Abdominal Trauma
Scott Reed, M.D.
Abdominal Trauma

“Abdomen”
– Derived from Latin word “abdere” which
means “to hide”
– Often referred to as “the black box.”
“Follow the clues”
Abdominal Trauma

Catagorized according to Mechanism
– Penetrating
Gunshot
 Stabbings

– Blunt
Motor vehicle / Motorcycle accidents
 Assault
 Falls
 Pedestrians struck

Abdominal Trauma
Trauma. Fourth ed. Mattox
Abdominal Trauma
Trauma, Fourth ed. Mattox
Abdominal Trauma


Major source of Morbidity and Mortality
Rapid Diagnosis is Key
– Autopsy study comparing two trauma systems
– 100 consecutive deaths
 San Francisco County – Trauma system where
all major injuries went to a Level I trauma
center
 Orange County – Transported to nearest
hospital
West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A
study of two counties. Arch Surg 114:455, 1979
Abdominal Trauma

San Francisco Co.
– 16 deaths – 1
considered preventable
– Missed Thor. Aortic
injury

Orange County
– 30 deaths- 22
considered preventable
– 10 of 22 died due to
shock from
unrecognized abdominal
injury
– 8 of 10 died in the first
6 hours
West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of
two counties. Arch Surg 114:455, 1979
Abdominal Trauma - Diagnosis

Physical Exam
– Requires neurologically intact patient
Pain / Tenderness
 Guarding
 Rebound / Peritoneal signs

– All that’s needed in penetrating
trauma
– All that’s needed in hemodynamically
unstable blunt trauma.
Abdominal Trauma – Diagnosis

Physical Exam
– Penetrating – Gunshot
wounds (high energy
injury)
Determining the trajectory
can give an idea of what is
injured
 Need even number of holes
and/or bullets on X-ray
 Must be careful since bullets
can “settle” to dependent
areas

Abdominal Trauma – Diagnosis

Physical Exam
– Penetrating – Stabbing (Low energy)
More difficult since there is only an entrance
and no “trajectory”
 Injury can be far from the injury
 May be all that is needed in hemodynamically
stable patients (observation). No good study
to pick up hollow viscus injuries.


Abdominal Trauma - Diagnosis
Ultrasound (F.A.S.T.)
– Focused Abdominal Sonogram
for Trauma
Really is fast (done in the trauma
bay)
 Non-invasive and can be repeated
 Only determines the presence of
fluid in the abdomen (between 80
– 95% sensitive)
 Not very specific (which organ) or
what type of fluid (blood, succus,
ascites)

Abdominal Trauma – X-Rays


Can show
evidence of free
air (hollow viscus
injury)
Can help
determine the
trajectory of the
missile
41 y/o female
S/P MVA
Level of the Aortic Arch
Abdominal Trauma - Diagnosis

Diagnostic Peritoneal Lavage (DPL)
– Has all but been replaced by FAST exam
– Inserted catheter into abdomen

Gross blood (10cc or more) - positive
– Instilled 1 liter normal saline

Over 100,000 RBC’s, 500 WBC, bile or fibers
of food on micro - positive
Abdominal Trauma - Diagnosis

Diagnostic Peritoneal Lavage
– Invasive – 1% injury rate
– Oversensitive (small amount of blood can
make a positive by micro) – 50cc
– Non-specific
– Problem in the era of non-operative
management of solid organ injury
– ? Role in CT with fluid but no solid organ
injury (? Hollow viscus injury)
Abdominal Trauma - Diagnosis

Computed Tomography (CT Scan)
– Started in mid-1980’s and has
revolutionize trauma care.
Sees more than just the abdomen (spinal and
pelvic fractures) Done in conjunction with the
head and C-spine.
 More specific (solid organ injury) and
examines the retroperitoneal areas (pancreas,
kidney, duodenum)
 Arterial injuries can be studied

Abdominal Trauma - Diagnosis

CT Scan – Drawbacks
– Misses hollow viscus injuries
– Can’t evaluate the diaphragm
– Involves IV contrast (allergic reactions
1:1000) and radiation
– Tough to run a code in a donut (need a
stable patient)
Abdominal Trauma - Angiography


