temporarily abandoned while resuscitative
measures are carried out.
History from prehospital care team or transferring
hospital : the vital signs, physical assessment,
prehospital course, and response to therapy should
be obtained

Mechanism of injury is an important factor in

developing a high index of suspicion; thus a
detailed history is helpful if available.

Details about accident

Damage to car
Velocity
Steering wheel damage
Type of seatbelts used
Air bags deployed
All patients involved in deceleration injuries
and bicycle injuries should be suspected of
having intraabdominal injury

In penetrating trauma:
# of shots or stabs
Type of weapon
Distance b/w firearm and victim

examination

Overall, the accuracy of the physical

examination in patients with blunt
abdominal trauma is 55% to 65%.

Although the presence of physical

findings makes intraperitoneal injury more
likely, their absence does not preclude
serious pathology, and none is exclusively
diagnostic of a specific injury.

 Hypotension in the acute stage results

from hemorrhage that is most often from a
solid visceral or vascular injury.
hypotension with significant multiple
blunt trauma and is unexplained, one
should assume the presence of
intraperitoneal hemorrhage until it is
excluded.

In conscious, alert pt, look for:

Abdo tenderness,90%
Peritoneal irritation
Penetrating: wounds (log roll pt)
Ecchymosis, Cullen and Gray-Turner signs

 Rectal exam is important; assess for blood

and palpable bony fragments and position
of the prostate. High riding prostate
suggests posterior urethral tears.
Urethral disruption should be considered
when blood is noted at the meatus.
Vaginal exam for bleeding may suggest
bony fragments causing laceration.
Implications of bleeding during pregnancy
should be considered.

 The major findings with injury of the solid

abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:

abdominal pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may
result from confined hemorrhage)

 The major findings with injury of the solid

abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:

abdominal pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may
result from confined hemorrhage)

DIAGNOSTIC STRATEGIES
Hct: can be a delayed sign, should do serial.
WBC: in stress, peritoneal irritation
Pancreatic enzymes: if normal, does NOT r/o
pancreatic injury
amylase: EtOH, narcotics
amylase & lipase: ischemia 2 hypotension
both non-specific & non-sensitive for
pancreatic injuries

 Are abdo x-rays useful in trauma?

Although plain abdominal films can

demonstrate numerous findings, their
place in acute trauma is limited. Because
of spinal precautions, hemodynamic
instability, time consuming or patient
discomfort.

Smaller diaphragmatic injuries are often missed,

with herniation occurring late as the negative
intrathoracic pressure gradually draws the
mobile abdominal organs into the chest. Early
radiographic findings may be absent or subtle
and include all of the following EXCEPT :

pleural effusion
appearance of the nasogastric tube in the chest
appearance of bowel loops in the chest
elevation of the diaphragm
blurring of the diaphragm

Smaller diaphragmatic injuries are often missed,

with herniation occurring late as the negative
intrathoracic pressure gradually draws the
mobile abdominal organs into the chest. Early
radiographic findings may be absent or subtle
and include all of the following EXCEPT :

pleural effusion
appearance of the nasogastric tube in the chest
appearance of bowel loops in the chest
elevation of the diaphragm
blurring of the diaphragm

Imaging
CT
Able to define organ
injury
Good for retroperitoneal
& vertebral column
Non-invasive
Not Operator dependant

Not great for hollow

viscus
Stable patient
Cost $$$
Complications: IV or oral
contrast

US

Good for solid organs

Portable
Fast
100 cc detection blood
Mediastinum evaluation
No radiation
No contrast need
Not see well: solid
parenchymal,
retroperitoneal,
diaphragm
Problem if: obesity, gas
Less sensitive than DPL for
hemoperitoneal
Operator dependant

20 y/o female patient involved in a low velocity MVA. Upon initial exam no
abnormalities noted, no complains.
The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT
Scan which showed Liver Laceration Grade III. This patient was treated nonoperatively.

Preferred Site of Diagnostic

Peritoneal Lavage

Standard adult :Infraumbilical midline C or SO

Standard pediatric: Infraumbilical midline C or SO
2ed &3ed trimester pregnancy :Suprauterine FO
Midline scarring :Left lower quadrant FO
Pelvic fracture: Supraumbilical FO

DPL RBC Criteria (per

mm3 )
Positive

Blunt

100,000

Indeterminate
20100,000

Stab wound
Anteriorabdomen

100,000

20,000100,000

Flank

100,000

20,000100,00

Back

100,000

20,000100,000

5000

1000-5000

5000

1000-5000

Low chest
Gunshot wound

 List causes false negative DPL?

