BLUNT TRAUMA ABDOMEN

(OPERATIVE v/s CONSERVATIVE

MANAGEMENT)

Dr.Anil Haripriya

INTRODUCTION
Motor vehicle accidents are responsible for
75% of all blunt trauma abdominal injuries
- More common in elderly due to less
resilience.
- Blunt injuries causes solid organ trauma
(spleen, liver and kidneys) more often than
hollow viscera.
- Multi organ injury and multiple system injury
are also more common in blunt injury than in
other types.
-

MECHANISMS OF INJURY
CRUSHING
-Direct application of a blunt force to the abdomen
SHEARING
-Sudden decelerations apply a shearing force across organs
with fixed attachments
BURSTING
-Raised intraluminal pressure by abdominal compression
accurately in hollow organs can lead to rupture
PENETRATION
-Disruption of bony areas by blunt trauma may generate bony
spicules that can cause secondary penetrating injury

PRESENTATION
Varies widely from haemodynamic
stability with minimal abdominal
signs to complete cardiovascular
collapse and may change from one
to the other with alarming rapidity

INITIAL ASSESSMENT
Whether the patient is haemodynamically

stable

unstable

FIRST PRIORITIES PROTOCOL :

Brief clinical examination to evaluate ABC along with
cardiovascular status with blood pressure and pulse
measurement.
Accordingly, resuscitation and management of shock by
-

maintenance of ABC

IV fluids

nasogastric tube insertion

Catheterization

SECOND PRIORITIES PROTOCOL

Physical examination
Base line investigations
Four quadrant tap
Diagnostic peritoneal lavage (DPL)
Ultrasound FAST
sonography for trauma)
Abdominal CT scan
Diagnostic laparoscopy
Laparotomy

(focus

assessment

with

HISTORY AND PHYSICAL EXAMINATION

HISTORY :
- To know injury mechanism (mode of injury)
to anticipate injury patterns and raise the index of
suspicion for occult injury
- Events preceding the injury
General principles: -

Serial examinations by the same

examiner improves sensitivity

Spinal cord injury masks clinical

findings

Tenderness blunted by intoxicants

PHYSICAL EXAMINATION
General Examination : relating to hemodynamic
stability
Abdominal findings:
- Inspection :
for abdominal distension
for contusions or abrasions
lap belt ecchymosis mesenteric, bowel, and
lumbar spine injuries
periumblical (Cullen sign) and flank (Grey Turner
Sign) ecchymosis retroperitoneal haematoma

PHYSICAL EXAMINATION cont.

- Palpation :
for tenderness, guarding and/or rigidity,
rebound tenderness hemoperitoneum
- Percussion :
Dullness/ shifting dullness
intrabdominal collection
Auscultation :
+/- nce of bowel sounds

The classical
seatbelt sign.
The bruising on
the left breast is
from the shoulder
belt and the low
bruising to the
abdominal wall is
from the lapbelt.

PHYSICAL EXAMINATION
cont..
Rectal findings
Check for gross blood - pelvic fracture
Determine prostate position high riding prostate
urethral injury
Assess sphincter tone neurologic status
Distal pulses
- Assess for absence or asymmetry
Assessment of other associated injuries i.e. multiple
fractures, spinal injuries etc.

DIAGNOSTIC STRATEGY
INVESTIGATIONS
Aim

To identify

To decide

(those with injury) (which ones

need laparotomy)

When
(how quickly
this must be
undertaken)

DIAGNOSTIC STRATEGY cont..

BASIC

DATA
Complete haemogram with hematocrit, ABG,
Electrocardiogram
- Renal function tests
- Urine analysis
+nce of hematuria genito urinary injury
-nce of hematuria does not rule out it
- Serum amylase / lipase or liver enzymes - se -suspicion
of intraabdominal injuries

DIAGNOSTIC STRATEGY
cont
Chest radiograph
Pneumothorax/hemothorax
Raised left/right hemidiaphragm
perisplenic/hepatic hematoma.
Lower ribs fracture liver/spleen injury.
Abdominal contents in the chest
ruptured hemidiaphragm
Abdominal radiographs
-Pneumoperitoneum perforation of hollow viscus
-Ground glass appearance
massive hemoperitoneum

DIAGNOSTIC STRATEGY
Abd. Radiograph cont
-

Dilated gut loops- retroperitoneal hematoma or

injury

Retroperitoneal air outlining the right kidney

duodenal injury
Double wall sign air inside and outside the bowel
Distortion or enlargement of outlines of viscera
hematoma in relation to respective organs

