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Updated: Dec 15 2021

Abdominal Trauma

Images
https://upload.medbullets.com/topic/120639/images/fastspleen.jpg
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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
  • ETIOLOGY
    • 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
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