Blunt Abdomen Trauma
Neneng halimatusa’diah
Perseptor
Liza nursanty.,dr.,Sp.B
ABDOMINAL REGION
Abdominal quadrant
Blunt Abdominal Trauma
• Greater mortality than PAT (more difficult to diagnose, commonly
associated with trauma to multiple organs/systems)
• Most commonly injured organs: spleen > liver, intestine is the most
likely hollow viscus.
• Most common causes: MVA (50 - 75% of cases) > blows to abdomen (15%)
> falls (6 - 9%)
Etiology
Motor vehicle accidents
Fall from heights
Compression
Deceleration
Physical assault
Patofisiologi
• Rupture or burst injury of a hollow organ by sudden rises in intra-
abdominal pressures
• Crushing effect
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
• “seat belt sign” = highly correlated with intraperitoneal injury
Signs and symptoms
• Abdominal pain • Abdominal distension
• Tendernes • Anemia
• Gastrointestinal hemorrhage • Lap belt marks
• Nausea & vomiting • Ecchymosis involving the flanks
• Kehr’s sign • Abdominal bruit
• Local or generalized tendernes,
• Hypovolemia
guarding, rigidity, or rebound
• Loss of consciousness tenderness
• Peritonitis
Diagnosis
HISTORY
Laboratory
• Blunt abdominal trauma • blood tests
• Penetrating abdominal trauma • Urinalysis
PHYSICAL EXAMINATION Radiological Studies (Plain abdominal
X-ray, CXR)
• General physical examination Peritoneal lavage (DPL)
• Examination of the abdomen FAST U/S of abdomen
CT scan of abdomen
Examination of the abdomen
• Look for signs of intraperitoneal injury
• abdominal tenderness, peritoneal irritation, gastrointestinal
hemorrhage, hypovolemia, hypotension
• entrance and exit wounds to determine path of injury.
• Distention - pneumoperitoneum, gastric dilation, or ileus
• Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) -
retroperitoneal hemorrhage
• Abdominal contusions – eg lap belts
• ↓bowel sounds suggests intraperitoneal injuries
• DRE: blood or subcutaneous emphysema
FAST
• Focused assessment with sonography for trauma (FAST)
• To diagnose free intraperitoneal blood after blunt trauma
• 4 areas:
• Perihepatic & hepato-renal space (Morrison’s pouch)
• Perisplenic
• Pelvis (Pouch of Douglas/rectovesical pouch)
• Pericardium (subxiphoid)
• sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
• Extended FAST (E-FAST):
• Add thoracic windows to look for pneumothorax.
• Sensitivity 59%, specificity up to 99%
FAST
• Morrison’s pouch (hepato-renal space)
FAST
• Perisplenic view
FAST
• Retrovesicle (Pouch of Douglas)
• Pericardium (subxiphoid)
FAST
• Advantages:
• Portable, fast (<5 min),
• No radiation or contrast
• Less expensive
• Disadvantages
• Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
• Limited by obesity, substantial bowel gas, and subcut
air.
• Can’t distinguish blood from ascites.
• high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture
Diagnostic Peritoneal Lavage
• Largely replaced by FAST and CT
• In blunt trauma, used to triage pt who is HD unstable and
has multiple injuries with an equivocal FAST examination
• In stab wounds, for immediate dx of hemoperitoneum,
determination of intraperitoneal organ injury, and
detection of isolated diaphragm injury
• In GSW, not used much
Diagnostic Peritoneal Lavage
• 1. attempt to aspirate free peritoneal blood
• >10 mL positive for intraperitoneal injury
• 2. insert lavage catheter by seldinger, semiopen, or open
• 3. lavage peritoneal cavity with saline
• Positive test:
• In blunt trauma, or stab wound to anterior, flank, or back: RBC
count > 100,000/mm3
• In lower chest stab wounds or GSW: RBC count > 5,000-
10,000/mm3
Treatment
• Airway, Breathing, Circulation
• History of injury and mechanism
• Physical examination and vital signs
• Radiologic studies
• Laboratory testing
Resuscitation & management priorities of major
abdominal trauma:
• Control airway and breathing
• Stabilize circulation with volume
infusion or blood
• Hemorrhage control
• Nasogastric tube and urinary catheter if
no pelvic fracture
INDICATIONS FOR EMERGENT SURGERY
• Peritonitis
• Hypotensive shock
• Evisceration of viscus
• Positive diagnostic (DPL)
• Determination of finding on FAST or CAT scan
Terimakasih