DIAGNOSTIC STRATEGY cont

Abd. Radiograph cont
-

Medial displacement of stomach splenic hematoma

Obliteration of Psoas shadow retroperitoneal
bleeding
Pelvic bone fracture bladder/urethral/rectal injury
Fracture vertebra ureter injury / retroperitoneal
hematoma

INDICATIONS FOR FURTHER TESTING

- Unexplained haemorrhagic shock
- Major chest or pelvic injuries
- Abdominal tenderness
- Diminished pain response due to
-

Intoxication
Depressed level of consciousness
Distracting pain
Paralysis

Inability to perform serial examination

FOUR QUADRANT TAP:

- Overall accuracy about 90%
- Positive tap obtaining 0.1 ml or more of non clotting
blood
- Negative tap does not rule out haemorrhage
DIAGNOSTIC PERITONEAL LAVAGE
Criteria for positive tap
- Gross bloody tap
- >1,00,000 RBCs per mm
- > 500 white blood cells per mm
- Elevated amylase level
- Presence of bile or bacteria or faeces

ULTRASOUND FAST EXAMINATIONS (focused assessment with sonography for

trauma).
Advantages
- Inexpensive, noninvasive and portable
- Performed by emergency physicians and surgeons trained in
performing FAST examinations.
- Avoids risks associated with contrast media
- Confirms presence of hemoperitoneum in minutes
- Deceases time to laparotomy
- Great adjunct during multiple casualty disasters
- Serial examination can detect ongoing hemorrhage
- Differentiates pulseless electrical activity from extreme
hypotension
- With pregnant trauma patients, determines gestational age and
fetal viability

Disadvantages A minimum of 70 ml of intraperitoneal fluid for positive study.

Accuracy is dependent on operator / interpreter skill and is decreased with
prior abdominal surgery.
Technically difficult with obese, ileus or subcutaenous emphysema is
present
Does not define exact cause of hemoperitoneum
Sensitivity is low for small-bowel and pancreatic injury
Sensitivity 69%-99%
Specificity 86%-98%

Technique Four basic transducer positions used to find

abdominal fluid.
Subxiphoied hemopericardium
Right upper abdominal quadrant fluid in Morrisons pouch
Left upper abdominal quardant
fluid in perisplenic space
Suprapubic
fluid in Douglas pouch

ABDOMINAL CT SCAN
-Latest generation of helical and
multislice scanners provides rapid
and accurate diagnostic information.
-Criterion standard for solid organ
injuries.
-Help quantitate the amount of blood
in the abdomen and can reveal
individual organs with precision.

TABLE
Diagnostic Modalities in Abdominal Trauma
PERITONEAL
LAVAGE

ULTRASOUND

CT SCAN

Use

Records intraabdominal
haemorrhage in
stable/unstable
trauma

Reveals intraabdominal
haemorrhage in
stable and unstable
in patients

Reveals organ of injury

and extent of
blunt/penetrating
abdominal trauma in
stable patients

Contraindications

Urgent demand for

laparotomy
Prior abdominal
surgery
Pregnancy and
obesity

Urgent demand for

laparotomy
Obesity and
subcutaneous
emphysema

Need for emergency

laparotomy in an
unstable patient
Unco-operative
patients
Allergy to contrast
material

Drawback

Unreliable in
retroperitoneal and
diaphragmatic
trauma

Failes to show small Unreliable in detection

amount of fluid
of rupture of bowel and
diaphragmatic injuries
Time consuming
High cost

TABLE
Diagnostic Modalities in Abdominal Trauma

PERITONEAL
LAVAGE
Sensitivity 100%
Specificity 97%
Accuracy 99%

ULTRASOUND
84%
88%
86%

cont..

CT SCAN

89%**
98%**
97%

* Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in

blunt abdominal trauma. J Trauma 29:242, 1999.
** Meyer D M, Thal E R, Weigelt J A, et al: The role of abdominal CT in the
evaluation of stab wounds to the back. J Trauma 29:1226, 1999.

