The Initial Assessment and
Evaluation of Abdominal Trauma
Tanya L. Zakrison
Trauma & Acute Care Surgery
St. Michael’s Hospital
Sept. 20th, 2011
Objectives
• How to recognize the trauma patient with an
abdominal injury
– Anatomy
• How to manage the patient with an abdominal
injury in the initial stage
• Damage control resuscitation
• How to evaluate the abdomen
– Different modalities & whole body pan scan
• Guidelines
– European & EAST
Case 1 - Blunt Abdominal Trauma
• 45F, high-speed MVC
• Seat-belt sign, HD normal
• How would you approach this patient?
• How would that change if the pt. is HD abnormal?
• What if the patient also had a pelvic fracture?
Case 2 - Penetrating Abdominal Trauma
• 23M, stab wound to anterior abdomen, HD
normal
• How would you approach this patient? GSW?
• How would that change if the patient is HD
abnormal?
• What if the patient was stabbed in the flank? The
back? The thoracoabdominal area? Cardiac box?
ATLS Approach
• A – intubation may be required if hypotensive
• B – watch H/PTX in both blunt and penetrating
TAA injuries
• C – start with 2 L crystalloid, may need to
activate MTP – MUST FIND & STOP THE
BLEEDING
• D – may see associated thoracolumbar #s with
BAT
• E – watch for SBS, other injuries
What is Hemodynamic Normality?
Base deficit
lactate
Shock?
•
•
•
•
Rapid responder (20%)
Transient responder (30%)
Non-responder (>30%)
Hypotension in the field
– ATLS - 2L warmed crystalloid
(3:1)
– Blood products as needed
– Tranexamic acid (antifibrinolytic)
– Follow urine output
The Lethal Triad of Death
More Complicated Than Anticipated –
Acute Coagulopathy of Trauma Shock
25% of trauma patients present coagulopathic
Damage Control Resuscitation
• Permissive hypotension
• 1:1:1 resuscitation (pRBCs, platelets, FFP)
• Damage control surgery
– Stop the bleeding (pack)
– Control the contamination
– Definitive surgical anatomical restoration later
Initial Resuscitation – The Bottom Line?
• Identify what is bleeding:
– “4 & on the floor”
1.
Chest
1. CXR
2.
Intraperitoneal abdomen
1. FAST
3.
Retroperitoneal
abdomen
1. PXR, CT scan
4.
Extremities – (femur #s)
1. XRs
• Then stop it:
–
–
–
–
OR
Angioembolization
Tourniquet
Reduction & stabilization
• Very little to do in the
trauma bay prior to OR if
HD abnormal:
– Intubate
– CXR
– Group & screen
• If crashing:
– Bilateral chest tubes
• If dying:
– ED thoracotomy
• Get to OR ASAP
Initial Management of the Bleeding Patient
– European Guidelines; CC 2007
• Recommendation 1:
– That time elapsed between injury and operation be minimized
for pts. In need of urgent surgical control (grade1A)
• Recommendation 2:
– That a grading system be used to assess the clinical extent of
hemorrhage (ACS COT)
• Recommendation 3:
– pts. presenting in hemorrhagic shock AND an identified source
of bleeding undergo an immediate bleeding control procedure
UNLESS initial resuscitation measures are successful
• Recommendation 4:
– pts. with an unidentified source of bleeding in hemorrhagic
shock should undergo immediate further assessment
• Recommendation 5:
– Trauma pts. should be resuscitated initially with crystalloid to a
BP of 80-100 mmHg in the absence of TBI
Tanya’s guidelines:
Find what is bleeding
then stop it
Patient in Extremis = ED Thoracotomy
The Abdomen
 Thoracoabdominal area
 Transverse nipple line to costal
margin
 Anterior abdomen
 Costal margin to groin crease
to anterior axillary lines
bilaterally
 Flank area
 Anterior axillary line to
posterior axillary line, costal
margin to iliac crests
 Back
 Medial to posterior axillary
lines, tip of scapula to iliac
crests
 Torso
 All the above
Cardiac Box
Mediastinum
Thoracoabdominal area
The Abdomen is More Than Just the
Abdomen
• Abdomen:
– Intraperitoneal cavity
•
•
•
•
•
•
Clinical exam
FAST
DPL
CT scan
Exploratory laparoscopy
Exploratory laparotomy
– Retroperitoneal cavity &
pelvis
• Pelvic xray
• CT scan
• Exploratory laparotomy
• Thorax
(thoracoabdominal
injuries)
– CXR
• Heart & Great Vessels
(cardiac box injuries)
– Cardiac FAST
– CXR
• Diaphragm & Bladder
(innocent bystanders)
– Diagnostic laparoscopy
– CT cystogram
Blunt Abdominal Trauma
Why investigate?
