1

ACS

Abdominal Trauma

ACS

Objectives
Describe external and internal anatomy

Recognize blunt vs penetrating injury

patterns

Identify signs of different types of injuries

Apply diagnostic and therapeutic

procedures

Demonstrate and discuss DPL

ACS

Abdominal Trauma

Unrecognized injury : Cause of

preventable death
Exam compromised by
Alcohol, illicit drugs
Injury to brain, spinal cord
Injury to ribs, spine, pelvis

ACS

Anatomy
External

Anterior abdomen
Flank
Back

Anatomy

ACS

ACS

Mechanism of injury
Blunt

Spleen, liver, and hollow viscus

Compression
Crushing
Shearing
Deceleration (fixed organs)

ACS

Mechanism of injury
Penetrating

Liver , small bowel, and colon

Laceration / low energy
Kinetic energy / high energy

ACS

Assessment : History
Blunt

Speed
Point of impact
Intrusion
Safety devices
Position
Ejection

Penetrating

Weapon
Distance

ACS

Assessment : Physical Exam

Inspection
Percussion
Palpation
Auscultation

10

ACS

Assessment : Physical Exam

Local wound exploration by surgeon

Pain over bony pelvis

Genitourinary, perineal, rectal,vaginal

and gluteal

11

ACS

Adjuncts : Intubation
Gastric Tube

Relieves dilatation
Decompresses stomach before DPL
Basilar skull / facial fractures
May induce vomiting /
aspiration

12

ACS

Adjuncts : Intubation
Urinary Catheter

Monitors urinary output

Decompresses bladder before DPL
Diagnostic
Urethral injury

13

ACS

Adjuncts : x ray Studies

Routine

Blunt : AP chest, pelvis

Penetrating : AP chest, abdomen with
markers (if hemodynamically normal)

Contrast

Urethrogram
Cystogram

GI
IVP

14

ACS

Special Studies in Blunt Trauma

DPL

US*

CT

Time

Rapid

Rapid

Delayed

Transport

No

No

Required

Sensitivity

High

High?

High

Specificity

Low

Intermediate

High

Eligibility

All
patients

All patients

Hemodynamically normal

*operator dependent

15

ACS

Indications for Celiotomy

Blunt

+ DPL or ultrasound
BP suspected
visceral injury
Peritonitis

Penetrating

+ DPL or ultrasound

Peritoneal /
retroperitoneal injury
Peritonitis
Hypotension
Evisceration

16

ACS

Indications for Celiotomy

Plain X ray
Free air
Retroperitoneal air
Ruptured diaphragm

17

ACS

Indications for Celiotomy

Special Studies
CT scan : Free air, visceral injury ?
Fluid?
Cystogram : Bladder rupture,
intraperitoneal injury
Arteriogram: Renal pedicle occlusion
Upper GI : Duodenal rupture

18

ACS

Special Problems : Blunt Trauma

Diaphragm :
Duodenum/
Small bowel :
Pancreas :
GU :

Abnormal chest x ray

Retroperitoneal air, contrast

Seat belt sign, Chance

fracture, free air
Amylase?, CT?
Extravasation of contrast
nonfunctioning renal

19

ACS

Pelvic Fractures

Significant force
applied
Associated injuries
Pelvic bleeding
Ends of bones
Pelvic muscles
Veins / arteries

20

ACS

Pelvic Fractures
Mechanism

AP compression
Lateral
compression
Vertical shear

Classification

Open
Closed

21

ACS

Pelvic Fractures
Assessment

Inspection
Palpate prostate
Pelvic ring
Leg-length discrepancy , external rotation
Pain on palpation of bony pelvic ring
AP x-ray

22

Pelvic Fractures : Management

ACS

Resuscitate
Transfer as needed with PASG
Determine if intraperitoneal hemorrhage
Operation
Control hemorrhage

Fixation device

Possible angiography

23

ACS

Questions

24

ACS

Summary

ABCDEs
Delineate mechanism
Repeated exams
Diagnostics as needed
High index of suspicion
Early recognition /prompt celiotomy