ABDOMINAL TRAUMA : AN OVERVIEW

Dr S. Lal MS
Associate Professor Department of Surgery ESI PGIMSR New Delhi

Introduction
Abdominal trauma is regularly encountered in the emergency department One of the leading cause of death and disability Identification of serious intra-abdominal injuries is often challenging Many injuries may not manifest during the initial assessment and treatment period

Epidemiology
Peak incidence Abdominal Trauma 15 - 30yr More than 1.5 Lac people die every year as a result of injuries by motor vehicle accident , fall, suicide and homicide Injury accounts for 10% of all deaths Estimates indicate that by 2020, 8.4 million people will die yearly. Prevalence: 13%

Types of Abdominal Trauma

1.Blunt Trauma 2.Penetrating Trauma -Stab -Gun shot Injury

M.V. Accidents involving high kinetic energy and acceleration or deceleration forces - 60%

Direct blow to abdomen - 15% Fall- 6-9%

Blunt Trauma Abdomen (contd.)

Child Abuse Domestic Violence Iatrogenic injury -Endoscopic /Laparoscopic surgical procedures -Bag-mask ventilations -Inadvertent esophageal intubation -External cardiac compressions -Heimlich manoeuvre

Penetrating Trauma

Penetrating abdominal trauma has a slightly higher mortality rate Second most common cause of abdominal injury

Gunshot Injury
Gunshot and stab wounds combine to cause 95% of penetrating abdominal injuries.

Prehospital Care
The goal of prehospital is to deliver the pt to hospital for definitive care as rapidly as possible. Scoop and Run Maintain airway & start I V line Care of spinal cord Communicate to medical control Rapid transport of patient to trauma centre

Initial Assessment and Resuscitation

Primary survey
Identification & treatment of life threatening conditions Airway , with cervical spine precautions Breathing Circulation Disability Exposure

Emergency Care
I V fluids Control external bleeding Dressing of wounds Protect eviscerated organs with a sterile dressing Stabilize an impaled object in place Give high flow oxygen Immobilize the patient with a fractured pelvis Keep the patient warm Analgesics

Secondary Survey
General &Systemic Examination-to identify all occult injuries . Special attention to Back, Axilla , Perineum PR - sphincter tone ,bleeding ,perforation , high riding prostate Foleys catheter- monitor urine out put Nasogastric tube

Secondary Survey(contd.)
AMPLE History A: Allergy M: Medications P: Past medical history L: Last meal E: Event - What happened

Examination
Laceration Abrasion Entry/Exit wounds Involvement chest & Head injury Seat Belt Sign

Cullens Sign:1918

Examination

Bluish discoloration around umbilicus Diffusion of blood along periumbilical tissues or falciform ligament Hemoperitoneum Severe pancreatitis

Examination Grey-Turners Sign: (1877-1951)

Bluish discoloration of the flanks Retroperitoneal Hematoma hemorrhagic pancreatitis.

Kehrs sign (1862-1916). Referred pain, Right shoulder irritation of the diaphragm (Splenic injury, free air, intra-abdominal bleeding)

Examination
Balances Sign
Dullness on percussion of the left upper quadrant ruptured spleen

Labia and Scrotum : Pooling of blood from abdominal and pelvic cavities.

Examination
Auscultation :1. Bowel sounds in the thoracic cavity (Diaphragmatic rupture) 2. Haemothorax Palpation: -Mass -Tenderness -Signs of peritonitis -# Ribs -Chest & Pelvic compression test

Investigations
FAST X-Ray Chest & Abdomen USG CT Scan Paracentasis Diagnostic Peritoneal Lavage Diagnostic Laparoscopy

Focused Assessment with Sonography in Trauma (FAST)

First used in 1996 Rapid , Accurate Sensitivity 86- 99% Can detect 100 mL of blood Cost effective Four different views- Pericardiac Perihepatic Perisplenic Peripelvic space Eliminates unnecessary CT scans Helps in management plan

