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

2. classification of abdominal trauma
blunt
penetrating

3. 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

4. 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

5. 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

6. 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)

7. specific investigations

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. Thank You