This document discusses the management of abdominal trauma. It begins with classifications for abdominal injuries and describes the pathophysiology of blunt and penetrating trauma. The primary and secondary surveys are outlined, including important physical exam findings. Diagnostic imaging options are presented, such as FAST ultrasound, CT scans, and DPL. Specific injuries to organs like the spleen are discussed. Management approaches for both blunt and penetrating trauma are covered, including options for non-operative management versus laparotomy. Damage control resuscitation principles and abdominal compartment syndrome are also mentioned.
2. Index
1. classification of abdominal injury
2. Pathophysiology of abdominal injury -PAT, BAT
3. Primary Survery
4. Secondary Survey- Physical examination,Lab Test
5. Imaging –Plain radiography , FAST scan, CT
6. Other diagnosis method -DPL,LWE,,Laparascopy, Exploratory Laparatomy
7. Management of BAT and PAT
8. Specific Organ injury
9. -Spleen , Diaphragm, stomach , small intestine, Colorectal injury,
10. Damage control resuscitation
11. Abdominal compartment syndrome
12. Reference
3.
4. Abdominal Trauma
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%)
Penetrating Abdominal Trauma
◦ Stabbing 3x more common than firearm wounds
◦ Gun shot wound cause 90% of the deaths
◦ Most commonly injured organs?
- small intestine > colon > liver
5. 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
7. 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
8. Primary Survey –ATLS approach
ABCDE pattern: Airway, Breathing, Circulation, Disability (neurologic status), and
Exposure.
A -intubation may be required if patient is shocked, hypotensive or unconscious or in need
for ventilation. *with cervical precaution.
B -watch for hemothorax in both blunt and penetrating thoracoabdominal injuries.
C -start with 2 L crystalloid (If active bleeding you must find source and stop the bleeding)
D –May seen associated with thorocolumbar #
E -Watch for other injury
9. Diagnostic and
treatment
priorities
First : recognize presence of shock or intraabdominal
bleeding
Recognize
Second : start resuscitative measures for
shock/bleeding
Resuscitation
Third : determine if abdomen is source for shock
or bleeding
Abdomen?
Fourth: determine if emergency laparatomy is
needed
Laparatomy ?
Fifth: complete secondary survery,ab,and radiograph
studies to determine if “occult” abdominal injury is
present.
Survey
Sixth : conduct frequent reassessments.Reassessment
10.
11. Secondary
Survey History
History for all trauma patients:
-Not necessary making an accurate diagnosis
S.A.M.P.L.E
S: Symptoms:
pain,vomiting,hematuria,hematochezia,dyspnea,respiratory
distress…
A: Allergies
M : Medications
L : Last meals
E : Events (mechanism of injury)
12. Physical
Examination
Inspection : abrasions, contusion,
lacerations, deformity, entrance and exit
wounds to determine path of injury…
(grey Turner, Kehr, Balance,Cullen,seat belt
sign)
Palpation: elicits superficial , deep , or
rebound tenderness; involuntary muscle
duarding
Percussion : subtle signs of peritonitis;
tympany in gastric dilatation or free air;
dullness with hemoperitoneum.
Auscultation : bowel sounds may be
decrease ( late finding).
13. Physical examination
Grey-Turner sign : bluid discoloration of
lower flanks, lower back; associated with
retroperitoneal bleeding of
pancrease,kidney or pelvic fracture.
Cullen sign : bluish discoloration around
umbilicus, indicates peritoneal bleeding,
often pancreatic hemorrhage.
Kehr sign: shoulder pain while supine
;caused by diaphragmatic irritation(splenic
injury, free air, intra-abdominal bleeding)
Balance sign : dull percussion in LUQ.Sign
of splenic injury; blood accumulation in
subcapsular or extracapsular spleen
In the trauma patient, a ‘normal’ physical exam of the
abdomen doesn’t equate to much. You NEED to do further
testing.
14. Laboratory tests
- limited
-Hematocrit – below 30% increases the likelihood of intra-
abdominal injury.
