1. Evaluation of Abdominal Trauma
Principles of Surgery
Evaluation of Abdominal Trauma
Anand Pandya MD FRCSC
Trauma Surgery and Critical Care Medicine
Clinical Associate
St. Michael’s Hospital, University of Toronto

2. Objectives Evaluation of Abdominal Trauma Mechanisms of Injury
Assessment of Unstable Patients
Assessment of Stable Patients
Case Discussions
Diagnostic tests
Decision making

3. External Anatomy of Abdomen
This slide illustrates the three main areas of external abdominal anatomy.
Briefly review each component while relating the potential structures for injury that exist within each.
The anterior abdomen extends from the 4th intercostal space superiorly (often the transnipple line in men) to the inguinal ligament and symphysis pubis inferiorly, and between the anterior axillary lines.
The flank area extends from the 6th intercostal space superior to the iliac wing inferiorly, and between the anterior and posterior axillary lines.
The back area extends from the tip of the scapula superiorly to the iliac crest (or the inferior gluteal fold) inferiorly, and between the posterior axillary lines. 3

4. Mechanism of Injury: Blunt
Compression, crush, or sheer injury to abdominal viscera: deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus)
Deceleration injuries: differential movements of fixed and non-fixed structures (e.g. liver and spleen laceration at sites of supporting ligaments)

5. Pattern of Injury in Blunt Abdominal Trauma
Spleen
40.6%
Colorectal
3.5%
Liver
18.9%
Diaphragm
3.1%
Retroperitoneum
9.3%
Pancreas
1.6%
Small Bowel
7.2%
Duodenum
1.4%
Kidneys
6.3%
Stomach
1.3%
Bladder
5.7%
Biliary Tract
1.1%
* Rosen: Emergency Medicine (1998)

6. Mechanism of Injury: Penetrating
Stab
Low energy, lacerations
Gunshot
Kinetic energy transfer
Cavitation, tumble
Fragments
5-8 Abdominal Injury: Penetrating Mechanism
How does penetrating force injure?
The radiograph is of a patient who presented with a single, small, round high-velocity rifle wound to the left upper quadrant. Three fragments (two large and one small) are seen at the diaphragm.
Emphasize the difference between stab and gunshot wounds. 6

7. Assessment: History AMPLE Mechanism MVC: Speed
Type of collision (frontal, lateral, sideswipe, rear, rollover)
Vehicle intrusion into passenger compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle

8. Assessment: Physical Exam
Inspection, auscultation, percussion, palpation
Inspection: abrasions, contusions, lacerations, deformity
Grey-Turner, Kehr, Balance, Cullen
Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.)
Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum
Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding

9. A missed abdominal injury can cause a preventable death.
Factors that Compromise the Exam
Alcohol and other drugs
Injury to brain, spinal cord
Injury to ribs, spine, pelvis
Caution
5-11 Abdominal Injury: Factors that compromise the exam
During the discussion on assessment, ask the students what factors can compromise the abdominal examination. The students should respond with the bulleted items on the slide.
You may ask the students, “How do associated orthopedic injuries compromise, limit, or distract from the abdominal examination?”
A missed abdominal injury can cause a preventable death. 9

11. Case 1 40 yo male, MVC – driver GCS=7, Airway 100% on 15L face mask
BP=80/50, P=140
Diagnosis?
Management?

12. Decision Making Airway Breathing Circulation S H O C K Hemodynamically
Stable
Hemodynamically
Unstable
Transient
Responder
How are you going to assess?

