Abdominal injuries
Types
Diagnosis
Treatment
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Types of abd trauma
Blunt
Direct blow
Deceleration
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Penetrating:
GSW
Stab wounds
Impalement
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Often thoracoabdominal
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Klinika Chirurgii Urazowej
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Diagnosis
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Determine the presence of abd injury (history, physical
examination, USG, CT, DPL, X-ray) – serial examinations
indicated
Altered consciousness → major confounding factor for
PE
PE: seat belt sign (ecchymotic area at the lower abd.
wall – bladder and bowel perforation, L distraction
[chance] fr.), Cullen`s sign (periumbilical ecchymosis
indicative of intraperitoneal hemorrhage), Grey Turner
sign (flank ecchymoses indicative of retroperitoneal
hemorrhage)
Indications for laparotomy:
is it the cause of hypotension?
is peritonitis present?
Posible nonoperative treatment of diagnosed
intraabdominal injuries
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Diagnosic peritoneal lavage
– DPL
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Open and blunt technique:
decompress UB and stomach
gross blood  laparotomy
1l warmed normal saline  gentle agitation
of abd.  wait 10min.  drain fluid 
macroscopic evaluation  ev. lab testing
(positive > 100th RBC/mm3, 500 WBCs/mm3)
Interpretation in context of clinical condition
(positive DPL does not mandate laparotomy
in stable patient)
In pelvic fractures supraumbilical entry, safe
distance from postoperative scars
Complications: false positive, bowel
perforation, UB perforation, haemorrhage,
wound infection
Contraindications: advanced pregnancy,
clotting disorders, obvious indications to
laparotomy, planned FAST
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ER US
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FAST - Focused Assesement with
Sonography for Trauma
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Limited ultrasound examination directed
solely at identifying the presence of free
intraperitoneal or pericardial fluid
In the context of traumatic injury, free
fluid is usually due to haemorrhage and
contributes to the assessment of the
circulation
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FAST - Focused Assesement with
Sonography for Trauma
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Perihepatic & hepato-renal space
Perisplenic
Pelvis
Pericardium
Pleural space
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FAST - Focused Assesement with Sonography for
Trauma
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haemodynamic instability and free intra-peritoneal fluid mandates a
laparotomy for intra-abdominal haemorrhage.
in the presence of haemorrhagic shock but a negative FAST
examination, other sites of haemorrhage must be sought and
controlled  thoracic haemorrhage may require thoracotomy, pelvic
haemorrhage angiographic embolisation; retroperitoneal
haemorrhage from vascular injury remains a possibility with a
negative FAST.
serial FAST examinations may be required.
positive examination relies on the presence of free intraperitoneal
fluid, detects a minimum of 200 mL of fluid; injuries not associated
with hemoperitoneum may be missed (not reliable for excluding
hollow visceral injury).
cannot be used to reliably grade solid organ injuries - detection of
solid organ injury with FAST - 41% (consider CE US).
(in the hemodynamically stable patient a follow-up CT scan should
be obtained if nonoperative management is contemplated). more
cost-effective when compared with DPL or CT.
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Abd CT
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Abd. CT
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recommended for the evaluation of hemodynamically stable patients
with:
equivocal findings on PE
associated neurologic injury
multiple extra-abdominal injuries
under these circumstances, patients with a negative CT scan should
be admitted for observation
is the diagnostic modality of choice for nonoperative management of
solid visceral injuries
in hemodynamically stable patients, DPL and CT scanning are
complementary diagnostic modalities
notoriously inadequate for the diagnosis of mesenteric injuries and
hollow visceral injuries (DPL is a more appropriate test)
unique ability to detect clinically unsuspected injuries and ability to
evaluate the retroperitoneal structures
requires a cooperative, hemodynamically stable patient that must be
transported out of the trauma resuscitation area to the radiographic
suite, need for specialized technicians and the availability of a
radiologist for interpretation
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CT 2006
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One abdominal CT is the equivalent of 500 chest x-rays
and will increase the lifetime risk for cancer by 1 in
2000.
