Key features
- Abdominal injuries are present in 7-10% of trauma patients. Theseinjuries, if unrecognized, can cause preventable deaths.
- Blunt trauma: most frequent injuries are spleen (45%), liver (40%),and retroperitoneal haematoma (15%). Blunt trauma may cause:
- compression or crushing causing rupture of solid or holloworgans;
- Blunt abdominal trauma is very common in road traffic accidentswhere:
- there have been fatalities;
- any casualty has been ejected from the vehicle;
- the closing speed is greater than 50mph.
- Penetrating trauma: these may be:
- stab wounds and low velocity gunshot wounds: cause damage bylaceration or cutting. Stab wounds commonly involve the liver (40%), small bowel(30%), diaphragm (20%), colon (15%);
- high velocity gunshot wounds transfer more kinetic energy and alsocause further injury by cavitation effect, tumble, and fragmentation. Commonlyinvolve the small bowel (50%), colon (40%), liver (30%), and vessels(25%).
Management primary survey
- Any patient persistently hypotensive despite resuscitation, forwhom no obvious cause of blood loss has been identified by the primary survey,can be assumed to have intraabdominal bleeding.
- If the patient is stable an emergency abdominal CT scan is indicated.
- If the patient remains critically unstable an emergency laparotomyis usually indicated.
Management secondary survey of the abdomen
History
- Obtain from patient, other passengers, observers, police, andemergency medical personnel.
- Mechanism of injury: seat belt usage, steering wheel deformation,speed, damage to vehicle, ejection of victim, etc. in automobile collision;velocity, calibre, presumed path of bullet, distance from weapon, etc. inpenetrating injuries.
- Prehospital condition and treatment ofpatient.
Physical examination
- Inspect anterior abdomen, which includes lower thorax, perineum,and log roll to inspect posterior abdomen. Look for abrasions, contusions,lacerations, penetrating wounds, distension, evisceration of viscera.
- Palpate abdomen for tenderness, involuntary muscle guarding,rebound tenderness, gravid uterus.
- Auscultate for presence/absence of bowel sounds.
- Percuss to elicit subtle rebound tenderness.
- Assess pelvic stability.
- Penile, perineum, rectal, vaginal examinations, and examination ofgluteal regions.
Investigations
Blood and urine sampling
Raised serum amylase may indicate small bowel or pancreaticinjury.
Plain radiography
Supine CXR is unreliable in the diagnosis offree intrabdominal air.
Focused abdominal sonography for trauma(FAST)
- It consists of imaging of the four Ps: Morrison's pouch, pouch ofDouglas (or pelvic), perisplenic, and pericardium.
- It is used to identify the peritoneal cavity as a source ofsignificant haemorrhage.
- It is also used as a screening test for patients without major riskfactors for abdominal injury.
Diagnostic peritoneal lavage
- Mostly superseded by FAST for unstablepatients and CT scanning in stable patients. Useful, whenthese are inappropriate or unavailable, for the identification of the presenceof free intraperitoneal fluid (usually blood).
- Aspiration of blood, gastrointestinal contents, bile, or faecesthrough the lavage catheter indicates laparotomy.
Computerized tomography
- The investigation of choice in haemodynamically stable patients inwhom there is no apparent indication for an emergency laparotomy.
- It provides detailed information relative to specific organ injuryand its extent and may guide/inform conservativemanagement.
Indications for resuscitativelaparotomy
Blunt abdominal trauma: unresponsive hypotension despite adequateresuscitation and no other cause for bleeding found.
Indications for urgent laparotomy
- Blunt trauma with positive DPL or free bloodon ultrasound and an unstable circulatory status.
- Blunt trauma with CT features of solid organinjury not suitable for conservative management.
- Clinical features of peritonitis.
- Any knife injury associated with visible viscera, clinical featuresof peritonitis, haemodynamic instability, or developing fever/signs ofsepsis.
- Any gunshot wound.
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