Abdominal Trauma Soheil Azimi, Student Of Medicine Islamic Azad University Islamic Azad University Tehran Medicine Unit Tehran Medicine Unit

The abdomen is frequency injured after both blunt and penetrating trauma. The abdomen is frequency injured after both blunt and penetrating trauma. Approximately 25% of all trauma victims will require an abdominal exploration. Approximately 25% of all trauma victims will require an abdominal exploration.

The Plan Abdominal Anatomy Abdominal Anatomy Mechanisms of Injury Mechanisms of Injury Common Pathology Common Pathology Evaluation Evaluation Management Management

Part 1: Abdominal Anatomy

Abdominal Anatomy Basics Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

Abdominal Anatomy Basics Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

Abdominal Anatomy Basics Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

Abdominal Anatomy: Four Quadrants

Abdominal Anatomy

Alternative Divisions

Lower Abdomen CT

Retroperitoneal

External Anatomy of Abdomen

Part 2: Mechanisms and Pathology

Abdominal Injuries Blunt vs. Penetrating Blunt vs. Penetrating Often both occur simultaneously Often both occur simultaneously Blunt is the most common mechanism in US Blunt is the most common mechanism in US

Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

Mechanism of Injury: Penetrating ● Stab ● Low energy, lacerations ● Gunshot ● Kinetic energy transfer ● Cavitation, tumble ● Fragments

A missed abdominal injury can cause a preventable death. Abdominal Injury Factors that Compromise the Exam ● Alcohol and other drugs ● Injury to brain, spinal cord ● Injury to ribs, spine, pelvis Caution

Techniques for Evaluation Physical Exam Serial exams in awake, alert and reliable pt Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvis are the standard Abd films little or no use, pelvis are the standardScreening Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams) Ultrasound: FAST (serial exams)

DPL: Procedure

Diagnostic Peritoneal Lavage Introduced by Root (1965) Introduced by Root (1965) Indications for DPL in blunt trauma: Indications for DPL in blunt trauma: 1. Hypotension with evidence of abdominal injury 2. Multiple injuries and unexplained shock 3. Potential abdominal injury in patients who are unconscious, intoxicated, or paraplegic 4. Equivocal physical findings in patients who have sustained high-energy forces to the torso 5. Potential abdominal injury in patients who will undergo prolonged general anesthesia for another injury, making continued reevaluation of the abdomen impractical or impossible

Contraindications of DPL Absolute : Absolute : Peritonitis Peritonitis Injured diaphragm Injured diaphragm Extraluminal air by x-ray Extraluminal air by x-ray Significant intraabdominal injury by CT scan Significant intraabdominal injury by CT scan Intraperitoneal perforation of the bladder by cystography Intraperitoneal perforation of the bladder by cystography Relative : Relative : Previous abdominal operations (because of adhesions) Previous abdominal operations (because of adhesions) Morbid obesity Morbid obesity Gravid Uterus Gravid Uterus Advanced cirrhosis (because of portal hypertension and the risk of bleeding) Advanced cirrhosis (because of portal hypertension and the risk of bleeding) Preexisting coagulopathy Preexisting coagulopathy

FAST

Focused Abdominal Sonography for Trauma (FAST) Demonstrate presence of free intraperitoneal fluid Demonstrate presence of free intraperitoneal fluid Evaluate solid organ hematomas Evaluate solid organ hematomas Advantages Advantages No risk from contrast media or radiation No risk from contrast media or radiation Rapid results, portability, non-invasive, ability to repeat exams. Rapid results, portability, non-invasive, ability to repeat exams. Disadvantages Disadvantages Cannot assess hollow visceral perforation Cannot assess hollow visceral perforation Operator dependent Operator dependent Retroperitoneal structures are not visualized Retroperitoneal structures are not visualized

FAST Four View Technique: Four View Technique: Morrison’s pouch (hepatorenal) Morrison’s pouch (hepatorenal) Douglas pouch (retropelvic) Douglas pouch (retropelvic) Left upper quadrant (splenic view) Left upper quadrant (splenic view) Epigastric (View pericardium) Epigastric (View pericardium)

Algorithm for the evaluation of penetrating abdominal injuries AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound.

Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit

Genitourinary Trauma

GU Trauma 2-5% of adult traumas 2-5% of adult traumas Vast majority blunt mechanisms Vast majority blunt mechanisms 80% renal injuries 80% renal injuries 10% bladder injuries 10% bladder injuries Abnormalities (tumor, hydro) increase susceptibility Abnormalities (tumor, hydro) increase susceptibility Rarely require immediate intervention Rarely require immediate intervention

Evaluation Rectal - high riding prostate Rectal - high riding prostate Perineum - ecchymosis, lacs Perineum - ecchymosis, lacs Genitals - meatal/vaginal blood Genitals - meatal/vaginal blood Difficult catheter placement (may need suprapubic) Difficult catheter placement (may need suprapubic) UA – hematuria (poor correlation to degree of injury) UA – hematuria (poor correlation to degree of injury)

Evaluation U/S and Plain films of little use U/S and Plain films of little use CT is the superior imaging modality CT is the superior imaging modality Careful with contrast (nephropathy) Careful with contrast (nephropathy) Angiography remains the gold standard Angiography remains the gold standard IVP/Cystoscopy less useful IVP/Cystoscopy less useful

GU Injuries: The Kidneys Kidneys are well protected Kidneys are well protected Most commonly bruised Most commonly bruised Pts with a shattered kidney become rapidly unstable Pts with a shattered kidney become rapidly unstable Renal vascular injuries may result in thrombosed vessels Renal vascular injuries may result in thrombosed vessels

GU Injuries: The Kidneys Operative management for: uncontrolled hemorrhage uncontrolled hemorrhage Penetrating injuries Penetrating injuries Multiple lacs Multiple lacs Shattered kidney Shattered kidney Avulsed vessels Avulsed vessels

GU Injuries: The Bladder Contusion Contusion Rupture: Intra vs. Extraperitoneal Rupture: Intra vs. Extraperitoneal Extraperitoneal presents with pain, hematuria and inability to void Extraperitoneal presents with pain, hematuria and inability to void Urethral injuries: Anterior vs. posterior Urethral injuries: Anterior vs. posterior No Foley for urethral injuries No Foley for urethral injuries

In Summary... Basic knowledge of anatomy necessary for initial assessment of abdominal trauma Basic knowledge of anatomy necessary for initial assessment of abdominal trauma Peritoneal vs. Retroperitoneal Peritoneal vs. Retroperitoneal Blunt vs. Penetrating Blunt vs. Penetrating Don’t miss GU injuries Don’t miss GU injuries

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