Dr Abdulaziz Alrabiah, MD Emergency Medicine, Trauma, EMS abdominal trauma Dr Abdulaziz Alrabiah, MD Emergency Medicine, Trauma, EMS

classification of abdominal trauma blunt penetrating

blunt abdominal trauma Common mechanisms include road traffic crashes, falls, sports injuries and assaults organs most affected are : spleen > liver > small and large intestine Blunt abdominal injuries often managed conservatively, though interventional radiology and surgery are indicated for severe injuries

PENETRATING ABDOMINAL INJURY Any wound between the nipple line (T4) and the groin creases anteriorly, and from T4 to the curves of the iliac crests posteriorly is potentially a penetrating abdominal injury

Assessment of abdominal trauma Primary survey : ABCDE Secondary survey nspection abrasions, wounds bruising seat belt lap belt: 30% chance of mesenteric or intestinal injury retroperitoneal haemorrhage: ecchymosis of the periumbilical area (Cullen’s sign) and the flanks (Grey-Turner’s sign) genital and perineum Palpation fullness: haemorrhage crepitation of lower rib cage: hepatic or splenic injury peritonism: ruptured viscus with leakage rectal or vaginal examination

investigations Trauma series (e.g. CXR, pelvis XR, c-spine XR) Trauma blood panel (e.g. FBC, UEC, LFTs, lipase, coags, group and hold, BHCG) Imaging (bedside FAST scan, +/- Ct abdomen if haemodynamically stable and imaging warranted)

specific investigations

FAST 70-95% sensitivity 4 regions: 1. subxipoid: pericardial space + rough assessment of contractility and filling 2. RUQ 3. splenorenal recess 4. pelvis Pros Quick to perform with immediate results Repeatable Patient doesn’t have to leave Emergency department Sensitivity approaching 96% in detecting >800mls blood Cons Requires >250 mL free fluid to collect in Morison’s pouch for a positive result Operator dependent Doesn’t specify anatomical structures injured Does not distinguish other causes of intraperitioneal fluid (e.g. ascites, residual fluid after DPL, bladder rupture) Doesn’t look at solid organs, hollow visci or retroperitoneal structures Can be technically difficult in obese patients, those with lots of bowel gas or if subcutaneous emphysema is present

Diagnostic peritoneal lavage (DPL) rarely performed minor surgical procedure Pros: Highly sensitive for intraperitoneal hemorrhage (>97%) Rapid Performed at the bedside Cons: Invasive Doesn’t specify anatomical structures injured False positives may result from trauma during the procedure (up to 25% negative laparotomy rate) Rarely performed, practitioner’s have become deskilled Residual fluid following DPL makes subsequent FAST scans unreliable Modified technique required if pregnant, pelvic fracture or midline scarring

CT abdomen and pelvis pt must be stable indications Trauma patients with abdominal tenderness Trauma patients with altered sensorium Distracting injuries or injuries to adjacent structures Pros Identifies specific anatomical structures injured, allows grading of severity and helps guide management Concurrent imaging of other body compartments is frequently indicated Images retroperitoneal structures Provides imaging of the thoracolumbar vertebrae and other skeletal structures A blush of IV contrast is a strong predictor of failure of non-interventional management Cons Patient usually has to leave the ED Patient transfers are time consuming Requires IV contrast and risk adverse reactions Radiation exposure Less sensitive with pancreatic, diaphragmatic and hollow viscus injuries Poor access to patient during the scan should he or she deteriorate Requires additional skilled staff (CT radiographers and radiologists

Management Address ABCDE IV lines i.e. 16, 18 G Fluids , Bloods +/- vasopressors

Laprotomy indications Peritonism Free air Evisceration Penetrating abdominal trauma + hypotension Gunshot wound traversing peritoneum or retroperitoneum GI bleeding following penetrating trauma Penetrating object is still in situ (risk of precipitous haemorrhage on removal) Blunt abdominal trauma + hypotension with positive FAST scan, positive diagnostic peritoneal lavage (DPL) or peritonism

Interventional radiology main role in abdominal trauma is stop bleeding without the physiological stress of surgery sources of bleeding are typically spleen, liver, pelvis, retroperitoneal or gastrointestinal haemorrhage techniques include embolisation and balloon occlusion in some centres may be performed in conjunction with operative intervention

Damage control surgery Damage control surgery, along with permissive hypotension and hemostatic resuscitation, is integral to the concept of damage control resuscitation This strategy was derived from military experience and is now increasingly adopted into civilian trauma management

Thank You aalrabiah@ksu.edu.sa