PRIMARY GOAL--> To recognize conditions

that require immediate surgical exploration

The most critical error is to delay surgical

intervention when it is needed

When to suspect abdominal injuries?
BLUNT
Result from either compression secondary to direct
blow or against a fixed external object. Example : a seat
belt or from deceleration forces

PENETRATING
This implies either a gunshot wound or high velocity
missile/fragment or a stab wound has entered the
abdominal cavity.
Weapon
Distance
Number and location of wounds
BLUNT FORCE MECHANISM

Commonly injured organs :

Spleen
Liver
Small bowel
PENETRATING MECHANISM
Any organ is at risk
1. Stab
Low energy
Lacerations

2. Gunshot
Kinetic energy transfer
i. Cavitation, tumble
ii. Fragments
ASSESSMENT OF ABDOMINAL
INJURY
NUR NADIRAH BT MD SIDEK
012013051899
 INITIAL ASSESSMENT
Brief history taken by the paramedics (at the scene
or in the ambulance):
Mechanism of injury: Blunt or penetrating injury
Co morbids: Drugs or alcohol
Vital signs (to asses the presence of
hypovolaemic shock):
o Pulse rate (weak pulse)
o Blood pressure (hypotension)
o Respiratory rate (tachypnea)
o Heart rate (tachycardia)
 PRIMARY SURVEY
1. Airway and cervical spine control
2. Breathing
3. Circulation and haemorrhage control
(to control any external bleeding)
4. Disability
5. Exposure and environment
 PRIMARY ADJUNCT
X-ray of the pelvis
ABG and ventilation monitoring
Urinary catheter and nasogastric tube
FAST scan to detect intra abdominal free fluid
 SECONDARY SURVEY
Rapid history (S.A.M.P.L.E)
Co morbidities:
o Substance abuse
o Suicide attempt
Head to-toe examination (*abdominal
examination)
 ABDOMINAL EXAMINATION
INSPECTION:
Abdominal distension
Abdomen moves with respiration
Evaluate any external signs of injury :
KEHRS SIGN:
Referred pain at the tip of the shoulder
due to irritation of the diaphragm
Splenic injury
Free air
Intra-abdominal bleeding

SEAT BELT SIGN:

Mesenteric or bowel injury
 GREY-TURNERS SIGN:
Bluish discoloration of the flank
Retroperitoneal Hematoma
Hemorrhagic pancreatitis.

PALPATION:
Tenderness.
Guarding (Peritoneal irritation)
Rigidity.
Positive rebound tenderness:
(Haematoperitoneum)
PERCUSSION:

BALANCES SIGN:
Dullness on percussion on the left upper
quadrant
Ruptured spleen

Auscultation (all 4 quadrants):

Active or diminished bowel sound: (Peritonitis)
 Pelvic Stability:
Use compression forces over the iliac creast
and pubic symphysis (If there is movement, it
shows pelvic unstable).

Genital and Rectal examination:

Blood in urethral meatus (Urethral injury)
Determine prostate position ( high riding
prostate in urethral injury).
Assess sphincter tone (Vertebral or Spinal
injury).
 SECONDARY ADJUNCT
1. FBC, Haematocrite, blood grouping and cross
matching.
2. LFT (increase in injury cases)
3. Toxicology screening ( drugs or alcohol)
4. CT scan of abdomen
5. Diagnostic peritoneal lavage (DPL) (to detect
fluid in abdomen surgically)
Investigation and management
of abdominal trauma
Farha Amalina Bt Ahmad Faudzi
012013051893
Patient should be managed in the critical care
area
Airway: establish and maintain the airway
Breathing: give high flow oxygen if patient
conscious and spontaneously breathing, if
unconscious require endotracheal intubation
Circulation; Establish (14/16G) cannulae for
venous access
Refer and consult the general surgeon early
 Modes of investigation in suspected
abdominal trauma patient

