Abdominal Trauma
Epidemiology
High risk: lower rib # (# 8-10th ribs has 20% assoc risk of splenic inj), major inj to chest/pelvis, high speed MVA, ped vs car, fall >standing height, class
II/III shock, inj on bilateral sides of abdo
Paeds: bladder/liver/spleen less protected, less abdo wall fat, mobile omentum for deceleration inj
10%
Assessment
Investigation
1 in 10 trauma deaths due to abdominal trauma (
)
Missed intra-abdo inj major cause of preventable death in trauma patients; should occur during C of ABC
History: AMPLE history
Examination: Localised tenderness 85-90% sens, 45% spec; unreliable if altered LOC / spinal inj / retroperitoneal inj; significant trauma often occurs in
absence of external signs; lap belt mark (Chance #, SI inj, pancreatic inj); PR (frank blood, high riding prostate, # palpation), PV, blood; unexplained
hypotension, change in BP with time and IVF; local exploration of penetrating wound (deep fascia breeched? Peritoneum breeched?)
Indications for imaging: abdo tenderness, macroscopic haematuria, unexplained hypoV assoc with altered LOC / lower rib # / multiple distracting
injuries
FAST: aim to identify FF and pericardial effusion
Sens and spec: 96% sens for >800ml FF, 90% sens for >250ml FF; 95% spec
100% sens, 96% spec, 100% NPV for determining need for laparotomy in hypotensive pt
insufficient sens to rule out significant inj in stable patient
Areas viewed: hepato-renal interface (Morrison’s pouch), spleno-renal interface, L+R CP angle, Pouch of Douglas, pericardium
Pros: bedside test, quick, cheap, repeatable, sensitive in experienced hands; can detect 250ml FF; can look at ascending aorta, good quantification of
intraperitoneal blood loss and damage to liver/speen, may get some info on retroperitoneal structures; suitable for screening mass casualties;
non-invasive
Cons: obese, unfasted, bowel gas, subC emphysema make hard; operator dependent, not available in smaller centres, low sens for less
severe inj; FF non-specific; poor view of retroperitoneum, hollow viscus, diaphragm; requires training
CT: Pros: excludes intra-abdo haem requiring OT; grades inj to determine need for OT; can be done with other CT; lower complication rate than DPL;
less false +ives; good view of solid organs, retroperitoneum, bones, chest, pelvis; non-invasive; provides anatomical info; gives indication of
renal perfusion and function
Cons: not suitable for unstable patients; false –ives for hollow organs; done in CT; access to pt; upper limb inj may make hard to get through
scanner; contrast scan; cost; low sens for intestinal / pancreatic / bladder / diaphragm inj
DPL: pass IDC and NGT  infraumbilical incision, visualise peritoneum, incise peritoneum  insert catheter angling towards sacrum  aspirate fluids
(if blood, +ive, up to 5ml clear fluid OK)  instil 1L N saline (10ml/kg in children)  tilt head and agitate abdo, leave for 5mins  drain fluid  remove
at least 600-800ml, then take sample for cell counts.
+ive = >20ml (>10ml in children) frank blood on free aspiration
>100,000 RBC/ml if blunt
>5000 RBC/ml if penetrating
>500 WBC/ml (if <3hrs since inj)
bile / food particles
exit of lavage fluid out of other catheters
?=
pink fluid of free aspiration
-ive = clear aspirate
50,000-100,000 RBC/ml blunt
100-500 WBC/ml
<100 WBC/ml
Pros: 98% sens for haemoperitoneum; better than CT for SI inj; bedside; quick; cheap; minimal training; good in mass casualties (can do on multiple
patients); good in unstable patients
Cons: CI in pregnancy, multiple abdo scars, local contamination; invasive; high sens, low spec (30% non-therapeutic laparotomy rate); misses
retroperitoneal injs; requires NG and IDC; provides no anatomical info; 15% false +ive with pelvic inj; false –ive if contained haematoma; 1%
complication rate; may introduce intraperitoneal air; makes subsequent CT scanning difficult to interpret; rarely used therefore out of practice
CXR: free subdiaphragmatic gas, abdo viscera in chest, elevated hemidiaphragm, pleural effusion
AXR: low sens and spec; detects FB’s, free air, ileus; for splenic inj: LUQ ST mass, displacement of splenic flexure / stomach / L hemidiaphragm,
obliteration of psoas shadow, fluid between adjacent loops of bowel
Others: cystogram; NG contrast and XR for duodenal inj; ureteric contrast; angiography for pelvic
Mng
Laparotomy in blunt trauma takes precedence over inj’s above diaphragm; if penetrating, only remove knife in OT
Indications for laparotomy in abdo trauma: blunt trauma with CV instability; haemodynamic instability despite appropriate resus; penetrating trauma
breeching peritoneum (2/3 breech); peritonism; evisceration; free gas of CXR; ruptured diaphragm; GSW; unstable patient with +ive FAST/DPL