Using catheters via a femoral /
brachial approach to occlude arteries
Used increasingly for solid organ injury
– Liver – Embolize either Right/Left hepatic
arteries (Liver has both arterial and portal
blood supplies)
– Spleen – Can be selective or embolize the
entire organ
Abdominal Trauma - Angiography


Can convert what would be a large and
bloody case into a easily managed situation
Doesn’t always work
– Now operating later on a sicker patient
– Can embolize too much and infarct other
vascular beds

All fluid isn’t blood – Can miss small bowel
injuries
Abdominal Trauma - Observation

Liver and Spleen injuries can be
observed
– Acceptable in minor injuries with minimal
bleeding seen on CT scan
– Have to observe VERY closely
Repeated abdominal exams
 Vital signs, dropping hematocrits

– Have to be ready to operate if needed
quickly
Abdominal Trauma - Diagnosis

Laparoscopy
– Excellent for stable stab
wounds (peritoneal
penetration/diaphragm injury)
– Hard to see everything
Can “run the bowel”
 hard to see retroperitoneum,
lesser sac, and assess liver /
spleen injuries

– Invasive, expensive
– may need to to open
Abdominal Trauma - Surgery

Once thought that all repairs needed
to be done at the initial surgery
– Long surgery / multiple repairs on
hemodynamically unstable patients
– Cold, Acidotic, Coagulopathic
– Patients died
Abdominal Surgery - Surgery

Damage Control surgery
– Stop the bleeding and contamination and
then get out.
Pack the liver
 Staple out injured small bowel/colon (no
anastamosis needed)
 Vascular shunts

– Leave abd open or just close skin
– Get to ICU for resuscitation/warming
Abdominal Trauma - Surgery

Damage Control Surgery
– After 24 to 48 hours go back to the OR

Patient is resuscitated, warm, stable
– Establish GI continuity
– Wash out areas of contamination
– Vascular repairs
– Patients live
Abdominal Trauma - Nursing

The Open Abdomen
– A clear, fenestrated plastic layer over the
bowel and viscera (Vi-drape)
– OR towel, Kerlex, or sponge in the dead
space
– Large drains in the gutters
– Cover entire opening with occlusive
dressing (Ioban)
– Place drains to suction
Abdominal Trauma - Nursing

Open Abdomen (VacPack, Blue Towel)
– Can be done fast in the OR
– Controls abdominal fluids (can measure)
– Prevents abdominal compartment
syndrome (more to follow)
– Can be taken down in ICU to allow
inspection of the abdomen
Abdominal Trauma - Nursing

Drains
– Placed in areas where fluid may collect.
Near an anastomosis
 Pancreatic injury

– Must look for changes in output
Increase could signal a leak, or sudden stop
could indicate the drain is clogged
 Type and quality of the fluid (suddenly
becomes bloody or bilious)

Abdominal Trauma – Nursing

Fistulas
– Abnormal connection between two
epithelialized compartments.
– Named for the two organs connected
Abdominal Trauma - Nursing

Fistulas
– Enterocutaneous (Small bowel to skin)
 Most common
 Usually involves the wound or incision
 Will see bowel contents in the wound
 Often due to surgical mishaps
Abdominal Trauma - Nursing



Colocutaneous (colon to skin)
Colovesicular (colon to bladder)
The stomach, pancreas, gallbladder,
arteries, and veins can all be involved
in fistulas
Abdominal Compartment Syndrome
Mechanism: Direct external pressure
on vascular structures,
diaphragm and abdominal wall
Abdominal Compartment Syndrome
What is normal?





At rest
Valsalva
Cough
Vomiting
Active lifting
0 – 5mmHg
60 – 80mmHg
80cmH2O
60cmH2O
Over 150mmHg
– During lifting the pressure is related to
the velocity of muscle contraction and
comes back to baseline once the
movement has ended
Abdominal Compartment Syndrome
Grading System




Grade
Grade
Grade
Grade
I
II
III
IV
10 – 15mmHg
16 - 25mmHg
26 – 35mmHg
>35mmHg
Abdominal Compartment Syndrome
Causes (Acute)
– Intra-abdominal







Bowel obstruction /
Ileus
Ruptured AAA
Mesenteric venous
obstruction
Abscess
Pneumoperitoneum
Intraperitoneal bleed /
trauma
Viseral edema