-Leukocyte count – In BAT, the white blood cell (WBC) count is
nonspecific and of little value. Catecholamine release due to
trauma can cause demargination and may elevate the WBC to
12,000 to 20,000/mm3 with a moderate left shift. Solid or hollow
viscus injury can cause comparable elevations
-Pancreatic enzymes – Normal serum amylase and lipase
concentrations cannot exclude significant pancreatic injury . And
while elevated concentrations raise the possibility of pancreatic
injury,
-Liver function tests – Hepatic injury is associated with
elevations in liver transaminase concentrations
-Urinalysis – Gross hematuria suggests serious renal injury and
mandates further investigation
-Base deficit and lactate - Base deficit less than -6 was
associated with intra-abdominal hemorrhage and the need for
laparotomy and blood transfusion
15. /
Imaging in Abdominal Trauma
Plain films generally have NO ROLE
in acute abdominal trauma
What else do we have?
• FAST ultrasound
• Diagnostic Peritoneal Tap
• CT Scan, contrast study
• Local wound exploration
• Angiography
• Urethrocystography
• IVU
16. Plain radiograph
Findings on chest radiograph that suggest intra-
abdominal injury include:
Lower rib fracture
•Diaphragmatic hernia
•Free air under the diaphragm
17. (FAST) Focused assessment with
sonography for trauma
- To diagnosed free intraperitoneal fluid.
- evaluate solid organ hematoma
- Four areas:
1. Pericardium (subxiphoid)
2. Perihepatic &hepatorenal space (morrison’s pouch)
3. Perisplenic
4. Pelvis (pouch of Douglas /rectovesical pouch)
Sensitivity 60-95% for detecting 100ml -500 ml of fluid
E-fast(extended)
-add thoracic windows to look for pneumothorax. Sensitivity
59%,specificity,specificity up to (99% for pneumothorax. )
12 3
4
18. FAST Ultrasound
Advantages
• Sensitivity at detecting 100cc fluid is 60-
95%
• Portable(bedside),fast(<5 min) and
ability to repeat
• No radiation or contrast
• Noninvasive
• Rapid results, hemodynamically unstable
patient that unable to go for CT scan
• Less expensive
Disadvantages
• -Injury to solid parenchyma, the retroperitoneum,
or the diaphragm is not well seen.
• -Uncooperative patients, obesity, bowel gas, and
subcutaneous air interfere with image quality.
• -Low sensitivity in comparison to CT, particularly for
non-hypotensive patients. Cannot reliably exclude
clinically significant injuries
• -Blood cannot be distinguished from ascites or
urine.
• -Subcapsular injuries cannot be detected.
• -Insensitive for detecting bowel injury
• -Limited in detecting<200cc intraperitoneal fluid
23. CT Imaging
◦ 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
24. Diagnostic Peritoneal Taps
DPA - The recovery of 10 cc of frank blood (or more) from the peritoneum
is a strong predictor (90% PPV in blunt trauma) of intraperitoneal injury,
and the procedure is then terminated.
DPL - If aspiration findings are negative, lavage is conducted in which the
peritoneal cavity is washed with saline. RBC count exceeding 100,000/cc
is considered positive and generally specific for injury. Sensitivity 90%.
25. Diagnositic Peritoneal ‘Lavage’
Is actually a 2 Step Process.
Step 1. DPA (closed).
◦ Patient supine
◦ Landmark is 2 finger widths below umbilicus
◦ Local freezing, puncture skin 30-degrees to the head
◦ Seldinger technique to introduce a DPL catheter
◦ Aspirate using 30cc syringe
26.
27.
28. DPA
Advantages
◦ Highly accurate for hemoperitoneum (SENS 90-100%)
◦ Most sensitive test for hollow viscus injury
Disadvantages
◦ Invasive (complication rate 1-5%)
◦ Time consuming (20 minutes)
◦ False positives. Up to 25% non-therapeutic laparotomies
29. DPA
•If 10cc frank blood or more is aspirated, you are
done, patient needs to go to the OR.
If the DPA is negative, you proceed to Step 2…
30. Diagnostic Peritoneal Lavage
Step 2. DPL.
◦Hook up 1L of Ringer’s to the peritoneal catheter, and
squeeze into the abdomen.
◦Once infused, put the empty Ringer’s bag on the floor,
and let it back-fill via gravity
◦Send off 10cc for analysis, if 100,000 RBC/cc it is positive
31. Is there still a role for DPA?
FAST has largely replaced DPA, likely due to
ease of use.