Indications for emergent laparotomy: +ive FAST / DPL
Splenic trauma
40-55%
1st blunt
Epidemiology: most common organ inj from blunt trauma (in 40-55% cases; including in children); stronger in kids; delayed
rupture can occur after 2-14/7 (liquefaction of haematoma); high risk if lateral impact; RF for rupture: EBV, plasmodium vivax, splenomegaly
Assessment: guarding/tenderness may not be severe; L shoulder tip pain, scapular pain; assoc with 8-10th rib #’s
Ix: CT: gold standard (>95% sens, 100% spec); false +ive – congenital splenic cleft, low CO  non-homogenous perfusion, lack of delay after contrast
admin
USS: haematoma = hypoechogenic mass; perisplenic haematoma; FF
Trt: OT needed for grade III and above; IVF; 20% require blood transfusion; usually mng non-operatively; angiography effective in 80%
Indications for laparotomy: grade III/IV; grade I/II but other intra-ab inj suspected/confirmed, unstable, compound inj, failure of conservative trt
Liver trauma
40%
1st penetrating
2nd blunt
Epidemiology: most common organ inj from penetrating trauma; also from deceleration inj; often assoc with splenic inj; present in
40% blunt abdo trauma patients (40-55% for splenic)
Assessment: guarding/tenderness may not be severe; R shoulder tip pain; lower R rib fractures
Ix: CT gold standard in stable patient; LFT low spec if population has high incidence of abnormal LFT’s; in children, AST >400 / ALT >250 = 90% sens for
hepatic inj
Trt: OT needed for grade III and above; conservative (indicated in only 20% when blunt inj) if contained haematoma, unilobular fracture, no
devascularised segments, small amount FF
Damage control laparotomy: if severe; perihepatic packing to temporarily control bleeding  stabilise in ICU  OT 24-48hrs later; best if performed
<10iu blood transfused; complications = abdo compartment syndrome
Bowel trauma
5%
Epidemiology: blunt compression inj (present in 5% of such)
Mesenteric inj: mesenteric haematoma / vascular lac; CT 85-95% sens, 75% spec for need for OT; haematoma treated conservatively, beware ileus
SI inj: in 3% abdo inj; in 90% Chance # L spine (perf in 55%); tear in jejunum / ileum; often assoc with mesenteric inj; peritonism in 85% (may take hours
to develop); initial CXR 25% sens; serial CXR 60% sens; CT shows free gas (40%), FF, extravasation of PO contrast (5%); DPL shows incr WBC/RBC ratio
compared to plasma (>95% sens and spec); trt with NG and 1Y repair
Colonic inj: mortality 10%; OT for grade II or above; stoma if faecal contamination / shock / major destructive inj
Duodenal inj: penetrating inj, seatbelt inj; blunt inj more severe; fixated at duodenojejunal flexure and ampulla, shearing tear  submucosal
haematoma; severe if involvement >75% wall, 1st 2 parts of duodenum or CBD; incr amylase in 50%; erect AXR shows retroperitoneal gas (psoas and
renal outline visible), intraperitoneal gas, gas in biliary tree, scoliosis to R, obliteration of R psoas shadow, distension of stomach; do contrast studies;
OT if free perf; conservative if intramural haematoma without perf; 10% mortality from perforating inj, 15% from blunt; 10% duodenal
fistula rate
Pancreatic
trauma
Epidemiology: penetrating inj; if blunt, assoc with duodenal inj / severe multi-organ inj; more common in children, with lap belts, with Chance #
Ix: CT sens 50%, spec >90%; amylase – large no false +ives, 35% sens in blunt
Trt: blunt – manage as pancreatitis; penetrating – ERCP and OT
Adrenal
haemorrhage
2-5% incidence with blunt trauma; 95% unilateral, 80% R sided (as L adrenal vein doesn’t drain directly into IVC); assoc with chest inj in 65%; usually
Urogenital
trauma
Renal: most common
conservative trt, embolisation if ongoing haem
urological organ injured (ie. 92% are contusions) (occurs in 2-5% blunt trauma, 10% of paeds); 70-80%
are blunt; diagnosis often delayed
Clinically significant = macroscopic haematuria, CV instability, loin tenderness; if microscopic haematuria  repeat in 1-2/52 (if penetrating,
investigate immediately)
Ix with contrast CT (USS sens 30%; IVP has lower sens and spec than CT; MRI differentiates perirenal from intrarenal, age of bleed better than CT
therefore use if equivocal findings)
Grade I and II - conservative trt; 30% risk of delayed bleed if grade III trted conservatively; grade II/III, 15/75% require OT (grade III, OT if CV
unstable, ongoing transfusion requirement, or needed for other inj; OT for grade IV and V ); grade III/IV/V, 5/10/85% r
require nephrectomy
Bladder: in 10-15% pelvic inj; 2nd most common GU inj; 85% assoc with pelvic #; usually blunt (defect will be larger than in penetrating); usually of
