Abdominal Trauma
Cheryl Pirozzi, MD
Fellow’s Conference 5/4/11
Abdominal Trauma
• Penetrating Abdominal Trauma
– Stabbing 3x more common than firearm wounds
– GSW cause 90% of the deaths
– Most commonly injured organs: small intestine > colon > liver
• Blunt Abdominal Trauma
– Greater mortality than PAT (more difficult to diagnose,
commonly associated with trauma to multiple organs/systems)
– Most commonly injured organs: spleen > liver, intestine is the
most likely hollow viscus.
– Most common causes: MVA (50 - 75% of cases) > blows to
abdomen (15%) > falls (6 - 9%)
Rosen’s Emergency Medicine, 7th ed. 2009
Pathophysiology of injury
Penetrating Abdominal Trauma
• Stab Wounds
– Knives, ice picks, pens, coat
hangers, broken bottles
– Liver, small bowel, spleen
• Gunshot wounds
– small bowel, colon and liver
– Often multiple organ injuries,
bowel perforations
Rosen’s Emergency Medicine, 7th ed. 2009
Pathophysiology of injury
Rosen’s Emergency Medicine, 7th ed. 2009
Pathophysiology of injury
Blunt Abdominal Trauma
• Rupture or burst injury of a hollow organ by sudden rises in
intra-abdominal pressures
• Crushing effect
• Acceleration and deceleration forces → shear injury
• Seat belt injuries
– “seat belt sign” = highly correlated with intraperitoneal
injury
Rosen’s Emergency Medicine, 7th ed. 2009
Physical Exam
• Generally unreliable due to distracting injury, AMS,
spinal cord injury
• Look for signs of intraperitoneal injury
– abdominal tenderness, peritoneal irritation,
gastrointestinal hemorrhage, hypovolemia, hypotension
– entrance and exit wounds to determine path of injury.
– Distention - pneumoperitoneum, gastric dilation, or ileus
– Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
– Abdominal contusions – eg lap belts
– ↓bowel sounds suggests intraperitoneal injuries
– DRE: blood or subcutaneous emphysema
Rosen’s Emergency Medicine, 7th ed. 2009
Diagnostic studies
• Lab tests: not very helpful
• May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox
screen
Rosen’s Emergency Medicine, 7th ed. 2009
Imaging
• Plain films:
– fractures – nearby visceral damage
– free intraperitoneal air
– Foreign bodies and missiles
Rosen’s Emergency Medicine, 7th ed. 2009
Imaging
• CT
–
–
–
–
Accurate for solid visceral lesions and intraperitoneal hemorrhage
guide nonoperative management of solid organ damage
IV not oral contrast
Disadvantages : insensitive for injury of the pancreas, diaphragm,
small bowel, and mesentery
Rosen’s Emergency Medicine, 7th ed. 2009
Imaging
• Angiography
– To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma in an unstable pt
– Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma
Rosen’s Emergency Medicine, 7th ed. 2009
FAST
• Focused assessment with sonography for trauma (FAST)
– To diagnose free intraperitoneal blood after blunt trauma
– 4 areas:
• Perihepatic & hepato-renal space (Morrison’s pouch)
• Perisplenic
• Pelvis (Pouch of Douglas/rectovesical pouch)
• Pericardium (subxiphoid)
– sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid
• Extended FAST (E-FAST):
– Add thoracic windows to look for pneumothorax.
– Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)
Rosen’s Emergency Medicine, 7th ed. 2009
Trauma.org
FAST
• Morrison’s pouch (hepato-renal space)
trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009
FAST
• Perisplenic view
trauma.org
Rosen’s Emergency Medicine, 7th ed. 2009
FAST
• Retrovesicle (Pouch of Douglas)
• Pericardium (subxiphoid)
Rosen’s Emergency Medicine, 7th ed. 2009
trauma.org
FAST
• Advantages:
– Portable, fast (<5 min),
– No radiation or contrast
– Less expensive
• Disadvantages
– Not as good for solid parenchymal damage, retroperitoneum,
or diaphragmatic defects.
– Limited by obesity, substantial bowel gas, and subcut air.
