Abdominal injury
The anatomical borders
• Superior - Level of the nipples
• Inferior - Level of the anus
• Flanks -Area b/n ipsilateral ant. & post. axillary
lines
• Thoracoabdominal - Area b/n level of the 4th
&12th ribs
• Back - Area post. to the post. axillary lines, below
the tip of the scapula
• Retroperitoneal organs - Duodenum, pancreas,
asc. and desc.colon, rectum ,kidney---
• MECHANISIMS OF INJURY
– Blunt injury (BAT) most common in civilian.
RTA Vehicular , vehicular/pedestrian
IndustriaL
sporting
– Penetrating injury (PAT)
Low energy (Sws) knife inj., impalement of a fall.
most survive with prompt Rx.
High energy (GSW) hand, shot guns ,rifles
mortality is high
1.Compression or concussive forces
direct blows
external compression VS fixed object (e.g. lap belt
,spinal column)
Cause tears & subcapsular hematoma to solid viscera
deform hollow organs &transiently intraluminal
pressure rapture.
2.Deceleration forces
stretching & linear shearing b/n relatively fixed &free
object
In BAT, Organs that can't yield to impact by elastic
deformation are most likely to be injured i.e. solid organs
• Frequency of Organ Injury in BAT
– Spleen 46%
– Liver 33%
– kidney 9%
– Intraperitoneal Small bowel 8%
&Mesentery
– Colon 7%
– bladder
– Diaphragm
– Pancreas
– Duodenum
• PAT(penetrating) & pelvic injury patterns
Most conspicuous wound assoc. injury
Liver diaphragm
Portal vein CBD, hepatic aa
SMA pancreas ,Lt. renal aa.
abdominal aorta
Spleen diaphragm ,Stomach
Stomach pancreas ,Spleen
Duodenum pancreas ,v. cava ,CBD
Rectum Bladder
• General principles of stab
– LUQ injury is most common in SWS
– 60%of ant. SWS violated the peritoneum (1/2
require repair of intra abdo. injury).
– Risk of intra abdo. injury requiring repair vary by
SWS entry & site
Ant. Or flank 30%
Thoraco abdominal 15%
Back 10%
Those with out clinical indication for laparatomy,
50% require laparatomy after diagnostic testing.
• General principles of Gsw
– In low-velocity injury(<1000ft/sec) ,damage is
confined to missile tract
– In high-velocity injury(>2000ft/sec ),blast effect &
cavitation occure in addition to damage by the missile
tract.
– 85% of ant. Gsw violate the peritoneum ,of these 95%
require repair of intra abdominal injury
– Organs occupying the most space are more often
injured.
s.bowel (29%), Liver(28%) ,colon(23%), stomach ,
spleen ,kidney ,pancreas.
Diagnostic approach
1.Clues from the History
Initially, evaluation and resuscitation simultaneously occur
• Mechanism of injury
• Rapid deceleration
• Use of lap belt, tire marks
• History of ejection or rollover.
• Fall from great height
• Obvious open injuries
• Shoulder pain (Rt &Lt)-kehr’s sign
• Damage to the interior or exterior of a vehicle
• Deaths at the accident scene
• Type of weapon
• Passage of haematuria
2.Examination
v/s
Inspection
• contusions/abrasions
• Lap belt ecchymosis
• The Cullen sign (i.e., periumbilical ecchymosis) &flank
ecchymosis in retroperitoneal hematoma
• Location of wound sites
• evisceration
Palpation
Tenderness (50% associated injury rate)
Crepitation or instability of the lower thoracic cage
guarding ,Distension
Auscultation
diminished bowel sounds
PR blood - sphincter tone -defect
NG aspirate blood
Abd. Wall findings from handlebar injury
Lap belt
Gsw flank
Gsw epigastrium
Gsw to flank
PAT tangential Gsw to liver
BAT Evisceration
Stomach injury
PAT Gsw to spleen
• Associated fractures
Left lower six ribs spleen
Right lower six ribs liver
upper lumbar vertebra pancreas
+duodenum
Transverse process kidney
pelvis bladder urethra
rectum
vascular
• Reliability of Clinical Evaluation
– Low sensitivity
– Unreliable in 34 - 45% patients
Why? head injury
spinal injury
alcohol
drug use
REPEATED P\E is mandatory
Workup
• Lab studies
CBC
Blood chemistry
coagulation profile
Blood type and cross match,
ABG
Urinalysis
• Imaging studies
CXR , Plain abdo. x-ray
Ultrasound Scanning (FAST)
Computer Tomography
• Diagnostic procedures
NGT, Foley catheter
Exploration of wound under LA
Explorative Laparotomy
Diagnostic Peritoneal Lavage
Rigid sigmoidoscopy
Laparoscopy, diagnostic paracentesis( 4-quadrant
tap)
• Immediate Laparotomy
– Abdominal distension + hypotension
– Peritonitis on P\E
– Retained stabbing implement
– Missile tract clearly enters abdo. cavity
– Abdominal visceral injury
• rectal bleeding and pelvic fracture
• ruptured diaphragm
• peritoneal air on CXR
• evisceration
surgical therapy : Laparotomy for Trauma
• Aims
Stop bleeding
Limit Contamination
• Method
Midline
Too large
• Priorities
Bleeding control
Haemodynamic stability
Contamination control
Full inspection
Indications for Investigation
When abdominal examination is
• Unreliable (altered mental state)
• Equivocal physical signs
• Unexplained hypotension or shock
• Suspicion of abdo. trauma.
Management
medical therapy
Step 1 ensure patent air way& adequate ventilation.
Step 2 correct hypovolaemia
• Iv lines
• Infusions of colloid or crystalloid soln
• Infuse blood when available
• Measure u.o.p & cvp, limit hypothermia, ANTIBIOTICS
Step 3 rapid assessment of injury
Step 4 Condn. of pt p¯ resuscitation
Persistent hypovol. stable pt c ¯minimal or
,or acute abdomen equivocal signs
Immediate surgery observe &investigate