Plain X-Ray Chest & Abdomen

Pneumotharax, Haemothorax Free air under diaphragm Nasogastric tube, bowel loops in the chest Elevation of the both /Single diaphragm Lower Ribs # -Liver /Spleen Injury Ground Glass Appearance Massive Hemoperitoneum Obliteration of Psoas Shadow Retroperitoneal Bleeding #vertebra

USG
Advantage Easy & Early to Diagnose Noninvasive No Radiation Exposure Resuscitation/Emergency room Used in initial Evaluation Low cost Disadvantage . Examiner Dependent Obesity Gas interposition Low Sensitivity for free fluid less 500 mL False Negative retroperitoneal & Hallow viscus injury

Paracentasis
Four quadrant aspiration of abdomen A Positive tap blood , air , bile stained fluid Negative tap doesnt rule out injury. False negatives are as high as 22-60%

Diagnostic Peritoneal Lavage

First described in 1965 Rapid & Accurate test used to identify intra-abdominal injuries Predictive value of greater than 90% The RBC count for lavage fluid is > 1,00,000/cu m.m. A WBC count > 500/cu m.m. Test is highly sensitive to presence of intraperitoneal blood However specificity is low

Diagnostic Peritoneal Lavage

Indications Unexplained Shock Altered sensorium (Head injury , Drug) General anesthesia for extraabdominal procedures Contraindications Clear indication for Exploratory Laparotomy Relative -Previous Expl. Laparotomy -Pregnancy -Obesity

CT Scan
Gold Standard Haemodynamically Stable Provides excellent imaging of pancreas, duodenum and Genitourinary system Standard for detection of solid organs injury. Determines the source and amount of bleeding Can reveal other associated injuries e.g. Vertebral & Pelvic # & injury in the thoracic cavity . High Specificity-95%

CT Scan Contraindication: Clear indication for Laparotomy Haemodynamically Unstable Allergy to contrast media

DIAGNOSTIC LAPAROSCOPY

Haemodynamically stable patients Inadequate/equivocal USG Mild hypotension or persistent tachycardia Persistent abdominal signs/symptoms It decreases non-therapeutic laparotomies Useful in penetrating injury Limitation :Retroperitoneal Injury

Solid Organ Injuries

Grading of injured solid organs such as Spleen, Liver & Kidneys are on the basis of subcapsular hematoma ,capsular tear, parenchymal lacerations & avulsion of vascular pedicle Bleeds significantly and cause rapid blood loss

Difficult to identify injury by physical exam

Repeated assessment is required to make the diagnosis

Slowly oozing blood into peritoneal cavity

SPLENIC INJURY
Most common intra- abdominal organ to injured (40-55%) 20% of splenic injuries due to left lower rib fractures Commonly arterial hemorrhage Conservative management : -Hemodynamic stability - Negative abdominal examination -Absence of contrast extravasation in CT - Absence of other indication of Laprotomy -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm) Monitoring Serial abdo. Examinations & Haematocrit are essential Success rate of conservative m/m is >80%

Splenic Injuries
Operative Management
Capsular tears (I)- Compression & topical haemostatic agent Deep Laceration (II)- Horizontal mattress suture or Splenorrhaphy Major Laceration not involving hilum (IV)Partial Splenectomy Hillar injury (V)Total Splenectomy Grade IV-V: intervention almost invariably require operative

Success rate of Splenic salvage procedure is 40-60%

 Liver is the largest organ in abdomen 2nd most common organ injured (3545%) in BTA Driving and fighting responsible for 50% of deaths due to liver injury Usually venous bleeding 85% of all patients with blunt hepatic trauma are stable CT is the mainstay of diagnosis in stable pt.