However, 2 areas where still is warranted:
◦ Hemodynamically unstable and an equivocal FAST
◦ No FAST available
“DPL is safe, sensitive, and reduces the use of
CT” (Journal of Trauma 2007)
32. 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
33. 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
34. Exploratory laparatomy
Potential indications include the following:
Haemodynamic instability
Evidence of Peritonitis to achieve control of haemorrhage and control of spillage
Traumatic diaphragmatic injury with herniation
Severe solid organ injury (e.g. kidney and spleen)
Infarction due to post traumatic occlusion of the blood supply
Mesenteric tear/s
Unexplained Moderate to large amounts of free fluid (200-≥500mls)
Failed non-operative management
35. Management
of BAT
• NOM: nonoperative management
• Abd CT: abdominal CT scan;
• DPT: diagnostic peritoneal tap;
• LAP: laparotomy
36. Management of penetrating abdominal trauma
Mandatory laparotomy
vs
Selective nonoperative management
37. 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
38. 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
39. 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
41. 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?
42. 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
44. 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
45. Management of PAT
Gunshot wounds
-assess peritoneal entry by missile path,
LWE, CT, US, laparoscopy (all limited)
laparoscopy (LPY), or serial physical examinations (SPEs)
46. Specific Organ Injury
Specific organ
trauma:
1. peritoneal
2. retroperitoneal
3. diaphragm
-Treatment of an organ injury is
similar whether the injury
mechanism is penetrating or
blunt
-An exception to the rule is a
retroperitoneal hematoma
-explore all retroperitoneal
hematoma caused by
penetrating injury.
47. Splenic Injury - Grading System(AAST)
I - Hematoma, subcapsular <10% SA
Capsular Laceration <1cm
II - Hematoma, subcapsular 10-50% SA; intraparenchymal <5cm
Capsular Laceration 1-3cm
III - Hematoma, subcapsular >50% SA; intraparenchymal >5cm
Capsular Laceration >3cm (or parenchymal depth)
IV - Hematoma ruptured into parenchyma
Hilar Injury devascularizing spleen >25%
V - Vascular hilar injury devascularing spleen 100%, or
‘Shattered’
48. WSES classification
Minor spleen injuries:
WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and penetrating lesions.
Moderate spleen injuries:
WSES class II includes hemodynamically stable AAST-OIS grade III blunt and penetrating lesions.
WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating
lesions.
Severe spleen injuries:
WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and penetrating
lesions.
49.
50. Diaphragmatic injury
Its possible in injuries to the thoracoabdominal region
Can be due to blunt(>85%) or penetrating injury and is larger in the blunt
Possible cardiac injury if the penetrating wound is more central
The weakest point of diaphragm is the left posteriorlateral(80%)
Often missed in multitrauma
In isolated injury it may go unnoticed and there is often a delay between the injury and the diagnosis
Patients present with non specific symptoms and may complain of chest pain,abdominal pain,dyspnea
,tachypnea and cough
Rupture with herniation is diagnosed by CXR or CT but without herniation is difficult to diagnose
Thoracoscopy or laparascopy is diagnostic
51. Treatment
Once identified must be repaired because it will not close spontaneously regardless the size.
Early diagnosis needs abdominal approach using the interrupted nonabsorbable suture and
the large defect(>25cm2) may need nonabsorbable mesh.
In the event of a gross contamination, endogenous tissue can be utilized for a definitive repair
as latissimus dorsi flap, tensor fascia lata or omentum.
There are some who advocate using biologic tissue grafts, such as AlloDerm(human acellular
tissue matrix).The durability of such a repair is questionable.
Place chest tube on the surgery side at the time of repair
52. Stomach
More common in penetrating trauma than blunt &
its about 10% of penetrating injuries of the abdomen
Diagnosis:
Physical exam:
-epigastric tenderness,
-peritoneal signs,
-bloody gastric aspirate.
Plain radiography in <50%:
-free air under diaphragm
• FAST examination:-
unreliable
• DPL: WBC, RBC < Gross
contamination
• CT scan:
pneumoperitoneum
• Laparoscopy:-operator
dependent
53. Stomach treatment is according to the
severity
administer preop abx
Hematoma is evacuated ,hemostasis and closure with nonabsorbable suture.
Small perforation can be closed in one or two layered
Large injuries near the greater curvature can be closed by suture or GIA stapler
Certain defects may be closed using a TA stapler
A pyloric wound may be converted to pyloroplasty
Destructive wound may need proximal or distal gastrectomy
In rare cases a total gastrectomy and Roux-en –y esophagojejunostomy are necessary for severe
cases.
