ABDOMINAL TRAUMA

BLUNT ABDOMINAL TRAUMA

Mechanism

1. intraabdominal pressure rise
    
2. compression
    
3. shearing  at points of attachment
   
   Following organs are injured in descending  order:
• spleen
• liver   
• retroperitoneum
• small bowel
• kidney
• colon
• diaphragm
• pancreas
• duodenum
• stomach

• Kehr's sign = left shoulder pain associated with hemoperitoneum present in spleen  injuries
• Contusions or abrasions
• Belt ecchymosis (gives clue for mesenteric, bowel, and lumbar spine injuries )
• Ecchymosis to periumbilical are late findings in retroperitoneal hematoma
• Tenderness, guarding, rigidity
• No clinical findings of hemoperitoneum
• Rectal exam-look for blood, prostate, tone
• Diaphragmatic ruptures may appear on C-Xray  as "haziness" due to GI contents and may be confused with pulmonary contusion. One can insert NGT to see if  this curls in stomach located in chest.

Diagnostic tests:

1. LABS: CBC , SMA, UA UPT, Amylase
    
2. Duodenal hematoma may be slow to develop (12-24 hrs). On labs pt may have    ­amylase and this should raise suspicion.  Pancreatic injury can be missed if not suspected.  Amylase is usually increased and   should raise suspicion. Pseudocyst is a late complication. If  LFTs are ­, liver injury is more likely. Hemobilia is a late complication (few weeks).
    
3. Cxray, AXray, Pelvic Xray prn
    
4. Diagnostic Peritoneal Lavage (DPL) -done when suggested by mechanism and if permitted by vital signs (if these unstable pt should go to OR). Keep the following in  mind:
    
1. insensitive for diaphragmatic, bowel, pancreas, retroperitoneal injury
    
2. only 5-20 ml of blood needed for diagnosis of organ injury
    
3. positive in blunt trauma when :
    
• 100K RBC/ml
• 500 WBC/ml
• amylase > 20 IU/L
• alkaline phosphatase > 3 IU/L
• bile, food matter
   
5. Abdominal CT Scan - for blunt trauma order IV and oral contrast;
   This can detect:
1. retroperitoneum
    
2. hemoperitoneum
    
3. liver and spleen injury
    
4. kidney injury. More accurate than IVP or US in detecting extent of injury
    
5. pancreatic injury
    
6. bowel (duodenum), mesenterum, diaphragm
    
7. bladder
   Hemodynamically  unstable pt shouldn't go alone  to CT without having trauma surgeon notified and involved
    
6. Ultrasound -
   This can detect:
1. hemoperitoneum and the peritoneal cavity (Morrison's and Douglas pouch)
    
2. solid viscera (pancreas, liver, kidney)
    
3. differentiates PEA from  shock state
    
4. fetal viability when emergency delivery considered
    
5. pericardial effusion
   
   Study is limited by the following:
1. requires l00-200 ml of intraperitoneal fluid for study (DPL requires 20ml)
    
2. accuracy is dependent on operator
    
3. obese patients
    
4. presence of air gas.
    
7. Laparotomy -
   Indications are:
1. peritonitis
    
2. evidence of diaphragmatic defect
    
3. blood from stomach or rectum
    
4. abdominal distention with hypotension
    
5. evisceration
    
6. positive diagnostic test (CT, DPL, US) for intraabdominal injury

PENETRATING ABDOMINAL TRAUMA

1. Stab Wounds ( SW ):

• left upper quadrant injury most common in stab wounds

2. GSW:

• in low-velocity injury is confined
   
• in high-velocity injury, there is blast

1. measure baseline hematocrit, SMA
    
2. urinalysis
    
3. upt
    
4. radiography

MANAGEMENT  OF  STAB  WOUND

Exploration

1. inspect wound to identify base
    
2. if base of wound shows that peritoneum was not involved  -  observe or discharge
    
3. if not conclusive ® DPL or CT

• 100K RBC/ml in anterior SW
   
• 10K RBC/ml in flank SW. DPL is not very sensitive thus less RBC needed for positivity
   
• 500 WBC/ml
   
• amylase >20 IU/L
   
• alk. Phos. > 3 IU/L
   
• food, bile

Laparotomy

Indications:

1. hemodynamic  instability
    
2. gross blood from orogastric tube or rectum, i.e. GI bleed
    
3. evisceration
    
4. evidence of diaphragmatic injury
    
5. clinical or radiographic evidence of intrabdominal injury, i.e. evidence that peritoneal cavity is violated
    
6. peritoneal findings on  exam positive DPL or CT

MANAGEMENT OF GSW

1. Inspect and/or Explore the wound and/or exit wound and other possible injuries of wound:
   if wound is superficial inspect the base of the wound.
                           ¯
                   If peritoneum ® laparotomy
                           ¯
                  If the base is not involved
                           ¯
   DPL  or  CT (RBC criteria  for DPL in GSW is 10K RBC/m)
                           ¯
        if negative all GSW are
   admitted for close observation
   with serial abdominal  examinations for l2~24 h
    
2. Radiography - AXray
    
3. One Shot IVP
    
4. Laparotomy
   Indications:
1. gunshot wound with obvious peritoneal penetration
    
2. unstable vital signs
    
3. positive DPL study "superficial" wounds

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