Liver injury

Liver Injury
50% liver injury have stop bleeding spontaneously by the time of surgery Non Operative m/m Haemodynamically Stable

No other intra-abdominal injury require surgery

< 2 units of BT required Hemoperitoneum <500 ml on CT Grade I-III(subcapsular & intr-perenchymal hematoma)

Liver Injury
Packing - Bleeding can be stopped by packing of abdomen -Pack removed after 48 hr -haemostatic agents -34 % survival in packing only

Operative m/m

Liver Injury
Operative Management(Contd.)
Suturing: -Simple suture -Deep mattress suture Laceration: -Mesh hepatorrhaphy -Omental flap to cover the laceration - Debridement Lobar Resection Liver Transplantation Ligate or repair damaged blood vessels & bile duct Mortality of liver injury is 10%

Pancreatic Injury
Rare 10-20% of all abdominal injury Crush , Direct blow to abdo & Seat belt injury Associated with abdo. Duodenal injury, Vascular injury & liver injury Diagnosis Difficult, High index of suspicion CECT Scan is helpful Serum amylase is a poor indicator Usually diagnose on Laparotomy Distal Pancreatic injury - Distal resection Pancreaticojejunostomy Injury to Ampulla of Vater, Head & Body of Pancreas

Pancreatic Injury

Renal Injury
Clinically not suspected & frequently overlooked Mechanism: Blunt , Penetrating # lower ribs or spinous process, Crush abdominal Pelvic injury Direct blow to flank or back Fall MVA

Renal Injury
Diagnosis
1.History ,Clinical examination 2. Presentation :Shock, hematuria & pain 3. Urine: gross or microscopic hematuria

Renal Injury
Diagnosis (contd.)
5.X-ray KUB IVP 7. USG 6.CT Scan abdomen 8. Radionuclide Scan The degree of hematuria may not predict the severity of renal injury

Renal Injury
.

Classification of Injury

Grade I : Contusion or Subcapsular Hematoma Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation Grade III: Laceration >1cm with urinary Extravasation Grade IV: Parenchymal Laceration deep to CM Junction Grade V: Renovascular injury

Management of Renal Injury

About 85% of blunt renal trauma can be manage by conservatively Renal Contusion : Conservatively Renal exploration : Indication Deep cortico-medullary Laceration with extravasation Large perinephric Hematoma Renovascular injury Uncontrolled bleeding Before Nephrectomy ,Contralateral Kidney should be assessed

Diaphragmatic Injury
Incidence -0.8%-1.6% in BTA High index of suspicion required , may be missed. 40 to 50% are diagnosed immediately Presentation may be delayed Imaging Nasogastric tube seen in the thorax Abdominal contents in the thorax Elevated hemidiaphragm (>4 cm Lt vs Rt) Distortion of diaphragmatic margin. Lt- 69% , Rt -24% B/L- 15%

Diaphragm Rupture /Hernia

S Lal, Y Kailasia , S Chouhan , APS Gaharwar, GP Shrivastava . Delayed presentation of post traumatic diaphragmatic hernia. JSCR 2011. 7:6

Diaphragm Rupture /Hernia

S Lal, Y Kailasia, S Chouhan, APS Gaharwar, GP Shrivastava. Delayed presentation of post traumatic diaphragmatic hernia. JSCR 2011. 7:6

Hollow Viscus Injuries

Gastric Injury :
Penetrating trauma MC Blunt trauma abdomen 1% Causes Penetrating Injury -Crushing Against the Spine -CPR -Vigorous Ventilation with ET Tube in the Esophagus -Heimlich Maneuver Diagnosis : X-Ray chest & Abdomen CT scan Diagnostic Peritoneal Lavage During Surgical Exploration T/t : Expl. Laparotomy with Primary Repair

Hollow Viscus Injuries (Contd.)

