Abdominal trauma

Background

• >35% of blunt trauma patients 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

Classes of hemorrhagic shock

Class	I	II	III	IV
Blood Loss (mL)	<750	750-1000	1500-2000	>2000
Blood Loss (%)	<15	15-30	30-40	>40
Pulse rate (per min)	<100	100-120	120-140	>140
Blood Pressure	Normal	Normal	Decreased	Decreased
Pulse Pressure (mmHg)	Normal or Increased	Decreased	Decreased	Decreased
Respiratory Rate (per min)	14-20	20-30	30-40	>35
Urine Output (mL/hr)	>30	20-30		Negligible
Mental Status	Slightly Anxious	Mildly Anxious	Anxious, Confused	Confused, Lethargic
Fluids	Crystalloid	Crystalloid	Crystalloid and blood	Crystalloid and blood

Clinical Features

Solid Organ Injuries

• Signs/symptoms due to blood loss
  • May bleed slowly / delayed onset of shock
  • Spleen most likely solid organ injured

Hollow visceral injuries

• Signs/symptoms 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

• Signs/symptoms may be subtle or completely absent initially
• Duodenal rupture is often contained within 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
  • shortness of breath, 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

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

Evaluation

Imaging

• Ultrasound (FAST)
  • Indicated for hemodynamically unstable trauma patients
  • Sensitivity increases with serial exams
  • Cannot reliably evaluate retroperitoneum / hollow viscous injury
  • Lower sensitivity in the setting of pelvic fractures
• CT
  • Consider triple-contrast (IV, PO, PR) if concern for GI trauma or penetrating flank or back trauma

ATLS Blunt Abdominal Trauma Algorithm

• Unstable
  • FAST to search for free fluid (vs. DPL if unavailable)
    • Positive: Exploratory laparotomy
    • Negative: CT scan
• Stable
  • CT scan
    • Exploratory laparotomy, angiographic embolization, conservative management as indicated

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, discharge 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 (main)
• 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.

Authors

Ross Donaldson