Abdominal trauma

Background

• >35% of blunt trauma pts thought to have a "benign abdomen" end up needing surgery
• Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen
  • Not appropriate for flank or back wounds
• Pts w/ transabdominal GSW virtually all have intra-abdominal injury requiring surgery

Diagnosis

• Solid Organ Injuries
  • S/s due to blood loss
    • May bleed slowly / delayed onset of shock
• Hollow visceral injuries
  • S/s due to blood loss and peritoneal contamination
• Retroperitoneal Injuries
  • S/s may be suble or completely absent initially
  • Duodenal rupture is often contained w/in the retroperitoneum
  • Pancreatic rupture may be initally asymptomatic / negative CT /negative lipase
• Diaphragmatic Injuries
  • Symptoms generally related to degree of displacement of abdominal viscera into thorax

Work-Up

Imaging

• Ultrasound (FAST)
  • Sensitivity increases w/ serial exams
  • Cannot reliably evaluate retroperitoneum / hollow viscous injury
• CT
  • Consider triple-contrast study (PO, PR, and IV) for penetrating trauma

Treatment

• Nonoperative management is the norm in children but not necessarily in adults

Indications for laparotomy

	Blunt	Penetrating
Absolute	Anterior abdominal injury with hypotension	Injury to abdomen, back, and flank with hypotension
	Abdominal wall disruption	Abdominal tenderness
	Peritonitis	GI evisceration
	Free air under diaphragm on chest radiograph	High suspicion for transabdominal trajectory after gunshot wound
	Positive FAST or DPL in hemodynamically unstable patient	CT-diagnosed injury requiring surgery (i.e., ureter or pancreas)
	CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury)
Relative	Positive FAST or DPL in hemodynamically stable patient
	Solid visceral injury in stable patient
	Hemoperitoneum on CT without clear source

Liver Injury

• Nonoperative management is successful in >90% of pts who are hemodynamically stable
• Low-grade injuries (grades I–III) can almost always be managed without surgery
  • Higher-grade injuries commonly fail nonoperative therapy.
• Consider angiographic embolization if:
  • Large amount of hemoperitoneum
  • Vascular injury (contrast blush) on CT

Splenic Injury

• Most commonly injured visceral organ in blunt trauma
• Nonoperative management of splenic injuries has failure rate of 10-15%
  • Same advocate nonoperative management only if <55yr and CT injury grade < IV

Disposition

• Penetrating
  • If local wound exploration shows no violation of ant fascia pt can be discharged
  • If CT shows a subcutaneous trajectory or minimal retroperitoneal violation pt can be d/c'd home after period of observation

Source

Tintinalli