ABDOMINAL TRAUMA Trauma Intensive Care Unit
Objectives At the end of this presentation, the participants will be able to: – Describe abdominal anatomy and functions of individual abdominal organs – Differentiate between blunt and penetrating trauma – Discuss different diagnostic tools used in abdominal trauma – Describe the management of organs injured by abdominal trauma
Abdominal Trauma Abdominal trauma is an injury to the abdomen. It may be blunt or penetrating and may involve damage to the abdominal organs • The abdomen is highly susceptible to injury because of it’s location and lack of boney protection • The pediatric population are highly vulnerable because their solid organs are comparatively larger and they have less musculature and padding • Injuries may go undiagnosed due to vast amounts of free space in abdominal cavity.
ANATOMY OF THE ABDOMEN • Four-Quadrant System • RUQ – Liver & gallbladder – Pylorus – Head of pancreas – Portions of ascending & transverse colon • RLQ – Cecum & appendix – Portion of ascending colon anatomy.med.umich.edu
QUADRANTS (Continued) • RLQ – Bladder (if distended), Right ureter • LUQ – Stomach – Spleen – Body of pancreas – Portions of transverse and descending colon • LLQ – Sigmoid colon, portion of descending colon – Bladder (if distended), Left ureter
Peritoneal vs Retroperitoneal • Abdominal Cavity • Peritoneal – Stomach – Small intestines – Liver – Gallbladder – Transverse & sigmoid – Part of bladder
• Retroperitoneal • Part of the duodenum – Ascending colon – Descending colon – Kidneys – Part of the bladder – Pancreas – Major vessels becomehealthynow.com
Blunt Trauma to the Abdomen • Blunt Trauma – Trauma that occurs without entry of the injuring agent into or through the skin • Leading cause of intra-abdominal injury, with MVCs being first • Common organs injured – spleen, liver, duodenum, pancreas & small bowel • Mechanisms of Injury – Compression • Steering wheel in direct contact with the abdominal & chest wall – Acceleration-deceleration forces – Shearing forces • During energy transfer, rupture of organs at attachment points or where blood vessels enter the organ
SEAT BELT SIGN
Penetrating Trauma to the Abdomen • Penetrating Trauma is when a foreign object enters the tissue • Gunshot wounds, stab wounds and impalements • GSWs produce a wide variety of wounds depending on bullet velocity • Bullet has potential to ricochet off bony structures making the trajectory difficult to determine • Tumbling increases amount of kinetic energy released • Shotgun shells contain up to 200 small pellets, with each pellet being considered a missile • GSWs responsible for almost 90% of mortality associated with penetrating trauma • Most commonly injured organs include small bowel, colon, liver and abdominal vascular structures
PENETRATING ABDOMINAL TRAUMA
• Stab wounds – low velocity, low energy wounds • Generally a low mortality rate (1-2%) • Most commonly injured organs from stab wounds include the liver, small bowel, diaphragm and colon – Many stab wounds do not even penetrate the peritoneum • Injury can usually be predicted by the trajectory, type of weapon, length of the object & location • Impalements – MVC, industrial accident, fall, assault or being hit by a flying object • Impaled object must be secured and left in place • Must consider abdominal injury when penetrating chest trauma present
EPIDEMIOLOGY • Blunt abdominal trauma = 66-75% – MVC leading cause • Seat belts can change the patterns of blunt trauma by increasing abdominal injuries from 18% to 40% • Abdominal trauma associated with 8.5% mortality rate in pediatric population
EPIDEMIOLOGY (Continued) • Penetrating – 96%-98% of GSWs are associated with significant intraabdominal injury – 30%-40% of SWs are associated with significant intraabdominal injury – USA firearm deaths far exceeds all European countries • Mortality – 6%-10% of all patients with abdominal trauma die • Polytrauma may skew this number – ~ 50% of all OR deaths 1º due to abdominal trauma
PERTINENT HISTORY • MVC – Restrained or unrestrained – Air bag deployment – Patient’s position in vehicle – Speed – Type of collision (frontal, side, rear) – Status of other passengers • FALL – Height
History (Continued) • PENETRATING – Time – Type of weapon (knife, handgun, shotgun) – Length of knife – Number of stab wounds or number of shots fired
ASSESSMENT/EVALUATION • Primary survey – A – Airway maintenance with cervical spine control – B – Breathing and Ventilation – C – Circulation with hemorrhage control – D – Disability: neurological status – E – Exposure/environmental control • Secondary survey – Lab studies (Hct, WBCs, ABGs & Type and Cross
Physical Exam • Manifestations of abdominal trauma may be subtle • Abdomen may sequester large amounts of fluid without apparent distension • Signs & symptoms associated with abdominal injury are: – Blood loss – Abdominal tenderness – Specific pain patterns – Absent bowel sounds
Blood Loss and Pain • Injuries to organs or abdominal blood vessels may lead to extensive hemorrhage • Spleen & liver are extremely vascular & serve as reservoirs for blood • Pain, rigidity, guarding or spasms of the abdominal musculature are classic signs of intra-abdominal pathology • Sudden movement of irritated peritoneal membranes causes rebound tenderness & guarding • Irritation may be due to the presence of free blood or gastric contents • Release of enzymes from a pancreatic or duodenal injury may lead to a “chemical peritonitis” which may not appear as a sign & symptom until several hours after injury • Referred pain – Kehr’s sign
DIAGNOSTIC TOOLS • CHEST X-RAY – may reveal lower rib fractures, causing associated injury to the liver or spleen • ABDOMINAL X-RAY – can identify retroperitoneal free air, gross organ injury or foreign objects • COMPUTED TOMOGRAPHY (CT) – In the hemodynamically stable patient – Source of bleeding can be identified – ONLY imaging modality capable of evaluating the retroperitoneum – Can determine the extent/grade of organ injury
Traumatic Splenic Rupture emedicine.medscape.com
Focused Abdominal Sonography for Trauma (FAST)
FAST • Rapid, bedside ultrasound examination • Screen for significant hemoperitoneum or pericardial tamponade • Directed solely at identifying the presence of free fluid; in trauma usually due to hemorrhage • Decision making tool to help determine need for transfer to the OR, CT or angiography • Timely diagnosis of potentially life-threatening hemorrhage
• 4 areas are viewed – Perihepatic (RUQ) – Perisplenic (LUQ) – Pericardium – Pelvis • Ultrasound machine immediately available
FAST cdemcurriculum.org
Positive FAST cdemcurriculum.org
FAST Pros and Cons • Pros – Easily performed at the bedside – Doesn’t require transfer of hemodynamically unstable patient – Used concurrently with ongoing assessment • Cons – Can’t identify or grade retroperitoneal injuries – Can’t identify injuries to the bowel or solid organs – Can’t distinguish whether fluid is ascites or blood
Diagnostic Peritoneal Lavage (DPL) • Also used to diagnose intraabdominal bleeding in abdominal trauma • Appropriate tool when the source of blood loss is obscure • Contraindications include: • Advanced pregnancy • Previous multiple abdominal surgeries • Advanced cirrhosis • Coagulopathy • Can make diagnosis of small bowel injury
Technique of DPL primary-surgery.org
Positive DPL • Initial aspiration of blood • (5 – 10 mL or greater) • Presence of bile, bacteria, • food particles or fecal • material • Presence of lavage fluid • via Foley or chest tube unboundedmedicine.com
Exploratory Laparotomy • Midline incision made in order to examine abdominal organs • Mandatory for: – Evisceration of bowel or omentum – Progressive abdominal distension with unexplained hypotension – Ruptured diaphragm – Free air on x-ray • Indicated for: – + FAST and hypotension – + DPL • Unstable patient (hemodynamically, coagulopathic, acidotic) – goal is damage control; further stabilization in ICU then return to OR at a later time
THERAPEUTIC INTERVENTIONS • Assure ABCs • Insert nasogastric/orogastric tube • Insert Foley catheter – if no contraindications • Prepare for surgical intervention – prophylactic IV antibiotics • Consider extra peritoneal injuries
Specific Types of Injuries from Blunt Trauma
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