• Unlike penetrating trauma, diagnosis of BAT by
clinical exam is unreliable, esp. decreased LOC
• Late diagnosis of missed injuries leads to
increased mortality rates
• Large prospective study- 10% of patients with no
clinical signs of injury had injuries found on CT
• Consensus guidelines suggest that the threshold
for investigation of BAT should be very low –
EAST, 2002
Tools Available For Abdominal Trauma
•
•
•
•
•
•
•
Physical exam
X-Rays
Ultrasound (FAST)
Computerized Tomography (CT)
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory laparotomy
Tools Available For Abdominal Trauma
• Physical exam – bad for blunt, good for
penetrating (serial physical exams)
• X-Rays
• Ultrasound (FAST) – helpful if positive
• Computerized Tomography (CT) – not for HVI
• Magnetic Resonance Imaging (MRI)
• Diagnostic Laparoscopy – for the diaphragm
• Exploratory Laparotomy – if needed
What Are We Worried About?
• Bleeding:
–
–
–
–
Liver
Spleen
Kidneys
Mesentery
• Bowel:
– Contamination
• Bladder:
– Intraperitoneal rupture
• Diaphragm:
– Mainly on the left side
How to Investigate Blunt Abdominal
Trauma? – BMJ 2008
• Concealed or occult hemorrhage is the 2nd
most common cause of death after trauma
• Missed abdominal injuries are a frequent
cause of morbidity and mortality
• Appropriate and expeditious investigations are
important
• Non-operative management of solid organ
injury now more common
Physical Exam
• Neither sensitive nor specific to rule out intraperitoneal hemorrhage (bleeding)
• Excellent to watch for the development of
peritonitis (contamination)
– Less than 24 hours, usually by 13 hours
– A modality usually employed in penetrating
trauma
• Very poor to detect bladder or diaphragmatic
injury
Seat Belt Sign – Not Just the Abdomen
Physical Exam Caveat –
The Seat Belt Sign
• Historically indicative of significant intra-abdominal
injury
– Especially when accompanied by a Chance fracture (L2
flexion distraction fracture) (up to 30-50% pts.)
– Can occur together or in isolation on the neck, chest or
abdomen
– Indicative of carotid, thoracic or intraabdominal injuries
• Hollow viscus injuries
• Retroperitoneal injuries (duodenum and pancreas)
• Solid organ (tearing of the falciform ligament)
– Odds of intraabdominal injury increased 2.6x if SBS
present on passenger seated in the front seat – Coimbra,
2009
Focused Assessment With Sonography
in Trauma (FAST)
• Looks for free intra-abdominal fluid (assumed to be blood
or gastrointestinal content, may be other)
– Also pericardial fluid
• Non-invasive, no radiation, repeatable
• Highly Sn (79-100%) and Sp (96-100%)
– Moreso in hemodynamic pts. after BAT
– Repeating FAST also increases Sn
• May still need other imaging modalities with a negative
FAST
• Can be performed with equal accuracy by surgeons
• Use controversial in penetrating trauma of the abdomen
– Only helpful if positive
– VERY helpful for detecting intrapericardial blood
• UABCDE
FAST
Diagnostic Peritoneal Lavage (DPL)
• Described in 1965, standard of care
• Open or closed (Seldinger) approach
• Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)
– Lead to a non-therapeutic laparotomy rate of 36%
• Laparotomy when:
– 10 cc gross blood
– Enteric contents
– 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3
• High false positives with pelvic fractures
– Do a supraumbilical approach
• High Sn for hollow viscus injuries
– Moreso than CT
• Risk of visceral injury = 0.6%
• Retroperitoneum can’t be assessed
Diagnostic Peritoneal Lavage
• In real life:
– Good tool if FAST equivocal
in the HD abnormal pt. in
the setting of a pelvic
fracture
– FAST unavailable, pt. is HD
abnormal
Computerized Tomography
• Imaging modality of choice only in HD normal patients
– Pts crumping in CT a performance indicator in trauma centres
• Sn = 92-97%, Sp = 99% for bleeding
– Active arterial contrast extravasation, blush or
pseudoaneyurysm
– Even with AKI, or in the elderly
• Only modality to directly detect retroperitoneal injury
• Less accurate for HVI
– Still need serial physical exams
– If pelvic fluid is present in absence of solid organ injury –
exploratory laparotomy is mandated, especially if moderate or
large amounts of free fluid – Chen, 2009
– 3% males may have pelvic fluid 2dary to resuscitation
• Poor test to diagnose diaphragmatic injury
Computerized Tomography
• Effect of whole-body CT during trauma
resuscitation on survival: a retrospective,
multicentre study
– Huber-Wagner et al., Lancet 2009
– Relative risk of mortality in blunt trauma reduced
by 25% according to TRISS
– NNT = 17
– Whole-body CT an independent predictor of
survival
Hypovolemic Shock Complex
Indications for Laparotomy –
Blunt Abdominal Trauma
Absolute Indications:
1.
