Abdominal Trauma

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Let’s open with a bit of trivia: what kind of injuries can you receive from a seatbelt?

A.     Retroperitoneal duodenal trauma

B.     Intraperitoneal bowel transection

C.     Mesenteric injury

D.    L-spine injury

E.     All of the above

If you chose D like me, you would be wrong! The answer is “all of the above”. Who knew seatbelts can cause so many abdominal injuries?!

Two main types of injuries can cause abdominal trauma: blunt (causing solid organ injury, with the spleen most commonly affected followed by the liver) and penetrating (causing hollow organ or liver injury). Penetrating injuries are most common.

Blunt trauma of the abdomen can result in two types of hemorrhage: intraperitoneal and retroperitoneal. When a patient presents with multi-system trauma, be extra suspicious of blunt trauma damage in the abdomen. A history focused on the mechanism of injury should be included in the general medical history.

Physical examination is often unreliable in multi-system trauma, with a wide spectrum of presentations; sometimes abdominal symptoms may be masked by other injuries—therefore serial examinations need to be done. Common findings include tachycardia, tachypnea, oliguria, febrile, and hypotension; signs of slow blood loss may not be apparent right away.

·      Inspect: contusions, abrasions, seatbelt sign, distention

·      Auscultate: bruits, bowel sounds

·      Palpate: tenderness, rebound tenderness, rigidity, guarding

·      DRE: rectal tone, blood, bone fragments, prostate position

·      Placement of NG tube and Foley catheter should be considered part of the abdominal exam. Foley catheter should be inserted in unconscious patient or patient with multiple injuries who cannot void spontaneously. NG tube can be used to decompress the stomach and proximal small bowel; but it’s contraindicated for patients with suspected facial fractures or basal skull fractures.

Investigations

·      Laboratory—CBC, electrolytes, coagulation profile, cross and type, glucose, creatinine, creatinine kinase, lipase, amylase, liver enzymes, ABG, blood alcohol levels, toxicology screen, and beta HCG (where applicable).

·      Urinary analysis

Imaging MUST be done if:

·      Equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia).

·      Unexplained shock/hypotension

·      Multiple trauma patients who must undergo GA for orthopedic, neurosurgical, or other injuries

·      Fracture of lower ribs, pelvis, spine

·      Positive FAST

*Criteria for positive lavage:

·      > 10cc gross blood

·      Bile, bacteria, foreign material

·      RBC count > 100,000 x 10⁶/L

·      WBC count > 500 x 10⁶/L

·      Amylase > 175IU

Management

·      General—ABCs, fluid resuscitation, and stabilization

·      Surgical—watchful waiting vs. laparotomy

·      Solid organ injuries—decision based on hemodynamic stability, not the specific injuries

·      Hollow organ injuries—laparotomy

·      Even if low suspicion of injury—admit and observe for 24hrs

Penetrating trauma of the abdomen has a high risk of gastrointestinal perforation and sepsis. It’s important to note the size of blade, caliber/distance from gun, and route of entry in the history. Local wound exploration under direct vision may determine lack of peritoneal penetration (not reliable in inexperienced hands) with exception to thoraco-abdominal region (may cause pneumothorax) and wounds of the back or flanks (muscles too thick).

Remember the Rule Of Thirds:

1/3 do not penetrate peritoneal cavity

1/3 penetrates but are harmless

1/3 cause injury requiring surgery

Laparotomy is mandatory if penetrating trauma and one or more of the following:

·      Shock

·      Peritonitis

·      Evisceration

·      Free air in abdomen

·      Blood in NG tube, Foley catheter, or DRE

Management

·      General—ABCs, fluid resuscitation, and stabilization

·      Gunshot wounds—ALWAYS require laparotomy