Abdominal Trauma

1
Abdominal Trauma
Cindy Kin Trauma Conference 8 January
2007 Stanford General Surgery
2
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.

3
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, TC

4
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

5
Blunt Abdominal Trauma
6
Blunt Abdominal Trauma
INDICATIONS FOR LAPAROTOMY

• Shock with
• expanding abdomen,
• pnemoperitoneum,
• retroperitoneal air

Peritoneal signs, HD unstable, sepsis
Stable w/ peritoneal signs

Observe, /- re-image
equivocal
Imaging CXR FAST/DPL/CT
7
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

8
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 gt3 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 50650-656, 2001

9
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
10
Blunt Abdominal Trauma

• SPLENIC INJURIES
• Often arterial hemorrhage, therefore nonoperative
  management less successful.
• Predictive factors for nonop success
• Localized trauma to flank/abdomen
• Agelt60
• No associated trauma precluding obs
• Transfusion lt4u prbcs
• Grade I-III
• Grade IV-V almost invariably require operative
  intervention
• Delayed hemorrhage (hours to weeks post-injury)
  8-21

11
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

12
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.

13
Blunt Abdominal Trauma

• DIAPHRAGMATIC RUPTURE
• 3-5 of all abdominal injuries, LgtR
• 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

14
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.

15
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.

16
Penetrating Abdominal Trauma

• Evaluation
• Any penetrating wound between nipples and gluteal
  crease potential intra-abdominal injury.

• Stab wounds stratify based on location
• GSW higher potential for serious injury.

17
Penetrating Abdominal Trauma

• Evaluation of Stab Wounds
• Local exploration
• DPL
• 5cc gross blood on aspiration
• gt20K RBC/mm3
• gt500 WBC/mm3
• gt175U 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

18
Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Lower Chest
Flank
Anterior Abdominal
Back
Peristernal Potential Mediastinal
19
Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Lower Chest
Flank
Anterior Abdominal Explore locally, manage
expectantly with serial PE
Back
Peristernal Potential Mediastinal
20
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
Back
Peristernal Potential Mediastinal
21
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
Back admit for obs
Peristernal Potential Mediastinal
22
Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Lower Chest ?Thoracoscopy, Laparoscopy
Flank explore locally triple contrast CT
Anterior Abdominal Explore locally, manage
expectantly with serial PE
Back admit for obs
Peristernal Potential Mediastinal
23
Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Lower Chest ?Thoracoscopy, Laparoscopy
Flank explore locally triple contrast CT
Anterior Abdominal Explore locally, manage
expectantly with serial PE
Back admit for obs
Peristernal Potential Mediastinal CVP monitor,
U/S Observe gt6h, repeat CXR
24
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
• Civilianlower 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

25
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 217557

26
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 199538(2)194

27
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 199539(3)501