2.
3.
4.
5.
Shock
Peritonitis
Blood out of NG tube or on rectal exam
Intraperitoneal bladder rupture
Diaphragmatic rupture
Initial Management of the Bleeding Patient
– European Guidelines; CC 2007
• Recommendation 6:
– Early FAST for the detection of FF in patients with
suspected torso trauma
• Recommendation 7:
– Pts. with significant FF on FAST with hemodynamic
instability should undergo urgent surgery
• Recommendation 8:
– HD normal pts. with suspected head, chest and/or
abdominal bleeding following high-energy injuries should
undergo further assessment using CT
• Recommendation 9:
– Single Hct is not helpful; lactate or base deficit is helpful to
estimate and monitor the extent of bleeding and shock
BAT & Pelvic #
• May have ongoing bleeding from the
abdomen, pelvis (retroperitoneum) or both
• FAST used for intraabdominal bleeding
• PXR for pelvic fractures (APC, VS, LC)
• Abdomen trumps pelvis (80-90% venous
bleeding)
– Pelvic bleeding should subside with stabilization in
the majority of cases
– Laparotomy done first if FAST positive
Open Book Pelvic Fracture
Pelvic Fracture has large potential
space for hemorrhage
Col (ret) Mark W. Bowyer MD
Close Pelvis – Many Devices
Available to Close Pelvic Ring
Surgical consult
Pelvic wrap
Intraperitoneal gross blood?
Yes
No
Laparotomy
Angiography
Control hemorrhage
Fixation device
Initial Management of the Bleeding Patient
– European Guidelines; CC 2007
• Recommendation 10:
– Pts. in shock with pelvic ring fractures should undergo
immediate closure and stabilization
• Recommendation 11:
– If ongoing instability, proceed to early angioembolization or
surgical bleeding control such as packing
• Recommendation 12:
– Early bleeding control must be achieved by packing, direct
surgical bleeding control, the use of local hemostatic
procedures. If pt. is exsanguinating, aortic cross-clamping may
be employed as an adjunct
• Recommendation 13:
– Damage control surgery should be employed in the severely
injured pt. with signs of shock, ongoing bleeding and
coagulopathy
EAST Guidelines – Evaluation of Blunt
Abdominal Trauma, 2001
• Level I:
– Exploratory laparotomy is indicative for patients with a
positive DPL
– CT is recommended for the evaluation of hemodynamically
stable patients with equivocal findings on physical
examination, associated neurologic injury, or multiple
extra-abdominal injuries. Under these circumstances,
patients with a negative CT should be admitted for
observation (i.e. contamination)
– CT is the diagnostic modality of choice for non-operative
management of solid visceral injuries (i.e. bleeding)
– In HD stable patients, DPL and CT are complementary
diagnostic modalities
EAST Guidelines – Evaluation of Blunt
Abdominal Trauma, 2001
• Level II:
– FAST may be considered as the initial diagnostic
modality to exclude hemoperitoneum
– Exploratory laparotomy is indicated in HD unstable
patients with a positive FAST
– If HD stable with a positive FAST, follow up CT permits
nonoperative management of select injuries
– Surveillance studies (DPL, CT, repeat FAST) are
required in HD stable pts. With indeterminate FAST
results
Tanya’s Summary - BAT
• In stable – go to the OR for a laparotomy
– If you are worried about contamination (HVI)
• Fluid in the pelvis in absence of SOI
– If you are worried about an intraperitoneal
bladder injury or large diaphragmatic injury
• In unstable – go to the OR for a laparotomy
– If the bleeding is in the abdominal cavity
– If the bleeding is in the pelvis for packing as still
ongoing after stabilizing
Penetrating Abdominal Trauma
ATLS Approach
• A – intubation may be required if hypotensive
• B – watch H/PTX in both blunt and penetrating
TAA injuries
• C – start with 2 L crystalloid, may need to
activate MTP – MUST FIND & STOP THE
BLEEDING
• D – may see associated thoracolumbar #s with
BAT
• E – watch for SBS, other injuries
Penetrating Abdominal Trauma
• Violation of peritoneum
– Therefore risk of intraabdominal injury that
requires surgery
•
•
•
•
Caused by stab wounds
Caused by gun shot wounds
Caused by shot gun wounds
Caused by other
penetrating objects
How common are injuries that require
surgical repair?
