1. Diagnosis & Management of Acute Abdominal Trauma
Trauma Services
Ottawa Hospital

2. Economic Burden of Injury in Ontario 1996
Injury death ,844
Hosp injuries ,382
Non hosp injuries 693,630
Total injuries 739,856
Partial perm. Disa ,232
Total perm. Disa ,141
Total annual cost $2.9 billion

3. INTRODUCTION Abdominal Trauma
Abdominal injuries present in 7-10% of admission
Present in ~ 20% of all trauma surgeries
½ of preventable trauma death are related to inappropriate management of abdominal trauma
Extra abdominal injuries are clues to the presence of injuries within the abdomen
Abdominal injuries should be suspect in all trauma

4. Diagnostic Methods Abdominal Trauma
Physical examination
Bruises, abrasion over the abdomen
Abdominal pain or tenderness
Absent bowel sounds
Unexplained hypotension
P/E equivocal or misleading.!!!
Peritoneal sign falsely negative in 40%
Peritoneal sign falsely positive in 20%
10% of all injuries are initially overlook
WHY?

5. PHYSICAL EXAMINATION Abdominal Trauma
Physical examination unreliable
Head trauma
Spinal cord injuries
Alcohol intoxication
Use of illicit drugs
Injuries to adjacent structure
Significant amount of blood present
Analgesia

6. CLASSIFICATION Abdominal Trauma
Penetrating
High velocity (85% penetrate peritoneum)
Low velocity (95% need surgery)
Stab(1/3 do not penetrate the peritoneum, of those 50% need Sx)
Blunt trauma
High energy transfer (car accident)
Low energy transfer (fall, fight)

8. Mandatory Exploration Abdominal Trauma
Anterior abdominal gunshot
Stab
Local exploration
Penetration of the fascia??
DPL
Laparoscopy
Laparotomy
Serial observation
Surgeon’s expertise

9. Initial management for stab wounds

10. Blunt Injuries Physical examination Investigation Case presentation
Specific organ injuries
Liver
Spleen
Small bowel

11. Epidemiology Injuries From Motor Vehicle Passenger Restraints
Decrease mortality from MVC
Increase morbidity
Seat belt syndrome
Lap belt injury in children
C-spine injury
Air bag

12. Blunt Injury Abdominal Trauma
Spleen 25%
Liver 15%
Hollow viscus 15%
Ileum
Sigmoid
Kidney 12%
Retroperitoneal 13%
Mesentery 5%
Compression
Crushing
Shearing
Avulsion

13. Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend
Inspection
Seat belt mark
Skin lacerations
Previous surgery scar

14. Physical Examination Abdominal Trauma Evaluation
Auscultation
Palpation
Rebound tenderness
Guarding
Pregnancy
Pelvic instability

15. Physical Examination Abdominal Trauma Evaluation
Rectal examination
Prostate
Rectal tone
Vaginal examination
Gluteal fold
Penetrating injuries = abdominal injuries

16. Tube Insertion Abdominal Trauma Evaluation
4- Gastric tube
Relives distention
Decrease risk of unattended vomiting
But can induce it , risk of aspiration !!!
Caution
Facial fracture/basilar skull fracture

17. Tube Insertion Abdominal Trauma Evaluation
Urinary catheter
Monitor urinary output
Caution
Inability to void retrograde
Pelvic fracture urethrogram
Blood at the meatus U/S
Scrotal Ecchymoses
High riding prostate

18. Special Diagnostic Studies Abdominal Trauma Evaluation
DPL
U/S
Ct abdomen & pelvis

19. X-Ray Abdominal Trauma Evaluation
C-spine
Chest AP +/- paper clips for penetrating injury
High association of chest injuries and abdominal injuries
Free air?
Pelvis +/- paper clips for penetrating injury

20. Others X-Ray Abdominal Trauma Evaluation
Urethrography
5. ? IVP for hematuria
IV contrast
Keep good urinary output
Better CT scan
6. Spine fracture
Chance Fracture
20% small bowel injuries