Hemodynamic
assessment

Stable unstable

Bedside ultrasound and/or Bedside ultrasound

abdominal CT and/or DPL
 DIAGNOSTIC PERITONEAL LAVAGE
Surgical diagnostic method to determine
presence of fluid in the abdomen.
Less frequently done due to advancement in
CT.
Mostly used to detect intra-abdominal
hemorrhage in unstable trauma patients.
Indications
any unstable patient in whom there is suspicion of
abdominal trauma or where clinical examination is
difficult
Unexplained hypotension in multiple trauma
Patient sustained blunt trauma require immediate
operation for extra-abdominal injuries
Contraindications
Presence of obvious indications for
exploratory laparotomy.
History/evidence of multiple previous
abdominal surgeries (do CT)
Coagulopathy
pregnancy
 Indicators of positive DPL
Frank blood >5ml/ obvious bowel contents
aspirated
Lavage fluid seen to exit from the chest
drain/urinary catheter
Effluent; - RBC >100,000cells per mm3
-WBC >500cells per mm3
-Graim stain positive for bacteria
 Laparotomy
Usually performed in patients with acute or
unexplained abdominal pain, in patients who have
sustained abdominal trauma, and occasionally for
staging in patients with malignancy.
 Indication for immediate laparotomy
Evisceration and gunshot wound traversing the
abdominal cavity
Any penetrating injury to the abdomen with
hemodynamic instability and hemoperitoneum
Strongly suspected intra-abdominal injury with shock
Obvious sign of peritoneal irritation
Rectal examination reveals fresh blood
Persistent fresh blood aspirated from nasogastric tube if
oropharyngeal injuries have been excluded as a cause for
bleeding
X-ray evidence of pneumoperitoneum/diaphragmatic
rupture
 Contraindications
Unfitness for general anaesthesia
-Peritonitis with severe sepsis
-Advanced malignancy
LAKSHMI A/P JEGATHEESAN
 FAST SCAN
Focussed Assessment with Sonography for
Trauma (FAST) scan

is a rapid, bedside limited ultrasound

examination directed solely at identifying the
presence Intra-abdominal free fluid
 INDICATION
Blunt abdominal trauma ( BAT)

Stable penetrating trauma

Assessment of the degree of intraperitoneal

free fluid
 TECHNIQUE

patient in supine position

3.5-5.0 MHz convex transducer used.

five regions may be scanned

subxiphoid transverse view: assess for pericardial effusion and left lobe
liver injuries
longitudinal view of the right upper quadrant: assess for right liver
injuries, right kidney injury, and Morison pouch
longitudinal view of the left upper quadrant: assess for splenic
injury and left kidney injury
transverse and longitudinal views of the suprapubic region: assess the
bladder and pouch of Douglas

left and right thoracic views to assess for pneumothorax

 Perihepatic scan

Probe placement for right upper quadrant

laterally
Right mid- to posterior axillary line at the level
of the 11th and 12th ribs
Hepatorenal space is the most dependent part
of the upper peritoneal cavity and small
amounts of intra-peritoneal fluid may collect in
this region first.
Blood shows as a hypoechoic black stripe
between the capsule liver and the fatty fascia
of the kidney
Probe position
for RUQ
 Perisplenic scan
Probe placement for left upper quadrant
laterally
The left upper quadrant examination
visualises the spleen and perisplenic areas.
The transducer is placed on the left posterior
axillary line region between the 10th and 11th
ribs.
Probe position for LUQ
 Pelvic scan
Suprapubic probe placement
The pelvic examination visualises the Pouch of
Douglas in females and the rectovesical pouch
in the male.
It is the most dependent portion of the lower
abdomen and pelvis, fluid will collect.
The transducer is placed midline just superior
to the symphysis pubis.
Probe position for pelvis
 Pericardial sub-xiphoid scan
Subxiphoid probe placement

The pericardial examination screens for fluid

between the fibrous pericardium and the
heart, and hence possible cardiac tamponade.

The transducer is placed just to the left of the

xiphisternum and angled upwards under the
costal margin
Probe position for pericardium
 BENEFITS OF FAST
Decreases the time to diagnosis for acute abdominal
injury in BAT
Helps accurately diagnose hemoperitoneum
Helps assess the degree of hemoperitoneum in BAT
Is non invasive
Can be perform at bedside
Can be integrated into the primary or secondary trauma
survey
Can be repeated for serial examinations
Does not expose patient to radiation
Safe in children and pregnant ladies
High specificity in the detection of free fluid
 DRAWBACKS OF FAST
Cannot asses retroperitoneal injuries
Limited ability to detect organ Injury
Requires at least 200 cc of fluid for
detection
May be difficult to differentiate ascites,
urine, and peritoneal dialysate from urine
Operator dependent
Difficult to examine obese patient
 CT SCAN

Computerized tomography
(CT) scan combines a
series of X-ray images
taken from different angles
and uses computer
processing to create cross-
sectional images

