Updated: 12/20/2019

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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