21. Case Presentation J.D. (3265709) -1
47 year old male
Car felt on his Rt chest, LOC at scene?
RUQ & Rt chest pain & deformity Rt shoulder
A good air entry
B Rt chest pain and bruising
C Pulse 92, Bp 120/90 HgB 140
EKG , few PVC, CK 1485, Triponin t < .05
D GCS 15
E Chest abrasions Rt side

22. Case Presentation J.D. (3265709) -2
Ct scan
Abdomen
Chest Xray

23. CT scan J.D. ( ) -2

24. Case Presentation J.D. (3265709) -2
Ct scan
Grade III liver laceration
Intra abdominal free fluid
HgB decrease to 93
Liver injury
85 % observation
10% -15% mortality
15 % Laparotomy
60 % mortality

25. Surgical management
A significant liver injuries will not heal spontaneously and surgical intervention is the only acceptable approach for it
Pringle 1908
Once the diagnostic of Hemoperitoneum has been made, routinely the next goal of the surgeons will be to prepare the patient for surgery as rapidly and efficiently as possible
Sclafani 1991

26. Surgical management (cont’d)
Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.
Grindlinger 1998
TIP
Patient selection
Type of Trauma
Age
Associated injuries

27. TIP Resuscitation ATLS Patient ‘s clinical condition Hemorrhage
Persistent or recurrent hypotention
Hemorrhage
Prompt control of bleeding
Judicious volume restoration
Maintenance of pH and To
TIP
Duration of shock
more critical than
the amount
of blood transfused

28. Blunt Liver Trauma Protocol 1998

29. Outcome
J Trauma;1998, 45,360

30. on the patient stability
Outcome
Nonoperative
Less blood
mortality 15% Vs up to 63%
LOS shorter
TIP
decision to treat
is base
on the patient stability

31. Spleen Injuries Diagnosis CT scan will save 70 % of spleen
Hemodynamic instability
LUQ pain
Left shoulder pain
CT scan will save 70 % of spleen
Observation X 72 hr
Healing over 6 weeks
OPSI (overwhelming post Splenectomy infection)
< 1% of splenectomy , increase in children

32. Small Intestine Injuries Epidemiology
15% of all laparotomy
High index of suspicion required
Serial examination
DPL diagnostic in 95 %
Enhance by enzyme
Increasing success with CT and laparoscopy
Delay in diagnosis increase M & M

34. Retroperitoneal air

35. Blunt Trauma in Pregnancy Abdominal Evaluation
½ Injuries due to MVA
Increase incidence of splenic injury and retroperitoneal bleed
Placenta abruption
2-5% minor injuries
20-50% in major injuries

36. Blunt Trauma in Pregnancy Treatment
Multidiciplinary approach
Stabilization of mother status
Avoid venocaval compression
Used shielding during X-Ray
Aggressive Hypotention treatment
Establish gestational age
Ultrasound
C-section…Group decision

37. Blunt Trauma in Pregnancy Treatment-2
Abdominal evaluation
DPL supraumbelical approach
CT scan (5-10 cGy, Max is 10cGy)
Pelvic X-ray
Pelvic fracture: associated with fetal skull #
Unstable pelvic fracture = c-section (10%)
Monitoring in labor & delivery room
Rh- : RhiG within 72 Hours

38. Epidemiology Multivariate Odd Ratio From 16,000 Patients
Gross hematuria
Admission hypotension 3.53
Lower ribs fracture 2.58
Hemo/pneumothorax 2.49
Abdominal wall hematoma 1.96
Base deficit(HCO3 < 21) 1.77
Pelvic fracture 1.5
(Brad Chushing)

39. What’s New in Abdominal Trauma
Diagnostic
Ct, U/S
Laparoscopy its impact is coming
Therapeutic
Nonoperative management
Spleen & liver
Non operative for liver gunshot
“Damage control” laparotomy
“Abdominal compartment syndrome”