Oral contrast is not helpful in liver or spleen injuries, with
free fluid or bony injuries.
Oral contrast is not helpful in detecting hollow viscus
injuries or duodenal injuries. Instead, adds costs, time
delay, and the risk for aspiration.
Additional intangible costs include the risks associated
with contrast, electrolytes to check for renal function,
longer time in the ED (although CT scanning does save
time in complete spinal evaluations), and the cost of
working up incidental findings which may in turn lead to
more radiation exposure.
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Special diagnostic studies
Category
US
 Rapid
++
 Portable
++
 Non-invasive
++
 Integration in resuscitation
++
 Sensitivity
 Specificity
+
 Quantitative
+
 Injury localisation
+
 Evaluation of retroperitoneum+
 Evaluation of pericardium
++
 Ease of interpretation
+
 Ease of repetition
++
 Radiation exposure
++
 Patient acceptance
++
 Cost
++
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CT
+
+
++
++
++
++
+
+
+
Grala
DPL
+
+
+
++
+
++
++
+
Indications for laparotomy
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BAT with positive DPL, US, CT
BAT with recurrent hypotension despite adequate
resuscitation
Peritonitis
PAT with hypotension, or violation of peritoneum esp. in
patients with altered consciousness
PAT with bleeding from the rectum, GU tract or stomach
GSW (except selected flank wounds)
Evisceration
On X-ray: retroperitoneal free air, diaphragmatic inj.
Be overaggressive
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Diaphragmatic injuries
Difficult to estabilish the diagnosis (CT, DPL, US, chest
Xray – miss 30%)
Pysical exam: false neg result in 20-45%
Explorative laparotomy
Explorative thoracoscopy?
 Poor healing (chronic hernias): constant motion, relative
thinness, pressure gradient (intrathoracic transposition of
abd viscera)
 Potentially catastrophic consequences (usual delay up to
8 years): strangulation of abd viscera through the defect
(20-50% mortality rate)
 Usually posterolateral left diaphragm
 Chest X-ray: elevation, blurring, hemothorax, abn. gas
shadow obscuring the diaphragm
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Rupture of the left diaphragm
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Rupture of the right diaphragm
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Spleen
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Receives 5% of cardiac output (splenic a., short gastric aa.)
Accesory s. (between stomach and pancreas) 20%
Functions: removal of aged and deformed RBCs, platelet storage,
phagocytosis of bacteria (25% of bodys fixed tissue macrophages),
production of IgM (main source) and IgG, opsonins (tuftsin,
properdin)
Postsplenectomy complications: atelectasis (drainage, pulmonary
toilet), thrombocytosis (up to 3mill, aspirin above 1), granulocytosis,
subphrenic abscess, pancreatitis, pancreatic fistula, gastric
perforation
OPSI – lifetime risk, majority within first 2ys (flulike symptoms
rapidly progressing to fulminant sepsis with consumptive
coagulopathy and death within 12-48h)
mortality 50-60%
encapsulated bacteria (Str. pneum.,Neisseria mening.,H.infl.) are
causative – post op. immunization
loss of splenic reticuloendothelial cells (clear particulate antigen in
the absence of antibody), opsonin synthesis, decrease in
lymphocyte T4-T8 ratio → limited responce to infection
supportive management, high dose 3rd gen. cephalosporins
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Splenic injury CT
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Mesh splenorrhaphy
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Splenic laceration
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Liver trauma
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Most commonly injured organ (possible massive
haemorrhage)
Initial hemostasis: mobilisation, bimanual compression,
Pringle maneuver (oclusion time<45min.) → no↓ →
retrohepatic v. cava or hepatic v. inj. → atriocaval shunt
(Schrock shunt), Folley catheter, perihepatic packing
Definitive hemostasis: electocautery, parenchymal
sutures (horisontal mattress stitches), hepatotomy with
selective ligation (finger fracture technique), topical
hemostatic agents, omental packing, resectional
debridement, hepatic artery ligation
Damage control
Drainage
Blunt trauma: nonoperative approach (observation,
selective embolisation).