Retroperitoneal
– Pancreatitis
– Pelvic Frx/bleeds
– Ruptured AAA

Abdominal Wall
– Burn Eschar
– Massive hernia repair
– Closing the tight abdomen
Abdominal Compartment Syndrome
Constellation of Symptoms

Renal failure
– Decreased urine output

Respiratory failure
– Dec compliance, inc pulmonary edema / airway pressure

Cardiac failure
– Decreased cardiac output (dec preload / inc afterload)

Visceral failure
– Dec blood flow to liver, bowel (bacterial translocation)

Neurologic complications
– Increased intracranial pressure

Abdominal wall “failure”
– Dehissence, hernia formation
Abdominal Compartment Syndrome
Types


Primary
– hypertension (IAH) Secondary A process
within or involving the abdomen itself
which leads to increased intra-abdominal
Secondary
– IAH which results even though no direct
abdominal injury has occurred
– Often overlooked
– Strongly related to resuscitation fluids
(iatrogenic)
Saggi et. al Journal of Trauma 1998
Abdominal Compartment Syndrome
Measuring pressures

Bladder Pressure (gold standard)
– Clamp foley catheter
– Instill 50-100cc saline into bladder
– Use pressure transducer via sampling
port
 Accurate
– Corresponds well with direct
intra-abdominal catheters and
insufflation during laparoscopy
 Reliable and reproducible
Abdominal Compartment Syndrome
New Perspectives on Old Concepts
Abdominal Compartment Syndrome
EVMS Experience

Resuscitation greater than 12 liters in
the first 24 hours was a risk factor for
the development of secondary
abdominal compartment syndrome
R.C. Britt, et. al.
Balough, The
American J. of
Surg. 2003
Abdominal Compartment Syndrome
Possible Prevention Stratagies


ACS carries high mortality
Abdominal decompression also has
high morbidity and mortality
– At risk groups can be identified
 High
volume resuscitations (burns,
traumas)
 Pt’s post hemorrhage and shock
– ACP can be easily measured
Abdominal Compartment Syndrome
Peritoneal Catheter Placement
– Abdominal pressures over 20 mmHg
– Abdominal perfusion pressures (APP)
less than 50mmHg
 Abdominal
perfusion pressure equals
the mean arterial pressure minus the
abdominal pressure. (MAP – ACP =
APP)
Results – Total Group

Thirty minutes after the DPL catheter was
placed: (Avg starting ACP was 24.9mmHg)
– Average ACP decreased 7.7mmHg
(p=0.003)
– Average MAP increased 9.7mmHg (p=0.02)
– Average APP increased 17.4mmHg
(p=0.007)
– Average Pulm Compliance increased 7.9
(p=0.002)
Abdominal Trauma – Case Report

19 y/o male – motorcycle crash
– Multiple rib fractures
– Facial fractures
– Bilateral Tibia/fibula fractures
– Grade I spleen laceration
Abdominal Trauma – Case Report





Had both lower extremities repaired on
HD#2
Rib fractures managed with pain control and
pulmonary toilet
Facial fractures repair on HD#5
Spleen observed
Left ICU on HD#4 and went to floor
Abdominal Trauma – Case Report

Morning rounds HD#8
– HR – 70 to 80 bpm
– BP 120/75
– Using only Percocet for pain
– H/H – 11/33

Planning D/C home soon
Abdominal Trauma – Case Report

10pm Nurse called for increased pain in Left
Shoulder
– Determined this was a new complaint and
no shoulder injury was documented
– Repeated vital signs
 HR – 110
 BP – 95/50
 Patient was diaphoretic and pale
Abdominal Trauma – Case Report

Nurse immediately contacted house staff
with new complaints and vital signs
– Patients seen and examined
– Abdomen now tender with guarding
– Repeat H/H – 6.5/19
Abdominal Trauma – Case Report



Emergent Abdominal CT Scan revealed
massive hemoperitoneum and delayed
rupture of the spleen
Taken immediately to OR for emergent
splenectomy
Did well and was discharged on HD#13
Abdominal Trauma – Nursing Quote

“I don’t need to know exactly what is
wrong…I just need to know that
something is wrong”

My Mom