Well-suited to quickly
examine people who may
have internal injuries from
car accidents or other
types of trauma
 INDICATION
Detect internal injuries and internal bleeding
Blunt trauma with stable haemodynamics and
with no indication for urgent laparotomy
Further assessment for pelvic fracture,
retroperitoneal, diaphragmatic and urogenital
injuries
 CONTRAINDICATION
Pregnancy
Contrast allergy
Claustrophobia
 BENEFITS OF CT SCAN
Able to precisely locate intra-abdominal lesions

Able to evaluate retroperitoneum

Able to indentify injuries that can be managed

non-operatively

Non invasive
 DRAWBACKS OF CT SCAN
Expensive

Time is required to perform

Transportation of patient to radiology unit

Use of contrast needed

deliver a relatively high dose of radiation to the

patient
GENITOURINARY INJURY

SHARMELARANI (012011100175)
 Anatomy
Controls reproductive functions and waste discharge
Male genitalia lie outside pelvic cavity.
Except prostate gland and seminal vesicles
Female genitalia lie within pelvic cavity.
Except vulva, clitoris, labia
1) Kidney injuries
Kidneys lie in well-protected area.
Forceful blow or penetrating injury often involved
Suspect kidney damage
Abrasion, laceration, contusion in the flank
Penetrating wound in region of flank or upper abdomen
A hematoma in the flank region
Kidney injuries
Injuries may not be obvious.
However, you will see:
Signs of shock
Blood in urine (hematuria)
Treat for shock,monitor vital signs
2) Urinary bladder injuries
May result in rupture
Urine spills into surrounding tissues.
Blunt injuries to lower abdomen or pelvis can rupture urinary bladder.
In males, sudden deceleration can shear the bladder from the urethra.
Urinary bladder injury
Suspect if you see:
Blood at urethral opening
Signs of trauma to lower abdomen, pelvis, perineum
In presence of shock or associated injuries:
Transport promptly.
Monitor vital signs
3) External male genitalia injuries
Soft-tissue wounds
Painful and of great concern for patient
External male genitalia
General rules for treatment:
Use sterile, moist compresses to cover areas stripped of skin.
Apply direct pressure with dry, sterile gauze dressings to control bleeding.
Never move or manipulate foreign objects in urethra.
If connective tissue surrounding erectile tissue is damaged, shaft can be
fractured or angled.
Sometimes requires surgical repair
Injury may occur during active sexual intercourse.
Associated with intense pain, bleeding, and fear
Laceration of head of penis
Associated with heavy bleeding
Apply local pressure with sterile dressing.
Avulsion of the skin of the scrotum may damage scrotal contents.
Preserve avulsed skin in a moist sterile dressing.
Wrap scrotal contents or perineal area with a sterile moist compress; use local pressure for
bleeding.
Direct blows to scrotum can result in rupture of a testicle or accumulation of
blood around testes.
Apply ice to scrotal area.
4) Female genitalia injuries
Internal female genitalia
Uterus, ovaries, fallopian tubes are rarely damaged.
Exception is pregnant uterus
Uterus enlarges substantially and rises out of pelvis
Injuries can be serious.
Also keep fetus in mind.
External female genitalia
Vulva, clitoris, major and minor labia
Consider sexual assault and pregnancy.
If there is external bleeding, a sterile absorbent sanitary pad may be
applied to the labia.
Do not insert anything into the vagina.
Female genitalia
Treat lacerations and avulsions with moist, sterile compresses.
Use local pressure to control bleeding.
Hold dressings in place with diaper-type bandage.
Do not pack dressings into vagina.
Leave any foreign bodies in place after stabilizing with
bandages.
 Assessment
Mechanism of injury/nature of illness
Common associated complaints with genitourinary
injuries are:
Nausea and vomiting
Diarrhea
Blood in urine
Vomiting blood
Abnormal bowel and bladder habits
Vital signs
Important to reassess vital signs to identify differences in
condition.
Tachycardia, tachypnea, low blood pressure, weak pulse,
and cool, moist, pale skin indicate hypoperfusion.
 Primary survey
Airway and breathing
Ensure the patient has a clear and patent airway.
Protect from further spinal injury.
Consider advanced airway if patient is unresponsive.
Circulation
Assess pulse rate and quality.
Determine skin condition, color, and temp.
Check capillary refill time.
Closed injuries do not have visible signs of bleeding.
Control bleeding if seen.
 Physical examinations
Genitourinary system injuries can be awkward to
assess and treat.
Privacy is a genuine concern.
Focus on specific region of body when isolated injury
is present.
Identify wounds and control bleeding.
Start with a full-body scan for significant trauma.
Presence of penetrating injury indicates possible internal
injury.
Presence of burns must be noted and managed immediately.
Palpate for tenderness to localize the injury and presence of
fractures.
Look for lacerations and local swelling.
 Primary adjunct
U/S and Plain films
CT is the superior imaging modality
Careful with contrast (nephropathy)
Angiography remains the gold standard
IVP/Cystoscopy less useful in the ED
 Secondary survey
Rapid history
Comorbidities leading towards trauma
Systemic examination (whole body)
 PELVIC TRAUMA

