Abdominal Trauma

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Abdominal Trauma
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A middle aged unidentified lady was hit by a car whilst crossing the road. She was brought to the ER unconscious with multiple injuries to the head chest and pelvis. She was obese and haemodynamically unstable despite aggressive fluid resuscitation. The x-ray shown was taken following primary survey. What does the xray show and what is its significance? How do you diagnose abdominal injury Should free intraperitoneal fluid be identified on USS. How would you proceed with the management of such a cas?
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Facts

• Abdominal signs are often subtle and difficult to
  interpret.
• Unrecognised abdominal injury is a major cause
  of death after trauma.
• Positive (hemoperitoneum) can result in
  management dilemma.

The Solution HIGH INDEX OF SUSPICION History and mechanism of injury Positive clinical signs Knowledge of Anatomy Objective Data
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Goal and Objectives

• By the end of this lecture you should be able to
  
• Assess the risk of abdominal injury in a
  poly-trauma patient and provide an index of
  suspicion for specific injuries.
• Describe the regions of the abdomen and the
  organs most likely affected within them.
• Discuss the difference between blunt and
  penetrating injuries
• Plan your management on priority basis
• Identify signs suggesting abdominal injury.
• Outline diagnostic and therapeutic procedures
  specific to abdominal trauma.

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Abdominal regions

• A. Intraperitoneal cavity
• Intrathoracic abdomen
• True abdomen
• Pelvic abdomen
• B. Retroperitoneal cavity

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Mechanisms

• Blunt
• A. 3 mechanisms
• Deceleration and shearing forces results in
  linear tears ligamentous attachments and intimal
  arterial tears
• Pressure against the lumbar vertebra
• Sudden compression with raised intra-abdominal
  pressure.
• Cause subcapsular hematoma and deformity of
  bowel resulting in rupture.
• B. The most commonly affected organs the spleen,
  liver followed by the small and large intestine

• Penetrating
• Fire arms
• 95 associated injury
• Chemical thermal combustion
• Secondary Missiles from bony shrapnel
• The closer the higher energy transfer
• Size of entry does not predict degree of injury.
• Missile trajectory is unpredictable
• Stab Wound
• 30 associated injury
• More predictable damage

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Clinical EvaluationOnly 60 reliable

• History
• Onset, delay in extrusion, condition of Vehicle,
  passenger/s
• Seat belt
• Abdominal, shoulder pains
• AMPLE
• Substance abuse, Alcohol intoxication
• For penetrating injuries
• The type of fire arm or impaling object
• Number of shots or stabs
• Distance
• Amount of blood at the scene
• Any history of hypotension

• Examination
• Following the ATLS protocol
• Secondary survey
• Identify Other injuries in the chest, back and
  pelvis
• Inspection
• Ecchymosis, lacerations
• Distension
• In gunshot wounds look for entry and exist wounds
• Locate the site of stab wound
• Palpation
• Tenderness and guarding
• Rebound
• Percussion
• Auscultation BS, bruit,
• FAST ( Focused Sonography for trauma assessment)

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Investigations

• 1. Laboratory
• CBC, UE, creatinie, amylase, glucose, X-match,
  clotting screen, ABG,
• Urine analysis
• 2. Screening plain x-rays
• C-spine, CXR, pelvic x-ray
• 3. USS
• 4 acustic windows
• Sensitivity of 78
• A small amount of fluid in Morisons pouch on USS
  may indicate 250-1000 ml

• 1. CT
• Fast and precise
• Quantifies hemorrhage
• Identifies retroperitoneal injuries
• Marginal use in diaphragmatic and small bowel
  injury
• 2. Contrast studies
• urethrogram, cystogram,
• GI contrast studies
• 3. DPL
• Indications
• Contraindications
• Positive findings
• Sensitivity
• 4. Laparoscopy

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Management

• Conservative
• ICU or not
• Blood transfusion and intravenous fluids
• Antibiotics
• Fluid input / output charts and aggressive
  monitoring
• Prevent hypothermia
• Correct coagulopathies
• Repeated lab series
• Repeated USS

• Surgery The indications
• Hypotension
• Gun shot
• Stab wounds
• Frank blood on DPL
• Bile or bowel content on DPL
• Peritonitis
• Recurrent hypotension despite adequate
  resuscitation
• Free air
• Diaphragmatic rupture
• Urinary Bladder injury
• Failure of conservative managemnt

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Seat Belt Injury

• The seat belt syndrome
• 75 associated with serious injuries
• Driver/ F. passenger/ 5 back seat passengers.
• 75 front impact
• It consists of
• Seat belt mark abrasions
• Musculo-skeletal Cervical spine, clavicle,
  sternum, ribs and lumber spine.
• Soft tissue damage
• Neck Laryngeal injury, carotid tear
• Chest Cardiac contusion
• Abdomen Duodenum, small bowel. Mesentery, large
  bowel, Caecum