Abdominal Trauma
Cindy Kin
Trauma Conference
8 January 2007
Stanford General Surgery
Blunt Abdominal Trauma
Mechanisms
• Direct impact
• Acceleration-deceleration forces
• Shearing forces
• No correlation between size of contact area
and resultant injuries.
• Abdomen = potential site of major blood
loss.
Initial Evaluation and Treatment
Is there a surgical intraabdominal injury?
PE: guarding, peritoneal signs, tenderness, nausea. DRE.
Lower rib fxs: 10-20% a/w spleen/liver injury
Seatbelt sign a/w intestinal injury and mesenteric tears.
Direct blunt trauma: rupture/tear of solid organs.
Flank pain or contusion often late signs of retroperitoneal bleed
Rapid resuscitation
CXR, Pelvic X-ray
FAST v DPL v CT
Labs: Hct, WBC, amylase, UA, ABG, T+C
Blunt Abdominal Trauma
INDICATIONS for CT
• Blunt trauma with closed head injury
• Blunt trauma with spinal cord injury
• Gross hematuria
• Pelvic fx, +/- suspected bleeding
• Pt requiring serial exams, but will be lost to PE for
prolonged period (ie orthopedic procedures, general
anesthesia)
• Pts with dulled or altered sensorium
CONTRAINDICATIONS: unstable patients
Blunt Abdominal Trauma
CT
FAST
DPL
Accuracy
Sensitivity
96%
97%
95-99%
90-92%
95%
100%
Specificity
95%
88-90%
85%
Drawbacks Stable pts Cannot evaluate retroperitoneum.
Cannot identify source of fluid.
only
0.5% miss intestinal
perforation; cannot
distinguish blood v
bowel contents
Blunt Abdominal Trauma
INDICATIONS FOR LAPAROTOMY
Shock with
expanding abdomen,
pnemoperitoneum,
retroperitoneal air
Peritoneal signs,
HD unstable,
sepsis
Stable w/
peritoneal signs
+
Imaging:
CXR
FAST/DPL/CT
equivocal
Observe,
+/- re-image
Blunt Abdominal Trauma
ROLE OF DIAGNOSTIC LAPAROSCOPY
• Hemodynamically stable patients
• Inadequate/equivocal FAST or borderline DPL
(80K-120K RBC/HPF)
• Intermittent mild hypotension or persistent
tachycardia
• Persistent abdominal signs/symptoms
• Potential to decrease # of nontherapeutic
laparotomies
Blunt Abdominal Trauma
PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME
ON FAST EXAM
• Hemoperitoneum score on ultrasound a better predictor of
need for therapeutic laparotomy than admission blood
pressure and/or base deficit.
• Hemoperitoneum characterized by measurement and
distribution, scored
• Ultrasound score >=3 statistically more accurate than
combination of SBP and base deficit in determining which
patient will undergo a therapeutic abdominal operation
• 83% sensitivity, 87% specificity, 85% accuracy
– McKenney et al, J Trauma 50:650-656, 2001
Blunt Abdominal Trauma
HEPATIC AND SPLENIC INJURIES
• Unstable patients: mandatory laparotomy
• Stable patients: selective nonoperative approach
Hepatic injury
-Usually venous bleeding
-Grade I-III: 94% success w/ nonop treatment
-Grade IV-V: 20% amenable to nonop tx
-HD stability, stable Hct, observation
-Complications: delayed hemorrhage, bile
leak, biloma, intra/peri hepatic abscess.
-If stable with ongoing bleeding - angiographic
embolization
Blunt Abdominal Trauma
SPLENIC INJURIES
• Often arterial hemorrhage, therefore nonoperative
management less successful.
• Predictive factors for nonop success:
–
–
–
–
–
Localized trauma to flank/abdomen
Age<60
No associated trauma precluding obs
Transfusion <4u prbcs
Grade I-III
• Grade IV-V: almost invariably require operative intervention
• Delayed hemorrhage (hours to weeks post-injury): 8-21%
Blunt Abdominal Trauma
RETROPERITONEAL HEMORRHAGE
• Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx,
retroperitoneal bowel.
• Minimal signs on examination; flank pain and contusion are late findings
• FAST/DPL negative; CT can identify
Blunt Abdominal Trauma
DUODENAL AND PANCREATIC INJURY
• Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal
air on plain abdominal films.
• DPL unreliable.
• At laparotomy, central upper abdominal retroperitoneal hematoma, bile
staining, or air: mandates visualization and examination of panc/duo
• Duodenal injury:
– 80% lacs (G I-III) - primary repair
– 10-15% RYDJ, pyloric exclusion, Whipple
• Pancreatic injury
– Late complications: time from injury to tx
• Abscess, pseudocyst, fistula.