54. Small intestine
The small bowel is the mc injured intraabdominal organ in penetrating
tauma, a blunt trauma cause is less common,but not rare(10%)
Small isolated perforation probably result from blowout of pseudoclosed
loops(seatbelt related injuries)
Larger perforation, complete disruptions and injuries associated with
large mesenteric hematoma or laceration are caused by direct blows or
shearing injury or contusion
Perforation from blunt injury is the mc at the ligament of triez,ileocecal
valve,midjejunum or in the areas of adhesion
55. Small intestinee
• CT has a significant false negative rate in the diagnosis of small-
bowel injury.
• CT findings in small-bowel injury include:
Fluid collections without solid viscus injury
Bowel wall thickening
Mesenteric infiltration
Free intraperitoneal air
Oral contrast extravasation
56.
57. Colon and rectum
-Diagnosis
• Peritoneal signs or free intraperitoneal air.
• At laparotomy, small injuries in the wall of the colon can be missed so explore all blood staining
or hematomas of the colonic wall.
• Consider proctoscopy or proctosigmoidescopy in :
- Gross blood on PR in the presence of a pelvic fracture
- Penetrating abdominal, buttock, thigh or pelvic wound.
- Any patient with a major pelvic fracture if the patient is stable.
• The location of the injury can be important in planning the operation. Even if the hole cannot be
visualized on proctoscopy, assume the patient has a colorectal injury, if there is intraluminal blood.
• In hemodynamically unstable patients, proceed with laparotomy first.
59. Traditional contraindications to primary repair include :
• Patients with shock, underlying disease, significant associated injuries, or peritonitis
• Extensive intraperitoneal spillage of feces,
• Multisegmental or extensive colonic injury requiring resection, and
• Major loss of the abdominal wall or mesh repair of the abdominal wall; Colon and rectum
Treatment is operative
If a primary repair cannot be
performed safely for anatomic
reasons (bowel wall edema,
vascular compromise), a
colostomy may be a safer
option.
The guidelines for primary repair include :
• Minimal fecal spillage,
• No shock (defined as systolic blood pressure <90 mmHg),
• Minimal associated intraabdominal injuries,
• <8-hour delay in diagnosis and treatment, and
• <1-L blood transfusion.
Colon and rectum
60. Rectum -intraperitoneal or extraperitoneal
1.Often, intraperitoneal rectal injuries can be managed as in colonic injury (primarily repaired).
2.Treat extraperitoneal rectal tears by diverting sigmoid colostomy. Acceptable options include:
• Hartmann resection with end colostomy,
• End colostomy with a mucus fistula, or
• Loop colostomy with a stapled distal end.
3.If the defect is not readily identified on proctoscopy…..
4.Presacral drainage and irrigation of the distal rectal stump…..
5.If a colostomy is necessary in a patient with a pelvic fracture requiring fixation……
6.Perioperative broad-spectrum antibiotics should be administered for colon and rectal wounds
61. Damage
control
Resuscitation
It’s an alternative resuscitation approach to hemmorhagic
shock which involves:
1. rapid control of surgical bleeding
2. Early and increased use of RBC, plasma and platelets in
a 1:1:1 ratio.
3. limitation of excessive crystalloid use
4. prevention and treatment of
hypothermia,hypocalcemia and acidosis.
5. Permissive hypotension. (hypotensive resuscitation
strategies).
-can be applied to unstable
patient who are with life
threatening hemorrhage &
going to need massive
transfusion.
65. Major complication of abdominal trauma-
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
69. 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
70.
71. Reference
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care
2010;16:609-617
https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0151-4#
http://www.aast.org/library/traumatools/injuryscoringscales.aspx#pancreas
https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-abdominal-trauma-
in-
adults?search=abdominal%20trauma&source=search_result&selectedTitle=1~150&usage_type=d
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Editor's Notes
Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures created by outward forces
Lap-belt restraints
“seat belt sign” = contusion or abrasion across the lower abdomen, highly correlated with intraperitoneal injury
The plain chest radiograph shows a traumatic disruption of the left hemidiaphragm. The anteroposterior view (A) obtained on primary survey and lateral view (B) obtained in follow-up show gastrointestinal gas shadows occupying about two-thirds of the left hemithorax (arrowhead). Bowel gas can be seeen adjacent the heart border (arrow).