 Anterior abdominal stab wounds:
 25-33% will need a laparotomy
 Posterior or flank stab wounds:
 15% will need a laparotomy
 Anterior gun shot wounds:
 58-75% will need a laparotomy
 Posterior gun shot wounds:
 33% will need a laparotomy
Indications for Laparotomy –
Penetrating Abdominal Trauma
Absolute Indications:
1.
2.
3.
4.
5.
6.
Shock
Peritonitis
Evisceration
Weapon still in situ
Blood out of NG tube or on rectal exam
Gross hematuria
Penetrating Abdominal Trauma –
When to Operate in Stab Wounds?
1. Shock
–
PPV = 80% for
therapeutic laparotomy
2. Peritonitis
–
PPV = 85% for
therapeutic laparotomy
•
•
Local (50%)
Diffuse (81%)
3. Evisceration
–
PPV = 75% for
therapeutic laparotomy
•
•
Intestinal (100%)
Omental (76%)
Stab Wounds –
Anterior Abdominal Wall
 Not all stab wounds to the anterior abdominal
wall (AAW) will have:
 Violated the peritoneum
 Caused intraabdominal injury requiring operative
repair
 Up to 50% of stab wounds to the AAW will not
violate the peritoneum
 Up to 50% that violate the peritoneum do not cause
injury requiring operative repair
Stab Wounds –
Anterior Abdominal Wall
1. Local Wound Exploration (LWE)
– Sterile procedure with local anesthetic
2. Serial Physical Examinations (SPE)
– Done by same clinician to assess for the
development of peritonitis
3. Focused Assessment with Sonography for
Trauma (FAST)
– ‘Not indicated’ in penetrating trauma
4. Diagnostic Peritoneal Lavage (DPL)
– Not done in many centers
Stab Wounds –
Anterior Abdominal Wall
5. Computerized Tomography (CT)

Historically not used for anterior abdominal stab
wounds
▪
More useful in penetrating injury to the flank and back
6. Diagnostic Laparoscopy

Used to rule out:
▪
▪
Peritoneal penetration
Diaphragmatic injury on left side
7. Exploratory Laparotomy

Still the gold standard in ruling out intra-abdominal
injury
Pitfalls
1. DPL:
–
–
–
–
Cumbersome
Sensitivity poor for hollow viscus injury
Different criteria for positive tests in different centers
Positive test for RBC’s does not equate to needing a
therapeutic laparotomy
•
Many solid organ injuries managed non-operatively now
2. FAST (Soffer, 2004):
– Very limited role in penetrating abdominal trauma
– Rarely changes management, even if positive (1.7%)
Pitfalls
3. Diagnostic laparoscopy:
– Only identifies peritoneal violation
– Not sensitive for hollow viscus or retroperitoneal
injury
– Automatic conversion to laparotomy will still
result in a high non-therapeutic rate
– Still largely reserved to rule out diaphragmatic
injury with left thoracoabdominal SWs
•
30% will have an injury to the diaphragm
–
Caution: 10% develop a tension pneumothorax
intraoperatively if no chest tube in place
Non-Operative Management of Stab Wounds –
EAST 2010
1.
2.
3.
4.