13. Shock Scalp Chest – clinically vs. chest x-ray Abdomen
FAST
DPL
Pelvic X-ray
Extremities – Femur
Other causes of shock – cardiogenic, obstructive, anaphylactic, septic

14. FAST

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

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

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

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

19. DPL: Procedure

20. Evaluation of DPL Index Positive value Aspirate Blood >10 mL Fluid
Fluid is sent for: cell count, amylase, alk phos, presence of bile
Index
Positive value
Aspirate
Blood
>10 mL
Fluid
Enteric content
Lavage
RBC
> 100,000/mL
WBC
> 500/mL
Amylase
>175 U/dL
Alk Phos
> 3 IU
Bile
Confirmed
Negative
< 50,000/mL
< 100/mL
< 75 U/dL

21. Diagnostic Peritoneal Lavage
RBC Count
Incidence of visceral damage
>100,000
95%
20, ,000
15-25% Warrant further investigation
<20,000
< 5%
Complications of DPL: Perforation of small bowel, mesentery, bladder and retroperitoneal vascular structures.
Limitation: offers no information about status of retroperitoneal organs nor allow determination of which organ has been injured.

22. Indications for Laparotomy – Blunt Trauma
Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)
Free air
Diaphragmatic rupture
Peritonitis
Positive CT
5-22 Laparotomy: Indications for Laparotomy – Blunt Trauma
What are the indications for a laparotomy in the patient who sustained blunt abdominal trauma?
The indications listed on this slide are commonly used to facilitate the surgeon’s decision-making process in this regard.
Explain the role of FAST and the use of CT for non-operative management. 22

23. On Route to OR ABC Chest x-ray, Pelvis x-ray IV access Resuscitation
What is the goal?
Group and Match
Notify OR, Surgeon, Anaesthesia
Request OR equipment
Consent
Antibiotics

26. Case 1: Learning Points Recognize Shock Hemodynamically unstable = OR
Role of FAST, DPL
Permissive hypotension in resuscitation until bleeding controlled

27. Case 2: 40 yo male, MVC Driver Airway Breathing = 100% on 5L NP
Circulation = 130/70, P=100
Disability, GCS=14
Exposure
Management?

28. How do you investigate the Abdomen?
Hemodynamically stable:
ABCDE, secondary survey
FAST
CT Scan
Lab work

29. Imaging in Blunt Abdominal Trauma – CT Scan
Sensitivity:
Solid organ injury: 97% [II,III]
Identify Contrast extravasation
Guide Operative vs. Non-operative management
Enteric injury: 64 – 94% [III]
Diaphragmatic injury: 61% [III]
Pancreatic injury: 30% [III]
Sensitivity:
Solid organ injury: 97% [II]
Enteric injury: 64 – 94% [III]
The largest study on enteric inj was a retrospective case control of 275K patients with BAT, 2249 had hollow viscus injury. FF without solid organ inj 84.2% = SBI (only 30.5% perf’d) % with pneumoperitoneum. Bowel wall thickening, stranding, contrast extrav, retroperitoneal blood were less ‘effective’ in identifying SBI.
Panc Inj. One study with N=10
Diaphragmatic inj. One retrospective case controlled study with N=11

30. CT Scan

31. CT Scan

32. CT Scan

33. Role of Laboratory Tests
Amylase
B-HCG

34. In Pregnancy X-rays Ultrasound Circumferential Lead Shield
Abdominal
Fetal
Circumferential Lead Shield
Caution with Radiation exposure

35. Decision Making Stable patient CT Scan Operative
Solid organ injury, hypotensive
Hollow viscus organ injury
Intraperitoneal bladder injury
Diaphragmatic injury
Non-operative management
Observation
Interventional Radiology

36. Learning Points Case #2
CT scan is helpful for decision making in a stable patient
Poor detection of hollow viscus, pancreatic and diaphragmatic injury
Be worried of free fluid in abdomen
Repeat CT Scan and close clinical observation

37. Case #3 30 yo male GSW to buttock Airway Breathing Circulation
What injuries are you concerned about?
How are you going to investigate?