Blunt Abdominal Trauma
DIAPHRAGMATIC RUPTURE
• 3-5% of all abdominal injuries, L>R
• May p/w few signs, need high index of suspicion
– Injury mechanism: compartment intrusion, deformity of steering wheel, need
for extrication, fall from great height
– Prominence/immobility of L hemithorax
– NGT in chest, bowel sounds in thorax
– CXR: (50% with non-dx initial CXR):
• Obliteration of L diaphragm on CXR
• Elevation/irregularity of costophrenic angle
• Pleural effusion
• Confirm with GI contrast studies, dx laparoscopy
• Ex-lap and repair
Blunt Abdominal Trauma
SMALL BOWEL INJURY
• Mechanism: rapid deceleration with compression, shearing
• Often at points of fixation: Treitz, ileocecal valve, prior adhesions,
mesentery.
• Chance fracture (transverse fx of lower thoracic/lumbar vertebral body)
raises index of suspicion for SB injury
• Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs
absent until 6-12h post-injury.
• Delayed perforation: due to direct injury, transmural contusion, ischemia
from mesenteric vascular injury; usually presents w/in days.
Blunt Abdominal Trauma
INJURY TO COLON AND RECTUM
•
•
•
•
Mechanism: rapid deceleration with steering wheel compression
uncommon
Disruptions of colonic wall or avulsion injury of mesentery
Present with hemoperitoneum, peritonitis.
Penetrating Abdominal Trauma
Evaluation
• Any penetrating wound
between nipples and gluteal
crease = potential intraabdominal injury.
• Stab wounds: stratify based
on location
• GSW: higher potential for
serious injury.
Penetrating Abdominal Trauma
Evaluation of Stab Wounds
• Local exploration
• DPL
–
–
–
–
–
–
5cc gross blood on aspiration
>20K RBC/mm3
>500 WBC/mm3
>175U amylase/100mL
Bacteria
Bile, Food particles
• CT
– Limited ability to dx hollow organ
injury
– Useful for posterior SW
• FAST
– Limited, high false
negative rate
– Useful for pericardial
injuries
• Diagnostic laparoscopy
– Useful for assessing
peritoneal penetration,
diaphragm injury
– Shorter LOS than
negative laparotomy
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
Anterior Abdominal
Back
Peristernal Potential
Mediastinal
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
Anterior Abdominal
Explore locally, manage
expectantly with serial PE
Peristernal Potential
Mediastinal
Back
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
explore locally
triple contrast CT
Anterior Abdominal
Explore locally, manage
expectantly with serial PE
Peristernal Potential
Mediastinal
Back
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
explore locally
triple contrast CT
Anterior Abdominal
Explore locally, manage
expectantly with serial PE
Peristernal Potential
Mediastinal
Back
admit for obs
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
?Thoracoscopy,
Laparoscopy
explore locally
triple contrast CT
Anterior Abdominal
Explore locally, manage
expectantly with serial PE
Peristernal Potential
Mediastinal
Back
admit for obs
Penetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Flank
?Thoracoscopy,
Laparoscopy
explore locally
triple contrast CT
Anterior Abdominal
Explore locally, manage
expectantly with serial PE
Peristernal Potential
Mediastinal
CVP monitor, U/S
Observe >6h, repeat CXR
Back
admit for obs
Penetrating Abdominal Trauma
Gunshot Wounds
• Usually require urgent exploration
• Evaluation for peritoneal penetration v tangential GSW.
– CT, diagnostic laparoscopy
– Use of DPL controversial due to high false negative rate
• Ballistics:
– Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles
– Permanent and temporary cavities: Yaw, Bullet size and type
– Shotgun:
• Short range: high-velocity and more concentrated
• Distant range: multiple low-velocity projectiles, more diffuse, less severe
• Antibiotics: cefotetan or cefoxitin in ED
Penetrating Abdominal Trauma
ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING
GSW AND NEED FOR LAPAROTOMY
• 66 GSW underwent DL, 2/3 of GSW in upper torso
• Peritoneal penetration ruled out in 62%
• 29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap,
4% had negative ex-lap
• Hospital stay:
– 4.3 days - negative DL and associated injuries
– 8.6 days - laparotomy
– 1.1 days - negative DL and no associated injuries.
– Fabian et al, Ann Surg 1993; 217:557
Penetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
NEGATIVE LAPAROTOMY RATE
• Retrospective review 817 pts who underwent ex-lap for abdominal GSW
over 4yr: negative ex-lap rate = 12.4%
– 22% morbidity, LOS 5.1days
• Review of 85 pts with abdominal GSW evaluated with DL
– Negative DL in 65%, no missed injuries, no subsequent need for ex-lap;
3% morbidity rate (one pt had urinary retention), LOS 1.4days
– Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and
14% nontherapeutic (remaining 2 were observed for nonbleeding liver
lacs)
– Sosa et al. J Trauma 1995;38(2):194
Penetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
NEGATIVE LAPAROTOMY RATE
• Prospective study of 121 patients with tangential GSW, HD stable
• 65% negative DL
• Of 25% positive DL, 92.8% (39) underwent ex-lap
– 82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative
• No false negative DLs, no delayed laparotomies
• Sensitivity for peritoneal penetration 100%
– Sosa et al. J Trauma 1995;39(3):501