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow).
Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
Grade 4 splenic laceration
Grade 3 right renal laceration (encircled).
CT is particularly helpful in guiding nonoperative management of solid organ damage.[44-46] This includes as-needed follow-up studies of convalescing patients with these injuries. It has also proven effective when incorporated in delayed fashion for patients with decreasing hematocrit, increasing base deficit, or subtle examination changes. By minimizing the incidence of nontherapeutic laparotomies for self-limited injury to the liver or spleen,
trauma centers are using CT with intravenous (IV) contrast only, as it has been shown that little additional information is provided by the addition of oral contrast, which delays scanning and may pose an aspiration risk for the patient.[48,49]
(many do not reach the peritoneum)
If LWE indicates that the peritoneum is violated, further diagnostics are indicated. When the stab wound is documented to be superficial to the abdominal cavity, the patient can be safely discharged home after appropriate wound care.[85]
Other areas: like back, flank, chest
DPL The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury
Even a single stab wound to the low chest can violate the mediastinum, thoracic cavity, diaphragm, peritoneal cavity, and retroperitoneum. The risk of diaphragmatic penetration from a left thoracoabdominal stab wound has been measured at 17%.[86] When all thoracoabdominal wounds are considered, the risk of occult injury is 7%.[100] US can be extremely useful in quickly assessing for hemopericardium and hemoperitoneum in the marginally stable patient when thoracotomy or laparotomy is not already clinically indicated.[106] LWE of slash-type wounds may obviate the need for further evaluation. However, the depth of investigation cannot be taken beyond the anterior rib margin to maximize safety and accuracy. Further assessment for intraperitoneal and diaphragmatic injury can be made by DPL. The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury.[77] Laparoscopy or thoracoscopy can visualize and potentially repair the diaphragm and other organs. Newer multidetector CT and MRI show promise in excluding diaphragmatic injury. CT has a sensitivity of 94% and specificity of almost 96% for detecting diaphragmatic injury. However, equivocal scans must be followed up with more definitive management, including DPL or exploratory laparotomy.[105] A very conservative approach to the left lower chest stab wound, in particular, is mandatory exploration. This approach avoids any opportunity for missed diaphragmatic rents and their delayed consequences but results in an exceptionally high incidence of nontherapeutic operation. Rapid-slice helical CT or MRI may provide a solution to this vexing concern, but data are limited to date.
Due to low incidence of intraperitoneal injuries, selective management is well accepted
Ask these 3 questions… algorithm
Immed lap for Hemodynamic compromise, peritoneal signs, evisceration,
However, the risk of mortality is significantly greater, especially if vascular structures are involved. Missiles striking the low chest commonly penetrate both intrathoracic and abdominal structures, including the diaphragm
Figure 43-11. Abdominal gunshot wound algorithm. *Can be assessed by missile path, plain films, local wound exploration, ultrasonography (US), and laparoscopy (LAP). †Most centers proceed to LAP if peritoneal entry is suspected. ‡Patients with documented superficial and low-velocity injuries can be discharged; unknown-depth or high-velocity injuries require further tests or observation. ?Computed tomography (CT), diagnostic peritoneal lavage (DPL), laparoscopy (LPY), or serial physical examinations (SPEs) can be used in singular or complementary fashion depending on the clinical scenario. ?Expectant management of injuries caused by gunshot wounds is rarely attempted.
Ois-orga injury scaling
Non operative mngmt
mportant to know that when assessing the spinal cord injured patient, any
injury between the third and fifth cervical vertebrae may affect the ability of the
patient to breathe due to its affect on the phrenic nerve and diaphragm.
The diaphragm is primarily innervated by the phrenic nerve, formed from cranial
nerves C3, C4, and C5. A useful mnemonic to remember this is, "C-3, 4, 5 keep
the diaphragm alive.
Diagnosis is clinical:
• Suspect small-bowel injury with evidence of an abdominal wall seat-belt contusion or fracture of the lumbar spine.
• Small-bowel injury is often not diagnosed on initial presentation because the patient is less likely to have peritonitis on initial examination.
• This delay contributes significantly to morbidity and mortality.
‘Damage Control Surgery’
Major complication of abdominal trauma
APP = MAP - IAP
Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures.