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
• Knife
  • Benign initial exam in 20% of patients
  • Liver most commonly injured in stab wounds
• GSW virtually all have intra-abdominal injury requiring surgery
  • Small bowel most commonly injured

Diagnosis

• Solid Organ Injuries
  • S/s due to blood loss
    • May bleed slowly / delayed onset of shock
    • Spleen most likely solid organ injured

• Hollow visceral injuries
  • S/s due to blood loss and peritoneal contamination
  • Seat belt sign, peritoneal signs
  • Free air on CXR
  • Lap Belt Injuries often with Chance fracture

• Retroperitoneal Injuries
  • S/s may be subtle or completely absent initially
  • Duodenal rupture is often contained w/in the retroperitoneum
  • Pancreatic rupture may be initially asymptomatic / negative CT /negative lipase
  • Grey-Turner sign: flank brusing, often associated with pancreatitis or pancreatic hemorrhage
  • Cullen’s sign: subcutaneous bruising and edema, often seen with AAA or pancreatic injury

• Diaphragmatic Injuries
  • Symptoms
    • SOB, Kehr Sign: shoulder pain from diaphragm or peritoneal irritation)
  • Generally related to degree of displacement of abdominal viscera into thorax
  • CXR: NGT curled in chest, abdominal organ herniation, thoracic aorta rupture

Differential Diagnosis

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Diagnosis

Imaging

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

Management

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

Disposition

• Stable
  • CT scan of the abdomen and pelvis
    • FAST neg, responding to IVFs, normotensive
  • Penetrating
    • Knife: If local wound exploration shows no violation of ant fascia, suture lac and discharged
    • If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, d/c home after period of observation
  • Angioembolization for hemodynamically stable patients with suspected bleed
• Unstable
  • IR vs Surgery
    • isolated bleed for angioembolization
    • polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy

See Also

• Trauma in pregnancy
• Thoracic and lumbar spine trauma

References

• Shah, Essential Emergency Trauma, pgs 143-148
• Bailitz J, Bokhari F, Scaletta TA, Schaider J. Emergent Management of Trauma. New York: The McGraw-Hill Company, 2011: pg 193.