FATIN AZREEN BINTI TAJUDIN

012011100278
 INTRODUCTION
Common pitfalls in management:
Failure to consider pelvic fracture in patient with
multisystem trauma.
Failure to give adequate resuscitation.
Failure to recognize associated in juries.

Blood loss is more severe in open pelvic fractures

compared to closed fractures.

Elderly women often have pelvic fractures with

minimal falls because of osteoporosis.
 MECHANISMS OF INJURY
Lateral compression
Anteroposterior compression
Vertical shear
Combination injuries
 ASSOCIATED INJURIES
Blood vessels and nerve trauma
Genitourinary trauma
Distal gastrointestinal tracts trauma

CAUSE OF DEATH

Uncontrolled bleeding
 PELVIC FRACTURES
Pelvic ring fracture
Fractures of a single bone without a break in
the pelvic ring
Acetabular fractures
 REFERENCES
Ooi, S., & Manning, P. (2004). Guide to the
essentials in emergency medicine. Singapore:
McGraw-Hill.
Tintinalli, J. E., Kelen, G. D., & Stapczynski, J. S.
(2004). Emergency medicine: A comprehensive
study guide. New York: McGraw-Hill, Medical
Pub. Division.
APPROACH TO PELVIC TRAUMA

NUR HIDAYU BT. RAHMAN

01201100270
 HISTORY

* suspect pelvis injury in every patient with

serious blunt trauma.
* ask patient about.
- areas of pain
- last urination or defecation
- presence of bladder sensation
- last solid or fluid intake
- brief past medical history
- current medications
- allergy
- in women, ask LMP (exclude pregnancy)
 PHYSICAL EXAMINATION

- Inspection: perineal / pelvic edema,

eccymoses,
lacerations,
deformities.
: any hematoma above the
inguinal region/scrotum (Destot sign)

- Palpate/Move : any tenderness or movement

: Stability assessment
: hip ROM
*avoid excessive motion in
unstable pelvis
 Stability assessment

Lateral iliac AP iliac pressure

pressure

AP pubic
pressure
- Rectal examination
: check for any high riding prostate
: abnormal bony prominence
: large hematoma or tenderness along the
fracture line. (Earle sign)
: anal spinchter tone
 RADIOLOGIC EVALUATION

Pelvis plain radiograph vs. CT scan

must be done once the patient is stable

Plain radiograph:
- standard AP pelvis radiograph
- Indications; hemodinamically unstable blunt
trauma patient.
; pelvic tenderness
; patient with signs of pelvic injury
- Additional views; lateral views
; AP views of each
hemipelvis
; int. and ext. oblique views
; inlet and outlet views
- CT scan is more sensitive (78% vs. 64%).
= gold standard.
- Do CT in stable patient who is going for
emergency abdominopelvic CT.
OR
Do CT if radiographic finding is negative for
highly suspicious cases.
- Others; contrast CT (soft tissue injury)
interventional CT (for embolisation
-pelvic angiography)
 Approach
Pelvic
Injury
- initial evaluation, ATLS algorithm
- ABCDE
Primary
: circulation survey
and
hemorrhagic Primary
control. adjunct

Secondary
survey
 Hemorrhagic control.
Stabilize the pelvis
- Benefits:-
: lesser space for blood accumulation
: tamponade bleeding sources
: prevent further damage of the pelvis
: reduces pain

- Methods
: Draw sheet methods
: PASG/MAST pants
: SAM pelvic sling
: Traumatic pelvic orthotic device (T-POD)
Draw sheet method
PSAG/MAST pant

T-POD
SAM pelvic sling
 On-going treatment
1) High flow oxygen
2) Fluid replacement
3) Analgesics

Repeat assessment of
- Vital signs
- Mental status
- Pain status