1. Management of blunt abbominal injury
Osama Jalal Kehil
Mohammed Habib
Mohammed Sbeinatai

2. Epidemiology
Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups.
Identification of serious intra abdominal pathology is often challenging.
Many injuries may not manifest during the initial assessment and treatment period.

3. Causes of trauma MVA Fall from height Gun shot Knife
Industrial accidents
Natural disasters

4. Types of trauma Blunt trauma results of an impact from blunt object
Penetrating trauma results from an object piercing the body
Assessment and diagnosis of blunt injuries are more difficult than of penetrating injuries
Multi-trauma- injury affecting simultaneously different organ and body system

5. Trimodal death in trauma
Immediate: Within seconds or minutes after injury
50% of deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress.
Early: Within hours of injury
approximately 30% of deaths. Half of these deaths are caused by hemorrhage and the other half by central nervous system (CNS) injury These patients can be saved by appropriate treatment
(golden hour).
Late: peaks from days to weeks, mortality due to infection and multiple organ failure.

6. Pre-hospital care
Delivery to the hospital for definitive care as rapidly as possible.
Only critical interventions at the scene
Airway established, hard collar, spine board, control any external hemorrhage
Infusion on way to the hospital

7. Hospital care ATLS approach A well defined order
Primary survey- initial assessment and management
Treat the greatest threat to life
Immediate intervention as the threat to life is identified
Re-evaluation of initial management
Secondary survey- head to toe evaluation

8. A B C D E Primary survey Airway Breathing Circulation
Disability (neurologic assessment)
Exposure and Environmental control

9. Primary survey team approach
Simultaneous diagnosis and treatment by multiple providers
Reduces the time to assess and stabilize a multiple trauma patients
Team should be organized before patient arrival.

10. Airway Verbal response: Salam! How are you? Airway is compromised if:
No response- unconscious , airway obstruction
Severe facial trauma
Oropharyngeal bleeding or foreign body
Patient agitated - hypoxia

11. Airway Adequacy of airway- completed within seconds
Open the front of the collar for airway manipulation
Maintain manual stabilization by an assistant
bag valve mask ventilation
Oxygen supplement + pulse oximetry
Rapid-sequence endotracheal intubation
Frequent reassessment for airway compromise

12. Difficult airway
Surgical airway when oral intubation cannot be accomplished:
Cricothyroidotomy
Tracheostomy

13. BREATHING Dyspnoea Unilateral diminished chest expansion
Bruising / abrasion
Distended neck vein

14. Circulation Assessment of cardiovascular compromise and management
Is the patient in shock?
Is there any external bleeding source?
Any internal hemorrhage?

15. Classes of hemorrhagic shock
Class I
Class II
Class III
Class IV
Blood loss (ml)
Up to 750
> 2000
Pulse
<100
>100
>120
>140 BP
Normal
Decreased

16. Circulation Indicators of shock in trauma patients
Tachycardia
Agitation
Tachypnea
Weak peripheral pulse
Hypotension
Oliguria

17. Circulation Initial management
External haemorrhage - compression dressing
IV access - two peripheral catheters
ECG monitoring
Blood sample - typing and lab. investigations
Initial resuscitation:1-2L of Ringer's lactate or NS
Packed RBC if no response
Foley’s catheter

18. Circulation Initial management
Search for any source of blood loss:
CXR, X-ray pelvis, FAST (focused abdominal sonography in trauma)

19. Glasgow Coma Scale (GCS) Total = 15
Eye response
Vocal response
Motor response
Spontaneous 4
Oriented
Obeys commands 6
To voice
Confused
Purposeful movement to pain 5
To pain
Inappropriate words 3
Withdraw from pain 4
None
Incomprehensible words 2
Flexion to pain
***
None
Extension to pain
None

20. Exposure/ Environment control
Completely undress the patient
Perform a rapid head to toe examination
Identify any injuries to the back, perineum, or other areas that are not easily seen in the supine position
Unexpected injuries may be discovered
Once assessment completed, cover the patient with blanket ( prevent cold exposure)

21. Secondary Survey Only after completion of primary survey (ABCDE)
Life threatening injuries have been controlled
Normalization of vital signs
A head to toe evaluation
Detailed history and examination
Continuous reassessment of vital signs
Additional lab. & radiological tests

22. Abdominal injuries
25% of all trauma victims require abdominal exploration.
Physical examination is inadequate to identify intra-abdominal injuries
Diagnostic modalities - CXR, FAST, CT & laparoscopy
Blunt trauma:
Hemodynamically stable - CT scan
Hemodynamically unstable - FAST

23. Splenic injury Most frequently injured in blunt trauma.
History of injury to the left side of the chest or flank
Bruising, pain ,tenderness lower chest and upper abdomen on left side
Diagnosis:
CT in hemodynamically stable patients FAST in an unstable patients

25. Splenic injury Non-surgical management
Hemodynamically stable patients:
CT for diagnosis
No other intra-abdominal injury requiring operation
Admission to ICU for continuous monitoring
Serial Hb. , & repeated abdominal assessment
If hypotension develops - taken for surgery

26. Splenic injury Surgical management
Hemodynamically unstable
FAST: splenic injury, free fluid (hemoperitoneum)
Surgery- splenectomy
Polyvalent pneumococcal vaccine (pneumovax)

27. Liver injury Spontaneous hemostasis
Profuse bleeding from deep hepatic lacerations
Mortality rate 8% - 10%, morbidity rate from 18% -30%,
Diagnosis: FAST in hemodynamically unstable, CT scan in hemodynamically stable
Management based on hemodynamic status

30. Liver injury Non-operative management
Hemodynamically stable patients
CT scan
No other indications for abdominal exploration
ICU admission for close observation
Serial hemoglobin estimation
Surgery- if become unstable

31. Liver injury Surgical management
Principles of surgical management: control of bleeding, removal of devitalized tissue, and adequate drainage.
Bleeding vessels & biliary radicles are individually ligated
Perihepatic packing- when fail to control hemorrhage
Packs removed in 48 hours

33. Pancreatic injuries Pancreatic injury is rare
Caused by penetrating injury or direct blow
Diagnosis is difficult to make
CT scan, elevated serum amylase may help
No duct injury: simple drainage
Ductal injury: distal resection

35. Bowel injuries Mostly due to penetrating trauma
Also seen after blunt trauma
Features of peritonitis
CT scan free air in peritoneum / contrast leak
Small bowel: Suture repair
Colon: suture repair± proximal colostomy

36. Renal injuries Minor : renal contusion (85%) Conservative management
Major: Deep medullary injuries with extravasation
Vascular injuries
Surgical repair