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Posttraumatic biloma
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Liver GSW
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Mesh hepatorraphy
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Femoro-caval (cavocaval) shunting
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Duodenum
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Usually unrestrained driver-frontal impact, direct
blow (eg.bike handlebars)
Bloody gastic aspirate, retroperitoneal air,
leftward scoliosis and blurring of psoas schadow
on X-ray, contrast CT
Slow evolution of abd symptoms: back or flank
pain
Laparotomy
Kocher maneuver, transverse, double layer
closure
Whipple procedure in d. devascularisation with
complex bile duct and pancreatic head injury
(high complication rate)
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Duodenal rupture
(750cc blood in ng tube,>50% circumferential tear)
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Duodenal acces, incision of the lig.
of Treitz
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Pancreas
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In 0.2% of BAT - direct epigastric blow (compression against VC)
and 1.1% of PAT. Penetrating pancreatic injury is usually diagnosed
at laparotomy and carries a high mortality because of associated
injuries of neighboring major blood vessels. Blunt pancreatic injury
is complicated by difficulty in establishing the diagnosis, which can
lead to delay in diagnosis and increased morbidity.
Serum amylase levels nondiagnostic
DPL, US, CT often nondiagnostic
ERCP
Celiotomy – associated stomach and liver involvement, Kocher
maneuver and gastrocolic and gastrohepatic ligament dissection
Determine presence of ductal injury: L to s. mesenteric vessels →
distal pancreatectomy with splenctomy, R → closure of proximal end
+ distal drainage (Roux-en-Y pancreaticojejunostomy
Extensive injury to the head of pancreas, duodenum, biliary tree →
pancreaticoduodenectomy (Whipple procedure)
Parenchymal lesions → drainage
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Pancreatic injury BAT CT
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Acces to the pancreas
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Small bowel
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Seat belts, direct blow or penetrating trauma
Minimal bleeding
Peritoneal signs (intoxicated or deeply
unconsious patients – absent)
US, CT nondiagnostic
Diagnosis - DPL and laparotomy
Primary repair or segmental resection and
anastomosis, close mesenteric defects
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Blunt bowel injury
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Blunt bowel injury
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Large bowel injuries
No physical findings or imaging modalities, no clinically useful combination
of findings that would reliably predict colonic injury.
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1.
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Colon
Usually penetrating trauma
Diagnosis at laparotomy (although BCI is rare, it ranks
4th among injuries found at laparotomy in BAT and is
an independent predictor of hospital and ICU LOS).
Debridement, drainage, wide spectrum antibiotic + :
primary 2 layer closure, excision, diverting colostomy
and Hartmann`s pouch considered in long operative
delay, severe fecal contamination, large transfusion
requirements (>4U), prolonged shock, high velocity
GSW
Rectum
Historic 3Ds: distal rectal washout, diverting
colostomy, presacral drainage – battlefield injuries
Civilian trauma: primary repair, colostomy
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RPH
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Penetrating trauma – require exploration (uncontained)
temoporary control: packing, cross clamping of
supraceliac aorta
gain acces: division of gastrohepatic lig., L medial
visceral rotation (Mattox maneuver), R visceral rotation
(Catell maneuver) with Kocher maneuver
direct repair, rarely grafting
Blunt trauma – CT, US or laparotomy for diagnosis
management determined by location and stability
Z I RPH (supramesocolic) – Mattox m.
Z II RPH (flank) – unless pulsatile, expanding or
ruptured do not explore
Z III RPH (pelvic) – as above, packing or angiographic
embolisation if required
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Cattel maneuver
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Mattox maneuver
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