Hemodynamically stable
No peritonitis or diffuse abdominal pain
In a center with surgical expertise
Patient is evaluable*
*Evaluable: absence of brain or spinal cord
injury, intoxication or need for sedation or
anesthesia
•
20% of patients selected for NOM will fail
(Clarke et al., 2010)
Stab Wounds Flank and Back
 Laparotomy used to be standard of care
 Phillips, 1986
 CT first reported for SWs to flank & back
 Fletcher, 1989
 Non-operative management with 3CT in 76% of
patients with SWs to flank & back
 Jurkovich et al, 2009
 Triple contrast CT scan has replaced DPL
 Evaluates retroperitoneum as DPL cannot
 Now mandatory laparotomy replaced with triple
contrast CT scan for stab wounds to flank and
back
 Some centers advocate IV contrast only is necessary
Thoracoabdominal Stab Wounds
• Historically, 33% of patients with left
thoracoabdominal stab wounds with have a
diaphragmatic injury
• Murray, 1998
– Prospective study of left throacoabdominal SWs
– Diaphragmatic injury in 26% of patients who had no
indication for laparotomy
– Patients with left thoracoabdominal stab wounds may
be observed for 12 hours
• If no need for laparotomy by that time, may repair
diaphragm using laparoscopic techniques
CT Scan for Anterior Abdominal Wall
Stab Wounds
 Not well defined, evolving modality
 Does not add much to serial physical exams
 Poor test for:
 Hollow viscus injuries
 Diaphragm injuries
 Use if:
1. High suspicion of solid organ injury (liver, spleen,
kidney) based on wound location (R or LUQ)
2. Positive FAST exam
3. Hematuria
• While selective management of anterior
abdominal stab wounds is appropriate...
• Selective management of anterior abdominal
GSWs is still controversial
• But this can reduce the rate of nontherapeutic
laparotomy from 30-50% to 5-10%
Non Operative Management of Gun Shot
Wounds – Guidelines (EAST) 2010
1. Hemodynamically stable
2. Tangential wound
3. No peritoneal signs
4. Consider only if patient is evaluable
5. Exception if GSW to RUQ
Non Operative Management of Gun Shot Wounds to
Right Upper Quadrant (Non-Tangential) - Guidelines
• Absolute indications:
1.
2.
3.
Hemodynamically stable
Patient is evaluable*
Minimal to no abdominal
tenderness
* Evaluable: absence of
brain or spinal cord injury,
intoxication or need for
sedation or anesthesia
EAST Guidelines 2010
• Patients with GSWs who are selected for initial
non-operative management should have other
diagnostic tests
• This should be an abdominal pelvic CT scan to
facilitate initial management decisions
Is a Non-Therapeutic Laparotomy Bad?
• Ventral incisional hernia rate 5 - 20%
• Lowe et al., 1972
– 245 pts. with negative or non-therapeutic laparotomies after mainly
penetrating trauma
• 20.4% complication rate (evisceration in 4 pts.)
• 1.6% mortality rate related to unnecessary laparotomy
• Demetriades, 1993
– 11% of non-therapeutic laparotomies with major complications
– LOS = 4.1 days if no complications vs. 21.2 days if complicated
• Renz & Feliciano, 1995
– Complications in 41.3% of 254 pts. with laparotomies for trauma
• Velmahos et al, 2001
– $ 9.5 million saving with NOM over 8 years, 1856 pts. with GSW
How long to observe?
• Patients with penetrating abdominal injuries
selected for NOM should be observed for 24
hours
• They may be discharged after 24 hours in the
presence of a reliable physical exam and minimal
to no tenderness
• The majority of asymptomatic patients who failed
NOM after SWs did so within 12 hours Alzamel et al,
2005
• 24 hours still recommended by most centers
Inaba & Demetriades,2007
Summary – Stab Wounds to Abdomen
• Non-operative management if no:
– Shock, peritonitis, evisceration & patient
evaluable
• LWE as per clinician preference
– May discharge patient home if no fascial violation
• Serial physical exams by same clinician X 24
hours
– Watch for peritonitis, discharge home if minimal
or no pain
Summary – Stab Wounds to Abdomen
• CT scan if
– SW to R or LUQ to rule out solid organ injury
– SW to flank or back as CT may rule out peritoneal
violation
• May send home after or..
– May observe patient after CT for 24 hours nonetheless
• Delayed laparoscopy after 12 hours of observation if
– TAA SW to left upper quadrant to identify and repair any
diaphragmatic injury
Summary – GSW to Abdomen
• Non-operative management if no:
– Shock, peritonitis, evisceration & evaluable
• All patients undergo CT scanning
– Anterior abdomen, flank or back
– If GSW tangential (no peritoneal breach) & no
peritoneal signs, patient may be discharged home
– If solid organ injury, may manage non-operatively
• Consider repeat imaging in 7 days to manage
asymptomatic complications in 50%
– If hollow viscus injury, proceed with laparotomy
– If no apparent injury, observe for 24 hours
Summary – Penetrating Abdominal
Trauma
• Low threshold to operate
• Don’t forget trauma to thoracic structures if
TAA
• FAST only helpful with bleeding if positive
– Always do a pericardial FAST if close to the box
• CT only helpful with bleeding
– Less so with HVI
• Serial physical exams helpful in all
Thank you!
zakrisont@smh.ca