Duodenum
Isolated Duodenum injury rare Incidence - 3-5%

Cause :Penetrating injury: mc Steering wheel injury Assault Fall Associated with other intra-abdominal injury Diagnosis: Plan X-ray Free air in abdomen -Intraoperative diagnosis
Rx : Primary Repair 80% case Roux-en Y duodenojejunostomy 20%

Hollow Viscus Injuries

Small Intestine& Colonic Injuries
Commonly Injured in Penetrating injury Blunt Trauma -Incidence 5% -20%
Mechanism : -Crush Injury -At Fixed point DJ & IC Junction Rx : Exploratory Laprotomy

Bladder Injury
Commonly in BTA 70% of bladder Injury are associated with pelvic fracture . Hematuria Type 1.Extraperitoneal Rupture-by bony fragment 2. Intraperitoneal Rupture- at dome when blow in distended bladder Diagnosis -1. Clinical 2. Cystography T/t 1. Intraperitoneal trans-peritoneal - closure +SPC 2:Extraperitoneal Rupture : Foleys catheter -10 -14 days

Ureteral Injury
Uncommon Mostly occur after penetrating trauma Associated with concomitant intra-abdominal or genitourinary injury Diagnosis -IVP -15-20% Retrograde ureteroscopy - At the time of Laparotomy Operative procedure Proximal & mid ureter -End to end Anastomosis over DJ Stent Distal Ureteric Reimplantaion

Vascular Injury
Incidence 5-10% Highly lethal. Associated with extremely rapid rates of blood loss Exposure is difficult in Laparotomy Initial Control by digital pressure Heparinized saline (50U/ml) injected in both end of vessel Rx Lateral suture ,End to end Anastomosis & Interposition graft Mortality rate is very high

Trauma in Pregnancy
Incidence- 10-20% Causes: 1.Domestic violence 2.Sexual Assault 3. Accident Third trimester- mc- balance & coordination disturbed Multidisciplinary team- Obstetrician, surgeon, and neonatologist Peritoneal sign are delayed Supine hypotensive syndrome > 20 weeks gestation. COMPLICATIONS Fetal Injury & Death fetoplacental injury, maternal shock, Placental Abruption Rupture of Uterus

Penetrating abdominal trauma

Gunshot Stab wound

Penetrating Abdominal Trauma

Patients with deep penetrating injuries always require surgery Common Organs Small int.(29%) liver(28%) Colon(23%)

EAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

Penetrating Abdominal Trauma(Contd.)

Multiple in 20% of cases Most stab wounds do not cause an intraperitoneal injury A complete Laparotomy is mandatory

Penetrating Abdominal Trauma(Contd.)

Abdominal Evisceration

Stab wound to right lower quadrant with caecal evisceration. No colon injury at laparotomy

Penetrating Abdominal Trauma(Contd.)

Abdominal Evisceration
Never try to replace organs
Cover with moist gauze, then sterile dressing.

Transport immediately

Gunshot Injury
Handguns, Rifles, and Shotgun More dangerous than penetrating injury

The degree of injury depends . Amount of kinetic energy imparted by the bullet to the
victim Mass of the bullet and the square of its velocity Distance .

Injury multiple organ

Injury Prevention
1.Primary: Prevent an injury from its occurrence in the first place: Educational activity such as antidrink-driving campaigns , speed limit rule -Children should accompanied with parent 2.Secondary: Attempts to lesson the consequences of injury making road & safer car, anti-locking brakes, air bags , helmets, seat belt 3. Tertiary: Minimize the effect of injury by health care by individuals & system.

Injury Prevention (Contd.)

Speed is a critical factor ; a 10% increase speed translate into a 40% rise in the case fatality rate. Use of seat belt reduces the risk of death or serious injury by 45%. Air Bags reduces the risk of fatal injury by 30% & deaths by 11 %. Children Below 12yrs should be properly restraints in the back seat. Motorcycle experience death rate 35 time greater than car.

Summary
Injuries are Preventable Trauma is a massive & growing health burden worldwide ,which increasingly afflicts the young & productive age group. Repeated assessment is required to make the diagnosis Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of Hemoperitoneum Conservative approach in Liver & Renal Injury Successful m/m of trauma requires integration of Prehospital ,in-hospital ,& rehabilitative care.