LAPAROSCOPY
Advantages
- extent of organ injuries and determines the need for
laparotomy
- Defines which intraabdominal injuries may be safely
managed nonsurgically
- More sensitive than DPL or CT in uncovering
- Diaphragmatic injuries
- Hollow viscus injuries

Surgery can be done in same sitting

- With laparoscope with minimal trauma
- Open surgery

Sampling for HPR can be taken

LAPAROSCOPY

cont

Disadvantages:
- pneumoperitoneum may elevate ICP
- General anesthesia usually necessary
- Patient must be hemodynamically stable
Complications:
- bleeding or injury
- Gas embolism and pneumoperitoneum

LAPAROTOMY
INDICATIONS
Absolute criteria
Peritonitis (gross blood, bile or faeces)
Pneumoperitoneum or pneumoretroperitoneum
Evidence of diaphragmatic defect
Gross blood from stomach or rectum
Abdominal distension with hypotension
Positive diagnostic test for an injury requiring
operative repair

NON OPERATIVE INJURY

MANAGEMENT
General considerations
criteria for non operative management
- Patient hemodynamically stable after initial
resuscitation
- Continuous patient monitoring for 48 hrs
- Surgical team immediately available
- Adequate ICU support and transfusion services
available
- Absence of peritonitis
- Normal sensorium

NON OPERATIVE INJURY

MANAGEMENT
- Angioembolization may be alternative to
surgical intervention
- All patients with solid organ injury
managed
nonoperatively
require
admission
for
observation,
serial
hematocrit measurement, and repeat
imaging

ORGAN INJURIES
SOLID ORGANSSolid organs most commonly injured
in blunt traumas
In decreasing incidence of injury
Spleen, liver, kidneys, intraperitoneal

small bowel, bladder, colon, diaphragm,

pancreas and duodenum

HOLLOW VISCERA:
- duodenum commonly injured
- Small bowel injured at relatively fixed areas
(duodenojejunal flexure and ileocaecal
junction) by shearing force
- Colon relatively protected.
- Gaseous distension of caecum most vulnerable

part as fixed.
-

Stomach rarely injured compression cause

esophagogastric junction bursting

RETROPERITONEUM AND
UROGENITAL TRACT
Kidney

injury - common next to spleen and liver

Pancreatic injury - 4% cases of trauma
Bladder
- most commonly injured extra
peritoneally by shearing at the vesico urethral
junction.
- intraperitoneally by blunt force on distended
bladder
Rupture of prostatic urethra by shear forces is
commonly seen with haemorrhage

CHILDHOOD TRAUMA
Blunt

trauma secondary to MVAs, falls or child

abuse is primarily responsible for 90% of
childhood injuries.
Predominance - Solid organ abdominal injuries.
Non-op. management 90% success rate
(standard of care in solid organ injuries)
Overall mortality approx 15% or <
(if major vascular injuries excluded)
Mortality from severe blunt trauma abdomen is
higher than penetrating injuries

CHILDHOOD TRAUMA

cont

General Principles Understanding anatomic and physiologic

characteristics unique to children.
Dose according to bodyweight
Resuscitation - maintenance of ABC
(golden hour)
IV fluids intraosseus (if needed)
Nasogastric tube insertion
Catheterization
Normothermia maintenance

PROTOCOL FOR BLUNT TRAUMA ABDOMEN

MANAGEMENT

RECENT TECHNIQUES
TRAUMA LAPAROTOMY
DAMAGE CONTROL LAPAROTOMY
- Aim :
- Control of haemorrhage and limitation of contamination

by rapid and temporary means

-

Technique :
- Abdominal packing for visceral bleeding
- Vascular shunting major vessel injury
- Control of contamination by stapling guns
- Gastrointestinal perforation or pancreatic leakage by

soft clamps or nylon ties

TEMPORARY CLOSURE OF THE ABDOMEN

Indication
- Permanent closure not possible due to need for
observation to avoid second look surgery.
- Techniques -

- By row of towel clips quickest method of

closure and re-opening

- Continuous nylon suture
With fascia left wide open in both
- Emptied and opened out intravenous fluid bag
(Bogata bag) Sutured or stapled to the skin
- Opsite covered abdominal pack

Temporary
closure of the
abdomen using
two Opsite sheets.

NEWER TECHNOLOGIES
ROBOTICS
Robot assisted surgeries
(eg. In microsurgical techniques eliminate hand
tremors)
Trainer robots (eg. Eagle trauma patient simulator)
INFORMATION TEHCNOLOGY
Establishment of city emergency medical system
(EMS) with personal status monitor (PSM), vehicle
status monitor (VSM), global positioning satellite
(GPS), and wireless local area network (LAN).

CONCLUSION
Controversies

regarding management
still exist b/c of varied presentation.
Close supervision with sophisticated
infrastructure
and
quick
action
significantly reduces mortality.
Establishment of trauma centres with
persons of different specialties working
together as a team.