1. Abdominal Trauma
Begashaw M (MD)

2. Anatomy

3. Abdominal Trauma Two mechanisms
_Bluntusually causes solid organ injury (spleen injury is most common)
_Penetratingusually causes hollow organ injury or liver injury (most common)

4. Mechanism of Injury
Blunt Force Trauma
Penetrating Trauma

5. Mechanism of Injury Africa style

6. Mechanism of Injury Blunt Speed Nature of Impact Position in vehicle
Ejection
Intrusion
Seatbelt
Airbag
Penetrating
Type of weapon
Distance
Number and location of wounds
Trajectory
Energy
Blast effect

7. BLUNT TRAUMA results in two types of hemorrhage
- intra-abdominal bleeding
- retroperitoneal bleeding
adopt high clinical suspicion of bleeding in multi-system trauma

8. Examination
Abdomen
Inspect: contusions, abrasions, seatbelt sign, distention
Auscultate: bruits,bowel sounds
Palpate: tenderness, rebound tenderness, rigidity, guarding
DRE: rectal tone, blood, bone fragments,prostate location
Placement - NG, foley catheter

9. Commonly injured organs
Spleen
Liver
Small Bowel

10. Assessment of abdominal trauma
Difficult due to:
_Altered sensorium (head injury, alcohol)
_Altered sensation (spinal cord injury)
_Injury to adjacent structures (pelvis, chest)

11. Investigations
Labs: CBC, electrolytes,cross & type, glucose, creatinine, amylase, liver enzymes
Imaging

12. Imaging Imaging strengths limitations X-ray Erect CXR
Soft tissue not visualized
CT scan
Most specific test
Radiation,cannot use if hemodynamic instability
Diagnostic peritoneal Lavage
Most sensitive test
Test for intra abdominal bleeding
Retroperitoneal hemorrhage, diaphragmatic rupture
Ultrasound FAST
Free fluid, Rapid, pericardium, plura
Specific organ injury

13. FAST Focused assessment for the sonographic assessment of trauma
Assess for intraperitoneal fluid
o Right upper quadrant
o Left upper quadrant
o Suprapubic region
Fluid in subphrenic, subhepatic spaces or Pouch of Douglas in hypotensive patient
Confirms likely need for emergency laparotomy

14. FAST

15. Criteria for positive DPL
>10 cc gross blood
Bile, bacteria. foreign material
RBC count >I 00,000
WBC >500
Amylase > 1751U

16. Imaging
Equivocal abdominal examination, suspected intra-abdominal injury
Multiple trauma
Unexplained shock/hypotension
Fractures of lower ribs, pelvis, spine
positive FAST

17. Management General: ABCs, fluid resuscitation and stabilization
Surgical: watchful wait vs laparotomy
Solid organ injuries: decision based on hemodynamic stability, not the specific injuries
Hemodynamically unstable or persistently high transfusion requirements: laparotomy
Hollow organ injuries: laparotomy
Even if low suspicion on injury: admit and observe for 24 hours

19. Indications for Laparotomy
Free Fluid on FAST
Unstable patient with suspected abdominal injury
Free Air
Diaphragm Rupture
Peritonitis
Positive findings on CT Scan

20. PENETRATING TRAUMA
High risk of gastrointestinal perforation and sepsis
History: size of blade, calibre/distance from gun, route of entry
Local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable in inexperienced hands) with the following exceptions:
-thoracoabdominal region (may cause pneumothorax)
-back or flanks (muscles too thick)

21. Penetrating Trauma Overall condition of the patient
Local wound exploration
DPL?

22. Penetrating abdominal trauma

23. Laparomy in penetrating injury
Shock
Peitonitis
Eviseration
Free air in abdomen
Blood in NG tube, Foley catheter, or on rectal exam

24. Management General: ABCs, fluid resuscitation and stabilization
Gunshot wounds-always require laparotomy