Abdominal Trauma

A middle aged unidentified lady was hit by a car whilst crossing the road. She was brought to the ER unconscious with multiple injuries to the head chest and pelvis. She was obese and haemodynamically unstable despite aggressive fluid resuscitation. The x-ray shown was taken following primary survey. 1.What does the xray show and what is it’s significance? 2.How do you diagnose abdominal injury 3.Should free intraperitoneal fluid be identified on USS. How would you proceed with the management of such a cas?

Facts 1. Abdominal signs are often subtle and difficult to interpret. 2. Unrecognised abdominal injury is a major cause of death after trauma. 3. Positive (hemoperitoneum) can result in management dilemma. The Solution HIGH INDEX OF SUSPICION History and mechanism of injury Positive clinical signs Knowledge of Anatomy Objective Data

Goal and Objectives By the end of this lecture you should be able to : Assess the risk of abdominal injury in a poly-trauma patient and provide an index of suspicion for specific injuries. Describe the regions of the abdomen and the organs most likely affected within them. Discuss the difference between blunt and penetrating injuries Plan your management on priority basis Identify signs suggesting abdominal injury. Outline diagnostic and therapeutic procedures specific to abdominal trauma.

Abdominal regions A. Intraperitoneal cavity Intrathoracic abdomen True abdomen Pelvic abdomen B. Retroperitoneal cavity

Mechanisms Blunt A. 3 mechanisms: 1.Deceleration and shearing forces: results in linear tears ligamentous attachments and intimal arterial tears 2.Pressure against the lumbar vertebra 3.Sudden compression with raised intra-abdominal pressure. Cause: subcapsular hematoma and deformity of bowel resulting in rupture. B. The most commonly affected organs : the spleen, liver followed by the small and large intestine Penetrating Fire arms  95% associated injury  Chemical thermal combustion  Secondary Missiles from bony shrapnel  The closer the higher energy transfer  Size of entry does not predict degree of injury.  Missile trajectory is unpredictable Stab Wound  30% associated injury  More predictable damage

Clinical Evaluation Only 60% reliable History:  Onset, delay in extrusion, condition of Vehicle, passenger/s  Seat belt  Abdominal, shoulder pains  AMPLE  Substance abuse, Alcohol intoxication For penetrating injuries:  The type of fire arm or impaling object  Number of shots or stabs  Distance  Amount of blood at the scene  Any history of hypotension Examination: Following the ATLS protocol Secondary survey  Identify Other injuries in the chest, back and pelvis  Inspection:  Ecchymosis, lacerations  Distension  In gunshot wounds look for entry and exist wounds  Locate the site of stab wound  Palpation  Tenderness and guarding  Rebound  Percussion  Auscultation: BS, bruit,  FAST ( Focused Sonography for trauma assessment)

Investigations 1. Laboratory:  CBC, U&E, creatinie, amylase, glucose, X-match, clotting screen, ABG,  Urine analysis 2. Screening plain x-rays: C-spine, CXR, pelvic x-ray 3. USS  4 acustic windows  Sensitivity of 78%  A small amount of fluid in Morison’s pouch on USS may indicate ml 1. CT:  Fast and precise  Quantifies hemorrhage  Identifies retroperitoneal injuries  Marginal use in diaphragmatic and small bowel injury 2. Contrast studies: urethrogram, cystogram, GI contrast studies 3. DPL  Indications  Contraindications  Positive findings  Sensitivity 4. Laparoscopy

Management Conservative  ICU or not  Blood transfusion and intravenous fluids  Antibiotics  Fluid input / output charts and aggressive monitoring  Prevent hypothermia  Correct coagulopathies  Repeated lab series  Repeated USS Surgery: The indications 1.Hypotension: 1.Gun shot 2.Stab wounds 3.Frank blood on DPL 2.Bile or bowel content on DPL 3.Peritonitis 4.Recurrent hypotension despite adequate resuscitation 5.Free air 6.Diaphragmatic rupture 7.Urinary Bladder injury 8.Failure of conservative managemnt

Seat Belt Injury The seat belt syndrome  75% associated with serious injuries  Driver/ F. passenger/ 5% back seat passengers.  75% front impact  It consists of:  Seat belt mark abrasions  Musculo-skeletal: Cervical spine, clavicle, sternum, ribs and lumber spine.  Soft tissue damage  Neck: Laryngeal injury, carotid tear  Chest: Cardiac contusion  Abdomen: Duodenum, small bowel. Mesentery, large bowel, Caecum