Abdominal

Trauma
 Outline
Anatomic definition of abdomen
Mechanisms of injury in trauma
Typical injury patterns
Assessment of blunt abdominal trauma
Diagnostic algorithms
 Abdomen: anatomic boundaries

 External:
 Anterior abdomen: transnipple line superiorly, inguinal ligaments and
symphasis pubis inferiorly, anterior axillary lines laterally.
 Flank: between anterior and posterior axillary lines from 6th intercostals space
to iliac crest.
 Back: Posterior to posterior axillary lines, from tip of scapulae to iliac crests.
 Internal:
 Upper peritoneal cavity: covered by lower aspect of bony thorax. Includes
diaphragm, liver, spleen, stomach, transverse colon.
 Lower peritoneal cavity: small bowel, ascending and descending colon, sigmoid
colon, and (in women) internal reproductive organs.
 Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women) internal
reproductive organs.
 Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal
aorta, IVC, most of duodenum, pancreas kidneys, ureters, and posterior
aspects of ascending and descending colon.
Etiology
Penetrating Trauma
◦ Low velocity e.g. stab, pistol
◦ High velocity e.g. rifle, shrapnel

Blunt trauma
Iatrogenic injuries
 Mechanisms of injury
Blunt injuries
◦ Compression, crush, or sheer injury to abdominal viscera 
deformation of solid or hollow organs, rupture (e.g. small bowel,
gravid uterus)
◦ Deceleration injuries: differential movements of fixed and non fixed
structures (e.g. duodenojejunal junction injuries, splenic
lacerations at sites of supporting ligaments)
Mechanisms of injury
Penetrating injuries
◦ Stab wounds and impalement injuries
◦ Injuries follow track of implement
◦ Gun Shot Injury
◦ Low velocity injuries follow tract of injury
◦ High velocity injuries have cavitation as well as non linear pattern
◦ Blast Injuries
◦ Primary blast wave
◦ Secondary blast wave
◦ Shrapnel
 Iatrogenic injuries
Endoscopic (G.I., Urology etc.)
Gynecologic
External Cardiac Message
Peritoneal Dialysis
Paracentesis
Percutaneous Biopsy
Barium Enema
 Common injury patterns
In patients undergoing laparotomy for blunt trauma, most frequently injured
organs are spleen (40-55%), liver (35-45%), and small bowel (5-10%). (ATLS,
2001)
Duodenum:
◦ Classically, frontal-impact MVC with unrestrained driver; or direct blow to
abdomen.
◦ Bloody gastric aspirate, retroperitoneal air on XR or CT
◦ Confirmed with upper GI series or double contrast CT

Small bowel injury:

◦ Generally from sudden deceleration with subsequent tearing near fixed points of
attachment.
◦ Often associated with seat belt sign, lumbar distraction fracture (Chance fracture)
◦ DPL superior to FAST or CT for diagnosis.
 Common injury patterns (2)
 Pancreas:
 Direct epigastric blow compressing pancreas against vertebral column.
 Early normal serum amylase does NOT exclude major pancreatic trauma.
 CT with PO/IV contrast – NOT particularly sensitive in immediate post-injury
period.

 Diaphragm:
 Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm.
 Noted on CXR: blurred or elevated hemidiaphragm, hemothorax, GT in chest

 Genitourinary:
 Anterior injuries (below UG diaphragm): usually from straddle impact.
 Posterior injuries (above UG diaphragm): in patient with multisystem injuries
and pelvic fractures.
 Iatrogenic
 Common injury patterns (3)
Solid organ injury
◦ Laceration to liver, spleen, or kidney
◦ Injury to one of these three + hemodynamic instability: considered
indication for urgent laparotomy
◦ Isolated solid organ injury in hemodynamically stable patient: can often
be managed nonoperatively.

Pelvic fractures:
◦ Suggest major force applied to patient.
◦ Usually auto versus pedestrian, MVC, or motorcycle
◦ Significant association with intraperitoneal and retroperitoneal organs
and vascular structures.
 Restraining devices
Lap seat belt
◦ Mesenteric tear or avulsion
◦ Rupture of small bowel or colon
◦ Iliac artery or abdominal aorta thrombosis
◦ Chance fracture of lumbar vertebrae (hyperflexion)

Shoulder Harness
◦ Rupture of upper abdominal viscera
◦ Intimal tear or thrombosis in innominate, carotid, subclavian, or vertebral arteries
◦ Fracture or dislocation of C-spine
◦ Rib fractures
◦ Pulmonary contusion