Catheter preperitoneal space
Fluid in compartment 2 adhesions
Diaphragmatic tear, so fluid goes into
thoracic cavity

-sole absolute contraindication to DPL is the

established need for laparotomy.
Relative contraindications:
- prior abdominal surgery
- Infections
- Coagulopathy
- obesity
- second- or third-trimester pregnancy.

CLINICAL APPROCHES TO PT
WITH:
o
o
o
o

BLUNT ABDOMINAL TRAUMA

STAB WOUND
GUNSHOT
ABDOMINAL WITH PELVIC TRAUMA.

Clinical Indications for Laparotomy

after Blunt Trauma
Manifestation

Pitfall

Unstable vital signs with

Alternate sources shock
strongly suspected abdominal
injury
Unequivocal peritoneal
Unreliable
irritation
Insensitive; may be due to
Pneumoperitoneum

cardiopulmonary source or invasive

procedures (diagnostic peritoneal lavage,

Evidence of diaphragmatic
injury
Significant gastrointestinal
bleeding

laparoscopy)

Nonspecific
Uncommon, unknown accuracy

Approach to abdominal stab

.wound
Step I: Clinical Indications for
Laparotomy.
Step II: Peritoneal Violation.
Step III: Injury Requiring
Laparotomy.

Clinical Indications for Laparotomy

Following Penetrating Trauma
Manifestation

Premise

Pitfall

Hemodynamic instability
Peritoneal signs

Major solid visceral or

vascular injury
Intraperitoneal injury

Thorax or mediastinum,
causal or contributory
Unreliable, especially
immediately post-injury

Evisceration

Additional bowel, other injury

Diaphragmatic injury

Diaphragm

Gastrointestinal
hemorrhage
Implement in situ

Proximal gut

No injury in one fourth to one

third of stab wound cases
Rare clinical, radiographic
findings
Uncommon, unknown
accuracy

Intraperitoneal air

Hollow viscus perforation

Vascular impalement

Comorbid disease or
pregnancy creates high
operative risk
Insensitive; may be caused by
intraperitoneal entry only or be
due to cardiopulmonary

.Peritoneal Violation

1.
2.
3.
4.
5.

Evisceration
Intraperitoneal air
Local wound exploration
Ultrasonography
Laparoscopy

Stabwoundtorightlowerquadrantwithcaecal
evisceration.Nocoloninjuryatlaparotomy.

 Eviscerated omentum is easily mistaken for

subcutaneous fat, so care must be taken in the
examination of open abdominal injuries. Which
of the following statements regarding
abdominal evisceration treatment is FALSE?
Cover eviscerated organs with moist gauze or
petrolatum gauze (to prevent desiccation) for
replacement at laparotomy.
Return all eviscerated organs to the peritoneal cavity.
Only organs with vascular compromise should be
promptly returned to the abdominal cavity.

 Eviscerated omentum is easily mistaken for

subcutaneous fat, so care must be taken in the
examination of open abdominal injuries. Which
of the following statements regarding
abdominal evisceration treatment is FALSE?
Cover eviscerated organs with moist gauze or
petrolatum gauze (to prevent desiccation) for
replacement at laparotomy.
Return all eviscerated organs to the peritoneal cavity.
Only organs with vascular compromise should be
promptly returned to the abdominal cavity.

In the abdominal stab wound victim without clear

indications for exploration (obvious peritoneal penetration,
unexplained hypotension, or signs of peritoneal irritation),
local wound exploration with local anesthesia should be
performed; laparotomy should be performed if the __ is
penetrated.

rectus abdominis muscle

posterior rectus sheath
transversalis fascia.

25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar
entered at the level of the epigastrium and exited through the left posterior thoracic wall.

Abdominal stab wound, with hepatic

. lesion grade II

Implements in situ
implements in situ of the torso in the operating room.
to ensure expeditious control of hemorrhage
the implement reside within a vascular space or highly
vascularized organ.

exceptions to this practice exist:

situations in which emergency department resuscitation is
impeded by the presence of the implement
the patient is at high risk of significant morbidity from
nontherapeutic laparotomy because of severe comorbid
conditions or pregnancy.

#?What is your approach to pelvic

conculsion
The accuracy of physical examination is limited in
cases of blunt and penetrating trauma. It is less
reliable by distracting injury, altered sensorium
(e.g., head trauma, alcohol or drug intoxication,
mental retardation), and spinal cord injury.
The choice of diagnostic studies for abdominal
trauma is based on clinical need first and
foremost, as well as study availability and the
trustworthiness of that study in a respective
center

 Ultrasonography and peritoneal aspiration are

rapid methods of determining or excluding the
presence of hemoperitoneum in the critically ill
blunt or penetrating trauma patient.

Clinical indications for laparotomy are more

dependable in and more frequently applicable to
cases of penetrating trauma than cases of blunt
trauma.

THANK YOU