Trauma Services
Ottawa Hospital

Economic Burden of
Injury in Ontario 1996
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Injury death
Hosp injuries
Non hosp injuries
Total injuries
Partial perm. Disa.
Total perm. Disa.
Total annual cost
2,844
43,382
693,630
739,856
15,232
1,141
$2.9 billion

Abdominal Trauma
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Abdominal injuries present in 7-10% of admission
Present in ~ 20% of all trauma surgeries
½ of preventable trauma death are related to inappropriate management of abdominal trauma
Extra abdominal injuries are clues to the presence of injuries within the abdomen
Abdominal injuries should be suspect in all trauma

Abdominal Trauma
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Physical examination
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Bruises, abrasion over the abdomen
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Abdominal pain or tenderness
Absent bowel sounds
Unexplained hypotension
P/E equivocal or misleading.!!!
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Peritoneal sign falsely negative in 40%
Peritoneal sign falsely positive in 20%
10% of all injuries are initially overlook
WHY?

Abdominal Trauma
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Physical examination unreliable
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Head trauma
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Spinal cord injuries
Alcohol intoxication
Use of illicit drugs
Injuries to adjacent structure
Significant amount of blood present
Analgesia

Abdominal Trauma
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Penetrating
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High velocity
(85% penetrate peritoneum)
Low velocity
(95% need surgery)
Stab
(1/3 do not penetrate the peritoneum, of those 50% need Sx)
Blunt trauma
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High energy transfer (car accident)
Low energy transfer (fall, fight)

Abdominal Trauma
Anterior abdominal gunshot
Stab
Local exploration
–
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Penetration of the fascia??
DPL
Laparoscopy
Laparotomy
Serial observation
Surgeon’s expertise

Initial management for stab wounds

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Physical examination
Investigation
Case presentation
Specific organ injuries
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Liver
Spleen
Small bowel

Injuries From Motor Vehicle Passenger Restraints
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Decrease mortality from MVC
Increase morbidity
Seat belt syndrome
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Lap belt injury in children
C-spine injury
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Air bag

Abdominal Trauma
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Spleen
Liver
25%
15%
Hollow viscus 15%
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Ileum
Sigmoid
Kidney 12%
Retroperitoneal 13%
Mesentery 5%
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Compression
Crushing
Shearing
Avulsion

Abdominal Trauma Evaluation
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BP and Pulse trend
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Inspection
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Seat belt mark
Skin lacerations
Previous surgery scar

Abdominal Trauma Evaluation
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Auscultation
Palpation
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Rebound tenderness
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Guarding
Pregnancy
Pelvic instability

Abdominal Trauma Evaluation
1.
2.
3.
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Rectal examination
Prostate
Rectal tone
Vaginal examination
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Gluteal fold
Penetrating injuries = abdominal injuries

Abdominal Trauma Evaluation
4
- Gastric tube
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Relives distention
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Decrease risk of unattended vomiting
But can induce it , risk of aspiration !!!
Caution
Facial fracture/basilar skull fracture

Abdominal Trauma Evaluation
6.
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Urinary catheter
Monitor urinary output
Caution
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Inability to void retrograde
Pelvic fracture urethrogram
Blood at the meatus U/S
Scrotal Ecchymoses
High riding prostate

Abdominal Trauma Evaluation
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DPL
U/S
Ct abdomen & pelvis

Abdominal Trauma Evaluation
1.
2.
3.
C-spine
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Chest AP
+/- paper clips for penetrating injury
High association of chest injuries and abdominal injuries
Free air?
Pelvis
+/- paper clips for penetrating injury

Abdominal Trauma Evaluation
4.
Urethrography
5. ? IVP for hematuria
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IV contrast
Keep good urinary output
Better CT scan
6. Spine fracture
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Chance Fracture
20% small bowel injuries

