Updated: 9/22/2019

Abdominal Trauma

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Snapshot
  • A 30-year-old male victim of an automotive hit-and-run incident presents to the ED. Initial primary survey reveals no airway obstruction and good ventilation. Two large bore IV's are inserted and blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 18/min, and SaO2 is 95% on room air. One liter of Lactated Ringer's is started. Secondary survey reveals no obvious source of blood loss. Despite this and fluid resuscitation, the patient's blood pressure drops to 85/55 mmHg. A FAST ultrasound exam reveals fluid surrounding the spleen and in Morrison's pouch. The patient is rushed to the OR for an exploratory laparotomy. 
Introduction
  • Overview
    • abdominal trauma is trauma to the abdomen causing visceral damage and hemorrhage
      • treatment depends on extent of trauma
  • Epidemiology
    • incidence
      • difficult to recognize clear symptoms early
      • blunt abdominal trauma
        • 2/3 of all intraabdominal injuries
        • mortality rate of ~8.5%
        • motor vehicle crash (MVC) is main mode of injury
      • penetrating abdominal trauma
        • 1/3 of all intraabdominal injuries
        • mortality rate ~12%
        • 95% of all penetrating trauma associated with gunshot and stab wounds
        • higher risk of wound site infection and abscess formation
    • demographics
      • 2/3 injuries occur in males
      • peak incidence between ages 14 and 30
    • location
      • blunt
        • spleen is most commonly injured ogan, liver is second
      • penetrating
        • liver is most commonly injured organ
    • risk factors
      • substance use
      • ownership or access to firearms
      • motor vehicle operation
  • Pathogenesis
    • blunt abdominal trauma divided into three mechanisms
      • 1st: rapid change in organ momentum and speed causes shearing forces to tear organs
      • 2nd: crush injury due to organ compression against blunt object and rigid structures in body (i.e. bones)
      • 3rd: external compression due to rise of pressure inside organ, especially hollow organs, leading to organ rupture
    • penetrating abdominal trauma divided into two mechanisms
      • 1st: direct damage via tissue penetration
      • 2nd: pressure damage from speed of penetrating object causes fragmentation of organ
Presentation
  • History
    • important to ascertain mechanism of injury from initial report to determine workup
    • unprotected trauma
      • pedestrian victims of MVC, motorcycle / bicycle crash, assaults with objects
      • high-energy trauma
        • MVC with no restraints, known high speeds, death at scene, substantial vehicular damage
          • falls greater than 15 feet
          • minor trauma in patients with limited reserve to tolerate injury
          • elderly, patients with chronic debilitating disease, immunosuppressed
          • seatbelt-associated injuries
            • retroperitoneal duodenal trauma
            • intraperitoneal bowel transection
            • mesenteric injury
            • lumbar spine injury
  • Symptoms
    • symptoms and signs of blood loss may not be evident
  • Physical exam
    • inspection
      • tachycardia, tachypnea, oliguria, febrile, hypotension
      • primary and secondary survey
        • abrasions, contusions, seatbelt sign, distension
        • bruits, bowel sounds on auscultation
        • referred pain to shoulder 
    • provocative tests
      • tenderness with and without rebound, rigidity, and guarding
      • digital rectal exam
      • nasogastric tube for bowel decompression
      • Foley catheter placement if patient cannot void spontaneously

Imaging

  • Radiograph
    • indications
      • free air under diaphragm, hernia, air-fluid levels, fractures
    • limitations
      • soft tissue not visualized
  • FAST ultrasound
    • indications
      • presence or absence of free fluid in peritoneal, pleural, pericardial cavities rapidly (<5 minutes)
    • NOT used to identify specific organ injuries
    • limitations
      • if patient has ascites, FAST will be a false positive
  • diagnostic peritoneal lavage (DPL) 
    • indications
      • most sensitive test for intraperitoneal blood
        • if > 10 ml gross blood, WBC > 500, amylase > 175, and/or bile/bacterial/foreign material found, DPL is considered positive
      • NOT for retroperitoneal bleed or diaphragmatic rupture
    • limitations
      • rarely used (takes 1 hour)
  • CT scan
    • indications
      • most specific test for all of above
    • limitations
      • significant radiation exposure
      • NOT used if patient is hemodynamically unstable
Studies
  • Serum labs
    • complete blood count
    • electrolytes
    • coagulation
    • type and cross
    • creatine kinase
    • lipase / amylase
    • liver function tests
    • arterial blood gas
    • blood EtOH
    • urine or serum β-hCG (pregnancy test)
    • urinalysis
    • toxicology screen
Differential
  • Cardiac trauma 
    • cardiogenic shock
    • can include cardiac tamponade, contusion, laceration
    • bleeding above diaphragm
  • Pulmonary trauma 
    • impaired oxygenation and ventilation
    • diaphragmatic injury can cause bleeding to spill into abdomen

Management

  • Medical
    • when to obtain imaging in blunt abdominal trauma
      • equivocal abdominal physical exam
      • multiple trauma patient with altered mental status 2/2 head trauma or drugs/alcohol
      • patient with suspected spinal cord injury causing abdominal anesthesia
      • unexplained shock/hypotension
      • fractures of lower ribs, pelvis, spine
    • start with FAST ultrasound for blunt abdominal trauma
  • Surgical
    • blunt abdominal trauma
      • if positive:
        • hemodynamically (HD) unstable:
          • start IV fluids 
          • go to OR for laparotomy 
        • HD stable: get CT (sometimes CT may be a better initial step depending on the context)
      • if negative:
        • HD unstable: repeat FAST or get DPL
        • but mechanism of injury is significant: get CT
        • if no risk factors: observe with repeat serial physical exams
      • if equivocal:
        • HD unstable: get DPL
        • HD stable: get CT
      • solid organ injuries in blunt abdominal trauma
        • treat based on hemodynamic stability, not specific injury
        • if unstable, go to OR for laparotomy
          • if stable, spleen/liver/kidney lacerations and hematomas can be graded
          • higher grade portends increased risk of bleeding
          • consider angiography with embolization
      • hollow viscus injuries in blunt abdominal trauma
        • evidence of perforation (free air in peritoneal cavity)
          • next best step: go to OR for laparotomy
    • penetrating abdominal trauma
      • if gunshot or stab wound
        • next best step: go to OR for laparotomy 
      • any gunshot wound below the nipple line is considered to be abdominal
      • if shock, peritonitis, evisceration, free air in abdomen, or blood in NG/Foley/DRE
        • nest best step: go to OR for laparotomy
    • retroperitoneal trauma
    • classified and triaged by zones on imaging 
      • zone 1 (central)
        • high risk of bleeding from major vessels, pancreas, and duodenum
        • next best step: go to OR for laparotomy
    • zone 2 (perirenal)
      • if stable, next best step: continue to observe
      • if HD unstable or penetrating trauma, first obtain contralateral renal function
        • next best step: go to OR for exploration based on renal function
    • zone 3 (pelvic)
      • first control bleeding with pelvic binder
      • if stable and blunt trauma, no surgical exploration
        • next best step: consider angiography and embolization
      • if unstable and penetrating trauma, surgical exploration may be necessary
Complications
  • Surgical wound infection
    • manage with surgical debridement and broad-spectrum antibiotics 
  • Shock 
    • resuscitate with a massive transfusion protocol (do NOT just give crystalloids)
    • positive pressure ventilation can worsen hypotension secondary to increased intrathoracic pressure

References

 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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