– Can’t distinguish blood from ascites.
– high (31%) false-negative rate in detecting hemoperitoneum
in the presence of pelvic fracture
Rosen’s Emergency Medicine, 7th ed. 2009
Diagnostic Peritoneal Lavage
• Largely replaced by FAST and CT
• In blunt trauma, used to triage pt who is HD unstable
and has multiple injuries with an equivocal FAST
examination
• In stab wounds, for immediate dx of
hemoperitoneum, determination of intraperitoneal
organ injury, and detection of isolated diaphragm
injury
• In GSW, not used much
Rosen’s Emergency Medicine, 7th ed. 2009
Diagnostic Peritoneal Lavage
• 1. attempt to aspirate free peritoneal blood
– >10 mL positive for intraperitoneal injury
• 2. insert lavage catheter by seldinger, semiopen, or
open
• 3. lavage peritoneal cavity with saline
• Positive test:
– In blunt trauma, or stab wound to anterior, flank, or back:
RBC count > 100,000/mm3
– In lower chest stab wounds or GSW: RBC count > 5,00010,000/mm3
Rosen’s Emergency Medicine, 7th ed. 2009
Local Wound Exploration
• To determine the depth of penetration in stab
wounds
• If peritoneum is violated, must do more diagnostics
• Prep, extend wound, carefully examine (No blind
probing)
• Indicated for anterior abdominal stab wounds, less
clear for other areas
Rosen’s Emergency Medicine, 7th ed. 2009
Laparoscopy
• Most useful to eval penetrating wounds to
thoracoabdominal region in stable pt
– esp for diaphragm injury: Sens 87.5%, specificity 100%
• Can repair organs via the laparoscope
– diaphragm, solid viscera, stomach, small bowel.
• Disadvantages:
– poor sensitivity for hollow visceral injury, retroperitoneum
– Complications from trocar misplacement.
– If diaphragm injury, PTX during insufflation
Rosen’s Emergency Medicine, 7th ed. 2009
Management
• General trauma principles:
– airway management, 2 large bore IVs, cover penetrating
wounds and eviscerations with sterile dressings
• Prophylactic antibiotics: decrease risk of intraabdominal sepsis due to intestinal perf/spillage
– (eg zosyn 3.375 g IV)
• In general, leave foreign bodies in and remove in the
OR
Rosen’s Emergency Medicine, 7th ed. 2009
Management of penetrating abdominal
trauma
forsurenot.com
Management of penetrating abdominal
trauma
• Mandatory laparotomy
vs
• Selective nonoperative management
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
• Mandatory laparotomy
– standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
– Now thought unnecessary in 70% of abdominal stab
wounds
– Increased complication rates, length of stay, costs
– Immediate laparotomy indicated for shock, evisceration,
and peritonitis
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
• Selective management used to reduce unnecessary
laparotomies
• Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
• Strategy depends on abdominal region:
– Thoracoabdomen
• Nipple line to costal margin
– Anterior abdomen
• Xiphoid to pubis
– Flank and back
• Posterior to anterior axillary line
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Thoracoabdomen
• Big concern is diaphragmatic injury
– 7% of thoracoabdominal wounds
• Diagnostic evaluation:
–
–
–
–
CXR (hemothorax or pneumothorax)
Diagnostic peritoneal lavage
FAST
Thoracoscopy
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Thoracoabdomen
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
• Anterior abdomen
–
–
–
–
–
Only 50-70% of anterior stab wounds enter the abdomen
of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of PAT
• Anterior abdomen
Rosen’s Emergency Medicine 7th ed
Management of penetrating abdominal
trauma
• Back/Flank
– Risk of retroperitoneal
injury
– Intraperitoneal organ injury
15-40%
– Difficulty evaluating
retroperitoneal organs with
exam and FAST
– In stable pts, CT scan is
reliable for excluding
significant injury:
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Gunshot wounds
• Much higher mortality than stab wounds
• Over 90% of pts with peritoneal penetration have
injury requiring operative management
• Most centers proceed to lap if peritoneal entry is
suspected
• Expectant management rarely done
