Abdominal Trauma
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Introduction
The Case of Mr. Mash
Causes and Risk Factors
Suspect abdominal injury with:
Blunt trauma:
- speed, point of impact, intrusion, safety devices (seatbelts, airbags), position of occupant, and ejection
penetrating:
- weapon, gun velocity, bullet type, distance, and number and location of wounds
Pathophysiology
Anterior abdomen
Flank
- ascending and descending
Back: signs of penetration
- step deformities in the spine
blunt trauma
The spleen is the most commonly injured organ during blunt trauma due to its relative mobility within the abdomen.
The liver can commonly be crushed.
The small intestine can be injured via closed loop blowout from seatbelt, or
Penetrating injuries
The liver is the most common organ damaged due to its size and relative immobility.
Explosions
Explosions often have 4 mechanisms: blunt, penetrating fragments, blast,
Lungs and tympanic membranes are the most responsive; if they are intact, blast
Signs and Symptoms
Abdominal exam can be clouded by alcohol or drugs, injury to the CNS, or distracting injury.
- history
- physical exam
History
Evidence of abdominal include:
- pain
Physical Exam
- vitals (hypotension, tachycardia)
inspection
- bruising, deformity
- bowel sounds not helpful
- palpation for rigidity or tenderness
Investigations
Blunt trauma requires surgery if signs of peritoneal irritation are present. A ruptured spleen is the most common source of significant intraabdominal bleeding, while a liver laceration is the most common source of ALL bleeding.
- lab investigations
- diagnostic imaging
- surgical exploration
Lab Investigations
blood type and cross-match are the most important
no mandatory blood tests
pregancy
alcohol or drug testing
hematuria
Diagnostic Imaging
C-spine, chest, and pelvis plain films are necessary for all trauma
Blunt trauma
CT is the most sensitive and specific diagnostic modality for abdominal bleeding. However, CT can only be carried out in patients who are hemodynamically stable. It misses diaphragm and .... injuries.
In unstable patients, diagnostic peritoleal lavage (DPL) or FAST (ultrasound) can reveal the presence of blood and guide further exploration in surgery.
DPL is rapid and sensitive, but has a low specificity and can miss diaphragm and retroperitoneal injuries.
FAST is noninvasive and fast, though requires operator skill and is less sensitive with obsese patients. It also misses diaphragm, bowel, and pancreatic injuries.
- pericardial fluid
- fluid around the liver
- fluid around the spleen
- fluid around the pelvis
Penetrating trauma
Surgical exploration
Indications for surgical exploration include:
- hemodynamic instability
- penetrating injury into the peritoneum
- peritonitis
- free air
- positive DPL, FAST, or CT
- evisceration
Penetrating wounds should be explored surgically if it is clear penetration of the peritonium has occurred, of there is signs of abdominal hemorrhage, or if peritoneal signs are present. If not evaluation with a glover finger, followed by observation, may be sufficient.
Differential Diagnosis
Treatments
The most important goal is to stop bleeding
Fingers or tubes in every hole
NG tube
- relieves distension and decompresses stomach before diagnostic peritoneal lavage
- ensure there is no basal skull fracture
Urinary catheter
- assess resuscitation
- decompresses bladder before DPL
- diagnostic for renal or ureteric damage
Consequences and Course
The Case of...
Additional Resources
Topic Development
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