Air Bag
◦ Corneal abrasions, keratitis
◦ Abrasions of face, neck, chest
◦ Cardiac rupture
◦ C or T-spine fracture
 Initial Management
. Immobilize Cervical spine
.100% oxygen
.Wide bore I.V line or central venous access
.Blood samples
FBC, Toxicology, Pregnancy
.Crystalloid/colloid infusion
.Trauma series X-ray
-Chest , cervical ,spine, pelvis
 Assessment: History
Mechanism
Symptoms, events, PMH, Medication, Alcohol/drugs
MVC:
 Speed
 Type of collision (frontal, lateral, sideswipe, rear, rollover)
 Vehicle intrusion into passenger compartment
 Types of restraints
 Deployment of air bag
 Patient's position in vehicle
 Assessment: Physical Exam
Inspection, auscultation, percussion, palpation
 Inspection: abrasions, contusions, lacerations, deformity
Grey-Turner, Kehr, Balance, Cullen
 Auscultation: careful exam advised by ATLS. (Controversial utility in trauma
setting.)
 Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air;
dullness with hemoperitoneum
 Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle
guarding
 Physical Exam: Eponyms
Grey-Turner sign:
◦ Bluish discoloration of lower flanks, lower back; associated with
retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

Cullen sign:
◦ Bluish discoloration around umbilicus, indicates peritoneal bleeding,
often pancreatic hemorrhage.

Kehr sign:
◦ L shoulder pain while supine; caused by diaphragmatic irritation (splenic
injury, free air, intra-abd bleeding)

Balance sign:
◦ Dull percussion in LUQ. Sign of splenic injury; blood accumulating in
subcapsular or extracapsular spleen.
 Diagnostic adjuncts
Labs: ,FBC, coagulation profile, ß-HCG, amylase, U/A, toxic
screen,
Plain films:cervical, CXR, pelvis;( abdominal films generally
lower priority)
DPL
FAST
CT
 Diagnostic Peritoneal Lavage
98% sensitive for intraperitoneal bleeding (ATLS)
Open or closed (Seldinger); usually infraumbilical, but may be supraumbilical
in pelvic frxs or advanced pregnancy.
Free aspiration of blood, GI contents, or bile in hemodynamically abnormal
pt: indication for laparotomy
If gross blood (> 10 mL) or GI contents not aspirated, perform lavage with
1000 mL warmed LR. Allow to mix, compress abdomen
lab. + test: >100,000 RBC/mm3, >500 WBC/mm3, Gram stain with bacteria.
Alters subsequent examination of patient

Has been somewhat superceded by FAST in common use; now generally

performed in unstable patients with intermediate FAST exams, or with
suspicion for small bowel injury.
FAST: Strengths and Limitations
Strengths Limitations
Rapid (~2 mins) Does not typically identify source of
bleeding, or detect injuries that do not
Portable cause hemoperitoneum
Inexpensive Requires extensive training to assess
parenchyma reliably
Technically simple, easy to train
(studies show competence can be Limited in detecting <250 cc
achieved after ~30 studies) intraperitoneal fluid
Can be performed serially Particularly poor at detecting bowel
and mesentery damage (44%
Useful for guiding triage decisions in sensitivity)
trauma patients
Difficult to assess retroperitoneum
Limited by habitus in obese patients
 FAST: Accuracy
For identifying hemoperitoneum in blunt abdominal trauma:
 Sensitivity 76 - 90%
 Specificity 95 - 100%
The larger the hemoperitoneum, the higher the sensitivity. So
sensitivity increases for clinically significant
hemoperitoneum.

How much fluid can FAST detect?

 250 cc total
 100 cc in Morison’s pouch
General indications for
Surgery in blunt injuries
Patients who are hemodynamically stable but in whom investigations
show a life threatening injury
Patients in hypovolemic shock who transiently respond to intravenous
resuscitation
Patients in hypovolemic shock who don’t respond to intravenous
resuscitation
 Does FAST replace CT?
Only at the extremes.
Unstable patient, (+) FAST  OR
Stable patient, low force injury, (-) FAST  consider
observing patient.

CT is far more sensitive than FAST for detecting and

characterizing abdominal injury in trauma. The gold
standard for characterizing intraparenchymal injury.

“Death begins with a CT.” Never send an unstable patient to CT.

FAST, however, can be performed during resuscitation.
EAST Algorithm: Unstable

Eastern Association for the Surgery of Trauma, 2001

EAST Algorithm: Stable
Penetrating injuries
Generally need laparotomy
Current thinking
◦ Tangential injuries
◦ Local exploration under aseptic conditions