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosen’s Emergency Medicine 2009
Management of PAT
Gunshot wounds
• assess peritoneal
entry by missile path,
LWE, CT, US,
laparoscopy (all
limited)
Rosen’s Emergency Medicine, 7th ed. 2009
Management of Blunt abdominal trauma
ashwinearl.blogspot.com
Management of Blunt abdominal trauma
• Exam less reliable
• Diagnostic studies to determine if there is
hemoperitoneum or organ injury requiring surgical
repair
– FAST, CT, DPL
– In HD stable pts, CT is preferred
Rosen’s Emergency Medicine, 7th ed. 2009
Management of Blunt abdominal trauma
• Clinical Indications for Laparotomy after Blunt Trauma
MANIFESTATION
PITFALL
Unstable vital signs with strongly
indicated abdominal injury
Alternative sources, shock
Unequivocal peritoneal irritation
Unreliable
Pneumoperitoneum
Insensitive; may be due to
cardiopulmonary source or invasive
procedures (diagnostic peritoneal
lavage, laparoscopy)
Evidence of diaphragmatic injury
Nonspecific
Significant gastrointestinal bleeding
Uncommon, unknown accuracy
Rosen’s Emergency Medicine, 7th ed. 2009
Damage Control
• Patients with major exsanguinating injuries may not
survive complex procedures
• Control hemorrhage and contamination with
abbreviated laparotomy followed by resuscitation
prior to definitive repair
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
• 0. initial resuscitation
• 1. Control of hemorrhage and contamination
– Control injured vasculature, bleeding solid organs
– Abdominal packing
• 2. back to the ICU for resuscitation
– Correction of hypothermia, acidosis, coagulopathy
• 3. Definitive repair of injuries
• 4. Definitive closure of the abdomen
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Resuscitation in the ICU
• IVF (crystalloid, not colloid)
• Transfusion
– ?1:1:1 PRBC/plt/FFP
• Recombinant activated factor VII
– Increased thromboembolic complications
• Rewarming if hypothermic
• Correction of metabolic abnormalities
• Low tidal volume ventilation recommended (4-6 ml/kg)
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Open abdominal wounds and definitive closure
• 40-70% can’t have primary closure after definitive repair.
• Temporary closure methods
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Abdominal Compartment Syndrome
• Common problem with abdominal trauma
• Definition: elevated intraabdominal pressure (IAP) of
≥20 mm Hg, with single or multiple organ system
failure
– ± APP below 50 mm Hg
• Primary ACS: associated with injury/disease in
abdomen
• Secondary (“medical”) ACS: due to problems outside
the abdomen (eg sepsis, capillary leak)
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29
Abdominal Compartment Syndrome
• Effects of elevated IAP
– Renal dysfunction
– Decreased cardiac output
– Increased airway
pressures and decreased
compliance
– Visceral hypoperfusion
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
• Management
– Surgical abdominal decompression
– Nonsurgical: paracentesis, NGT, sedation
– Staged approach to abdominal repair
– Temporary abdominal closure
Bailey J. Crit Care 2000, 4:23–29
Sugrue M. Curr Opin Crit Care 2005; 11:333-338
Conclusions
• Watch out for implements and missiles violating the abdomen
• Laparotomy is mandatory if shock, evisceration, or peritonitis
• Diagnostic studies used to determine need for laparotomy in
PAT and BAT
• FAST is noninvasive, quick and accurate way to evaluate for
intraperitoneal blood
• Damage Control is a principle of staged operative
management with control and resuscitation prior to definitive
repair
• Abdominal compartment syndrome is a common problem in
abdominal trauma
References
• Biffl WL, Moore EE. Management guidelines for penetrating
abdominal trauma. Curr Opin Crit Care 2010;16:609-617
• Waibel BH, Rotondo MF. Damage control in trauma and
abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S42130.
• Marx: Rosen’s Emergency Medicine, 7th ed. 2009 Mosby
• Sugrue M. Abdominal compartment syndrome. Curr Opin Crit
Care 2005; 11:333-338
• Bailey J, Shapiro M. Abdominal compartment syndrome. Crit
Care 2000, 4:23–29