38. Transpelvic GSW Rectal injury Bladder injury Urethral injury
Extraperitoneal – rigid sigmoidoscopy
Intraperitoneal – CT scan with rectal contrast or laparotomy
Bladder injury
Hematuria
Cystogram
Urethral injury
Retrograde urethrogram

39. Transpelvic GSW Vascular injury Pelvic fracture
FAST
CT Scan
Pelvic fracture
X-ray
Female – Uterine injuries

41. Decision Making Low threshold for laparotomy with GSW
Bowel injury = sigmoidoscopy
Intraperitoneal – repair/resect
Extraperitoneal – diversion
Bladder injury = cystogram
Intraperitoneal – surgical repair
Extraperitoneal – foley catheter

42. Learning Points Case #3 Think of associated injuries
GSW have blast effect, variable trajectory
Diagnostic tests guide treatment
Early laparotomy

43. Case #4 30 yo male Stab wounds to abdomen Airway Breathing Circulation
What is your management?

44. Options for Management
Diffuse Abdominal Tenderness
Yes No
Laparotomy
Hemodynamic Stability?
Indications for Laparotomy – Penetrating Trauma
Hemodynamically abnormal
Peritonitis
Evisceration
Positive DPL, FAST, or CT
Violation of peritoneum

45. Options for Management
Hemodynamically stable penetrating injury
Serial Observation
Wound Exploration
DPL
CT scan +/- Contrast
Laparoscopy
Laparotomy
Ultrasound/echo – cardiac box
Pericardial window – cardiac box

46. Even of these, 31% negative 176 (53%) observed
Stab Wounds
Shorr RM, Gottlieb MM, et al. Selective management of abdominal stab wounds: Importance of the physical examiantion. Arch Surg 1988, 123(9):
330 patients over 12 months 154 (47%) acute abdomen, underwent immediate celiotomy
Even of these, 31% negative
176 (53%) observed
3 (1.7%) injuries required celiotomy (no adverse effects)

47. The Value of Serial Observation

48. Learning Points Case #4 Injury from stab wounds are different from GSW
Indications for early surgery
Consider diagnostic options
Value of serial exam

49. Case #5 50 yo male, MVC driver Airway Breathing Circulation
100/70, P=130
What is the next step?

50. Priorities ABC Consider associated injuries with pelvic trauma
Blood vessels – arterial and venous
Bone
Bladder and urethral
Bowel
Baby (Uterus)
Other Body injuries

51. Vascular Anatomy Abdominal Aorta Common Iliac Artery Internal Iliac
External Iliac
Superior Gluteal
Obturator Artery

52. AP Pelvic # with bladder injury

53. Unstable Fractures Lead to Unstable Patients
The Pelvic Mantra….
Unstable Fractures Lead to Unstable Patients
- stability should be tested by GENTLE manipulation
- stability should only be performed ONCE
Minimize further hemmorage !

54. Young-Burgess Classification SystemLC
APC VS
Unstable

55. Decision Making Hemodynamically Stable
CT Scan + cystogram
If blush then observe vs. embolize
Hemodynamically unstable, Pelvis unstable
FAST or DPL to rule out intra-abdominal injury
Bedsheet wrap pelvis, Ex-fix, C-clamp
If intraperitoneal blood = laparotomy
If no intraperitoneal blood = Angiogram

56. Angiography and Embolization
Initial Angiogram
Post-Embolization
Right iliac angiogram: acute extravasation (left) from the right superior and inferior lateral sacral arteries. Post-embolization (right) showing no evidence of acute arterial bleeding

57. Learning Points Case #5 Unstable vs. Stable patients
Recognize pelvic fracture
Rule out bladder injuries
Angiogram and emobolization of arterial injuries

58. Role of Interventional Radiology
Embolization
Spleen
Liver
Pelvis
Angioplasty + Stent
Renal artery dissection
Stent
Thoracic aortic injuries

59. Spleen Embolization

60. Renal Artery Dissection

61. Blunt Thoracic Aortic Injury

62. Summary Mechanism of injury – Blunt vs. Penetrating
ABC  Stability of trauma patients
Select ppropriate diagnostic imaging
Think about associated injuries
Multi-modality
Clinical
FAST
CT Scan
Interventional Radiology
Surgical exploration

63. Questions