dome; macroscopic haematuria present in >95%; either dome inj with intraperitoneal leak (occurs from blunt force with full bladder), or body inj with
intrapelvic (extraperitoneal) leak (assoc with pelvic #), or contusion (partial thickness without rupture)
Ix with cystography (at least 300ml contrast into bladder; if intraperitoneal, extravasates to pericolic gutters, around liver; if extraperitoneal, found
in pelvis; 80% sens, 99% spec for intraperitoneal rupture); CT cystography if other inj suspected
Transurethral catheter better than suprapubic; OT if dome, conservative if body (catheterisation and expectant mng)
Urethra: more common than bladder inj, more common in males; usually blunt; usually below urogenital diaphragm
50% have no physical signs <1hr; may track over abdo wall, but not thigh; high riding prostate in 2%; if not perineal trauma, nearly all assoc with pelvic
# (esp displaced sup pubic ramus, SI jt, bilateral sup and inf pubic ramus); usually PVB if female
Ix with urethrogram (if high riding prostate / boggy haematoma on PR, then urethrogram is unneccessary as there is definitely post rupture)
If minor, manage conservatively (scope guided catheterisation); if major, suprapubic catheter and OT
Ureter: penetrating; rare; initial haematuria in only 75%; Ix with CT or retrograde ureterogram; 50% distal 1/3, 50% prox 2/3; 25% grade II,
>50% grade III; requires OT
Scrotum: intratesticular bleeding  pressure necrosis; may cause intra-testicular haematoma (40-50% risk of infection / testicular necrosis), tunica
albuginea rupture and haematocoele contained by tunica vaginalis suggesting testicular rupture
USS may underestimate severity, may miss small tear in tunica albuginea
Conservative trt if no testicular haematoma (RIcE); indications for OT (immediate exploration - orchidectomy rate 5%, short hospital stay, decr
disability) = testicular haematoma, haematocoele, rupture of tunica albuginea, penetrating trauma
Notes from: Dunn, computer notes, Cameron
Italics = requires OT
Organ
Spleen
Liver
I
II
III
Subcapsular
haematoma <10% SA
Subcapsular haematoma
10-50% SA
Subcapsular haematoma >50% SA or
expanding
Capsular lac <1cm
depth
Lac 1-3cm depth not
involving trabecular BV
Lac >3cm depth or involving trabecular BV
Single/multiple lacs not
involving hilum
Ruptured subcapsular / intraparenchymal
haematoma
Intraparenchymal
haematoma >5cm or expanding
Subcapsular haematoma >50% SA or
expanding
Subcapsular
haematoma <10% SA,
non-expanding
Subcapsular haematoma
10-50% SA, nonexpanding
Intraparenchymal
haematoma <2cm
Capsular lac <1cm
Lac 1-3cm depth or active
IV
V
Lac involving segmental /
hilar vessels with <25%
devascularisation of
spleen
Shattered spleen
Ruptured subcapsular
haematoma with active
bleeding /
Injuries to major hepatic
vessels without avulsion
Lobular tissue
Hepatic
avulsion
100%
mortality
Expanding central
haematoma
Lac >3cm depth or active bleeding
V!
Hilar vascular inj with
devascularisation of spleen
Lobular tissue destruction
depth involving only
parenchyma, not
bleeding
bleeding; <10cm length
25% mortality
Colon
Contusion /
haematoma without
devascularisation
destricution >50% hepatic
lobe
>50% of hepatic lobe
lesions of both hepatic lobes
30% mortality
Transection
66% mortality
Transection with tissue loss
Devascularisation of segment
Partial thickness lac
without perf
Minor contusion /
superficial lac without
duct inj
Haematuria with
normal urologic studies
Lac <50% circumference
Lac >50% circumference
Major contusion / lac
without duct inj / tissue
loss
Lac <1cm deep without
urine extravasation
Distal injury with duct involvement
Prox inj (ie. To R of SMV)
Massive disruption of
pancreatic head
Lac >1cm deep without urine extravasation
Renal fracture
avulsion of hilum with
devascularised kidney
Haematoma confined to
retroperitoneum
Bladder
Small, subcapsular,
non-expanding
haematoma
Partial thickness lac
Deep lac into collecting
system
renovascular inj with
contained haematoma
Urethra
Contusion / intramural
haematoma
Contusion
Pancreas
Renal
Extraperitoneal bladder
wall lac <2cm
Extraperitoneal bladder wall lac >2cm
Intraperitoneal bladder wall lac <2cm
Elongation of urethra
without extravasation
Partial disruption with extravasation, but
contrast in bladder
Blood at meatus but
normal imaging
Ureter
Contusion /
haematoma without
devascularisation
<50% transection
>50% transection
Intraperitoneal bladder
wall lac >2cm
Complete disruption
(<2cm separation) with
extravasation, but no
contrast in bladder
Complete transection
with devascularisation
Intra/extra peritoneal bladder
wall lac extensing into neck /
ureteral orifice
Complete disruption (>2cm
separation)
Extension into prostate /
vagina
Avulsion of hilum with
devascularisation