J.D. (3265709) -1
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47 year old male
Car felt on his Rt chest, LOC at scene?
RUQ & Rt chest pain & deformity Rt shoulder
A good air entry
B Rt chest pain and bruising
C Pulse 92, Bp 120/90 HgB 140
EKG , few PVC, CK 1485, Triponin t < .05
D GCS 15
E Chest abrasions Rt side

J.D. (3265709) -2
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Ct scan
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Abdomen
Chest Xray

CT scan J.D. (3265709) -2

J.D. (3265709) -2
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Ct scan
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Grade III liver laceration
Intra abdominal free fluid
HgB decrease to 93
Liver injury
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85 % observation
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10% -15% mortality
15 % Laparotomy
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60 % mortality

A significant liver injuries will not heal spontaneously and surgical intervention is the only acceptable approach for it
Pringle 1908
Once the diagnostic of Hemoperitoneum has been made, routinely the next goal of the surgeons will be to prepare the patient for surgery as rapidly and efficiently as possible
Sclafani 1991

(cont’d)
Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.
Grindlinger 1998
TIP
Patient selection
Type of Trauma
Age
Associated injuries

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ATLS
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Patient ‘s clinical condition
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Persistent or recurrent hypotention
Hemorrhage
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Prompt control of bleeding
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Judicious volume restoration
Maintenance of pH and T o
TIP
Duration of shock more critical than the amount of blood transfused

1998
BP>=100
HR <= 100
GCS >3
Liver Injury
Class 1&2
<= 4 units/24hr > 4 units/24 hr
Conservative management
Stable
CT Scan
Liver Injury
Class 3,4,5 assoc abd. inj.
Unstable <90
Lavage
OR
OR

Age
Syst BP
Nonoperative Operative
38
106
48
122
HR 91
Transfusions 1.7
102
10
ER fluids
ISS
2,500
13
LOS 11.8
# associ. inj 67%
3,000
25
37
100%
J Trauma ;1998, 45,360

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Nonoperative
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Less blood mortality 15% Vs up to 63%
LOS shorter
TIP decision to treat is base on the patient stability

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Diagnosis
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Hemodynamic instability
LUQ pain
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Left shoulder pain
CT scan will save 70 % of spleen
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Observation X 72 hr
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Healing over 6 weeks
OPSI
(overwhelming post Splenectomy infection)
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< 1% of splenectomy , increase in children

Epidemiology
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15% of all laparotomy
High index of suspicion required
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Serial examination
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DPL diagnostic in 95 %
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Enhance by enzyme
Increasing success with CT and laparoscopy
Delay in diagnosis increase M & M

Retroperitoneal air

Abdominal Evaluation
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½ Injuries due to MVA
Increase incidence of splenic injury and retroperitoneal bleed
Placenta abruption
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2-5% minor injuries
20-50% in major injuries

Treatment
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Multidiciplinary approach
Stabilization of mother status
Avoid venocaval compression
Used shielding during X-Ray
Aggressive Hypotention treatment
Establish gestational age
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Ultrasound
C-section…Group decision

Treatment
-2
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Abdominal evaluation
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DPL supraumbelical approach
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CT scan (5-10 cGy, Max is 10cGy)
Pelvic X-ray
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Pelvic fracture: associated with fetal skull #
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Unstable pelvic fracture = c-section (10%)
Monitoring in labor & delivery room
Rh- : RhiG within 72 Hours

Multivariate Odd Ratio From 16,000 Patients
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Gross hematuria 3.62
Admission hypotension
Lower ribs fracture
3.53
2.58
Hemo/pneumothorax 2.49
Abdominal wall hematoma 1.96
Base deficit(HCO
3
Pelvic fracture
< 21) 1.77
1.5
(Brad Chushing)

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Diagnostic
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Ct, U/S
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Laparoscopy its impact is coming
Therapeutic
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Nonoperative management
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Spleen & liver
Non operative for liver gunshot
“Damage control” laparotomy
“Abdominal compartment syndrome”