abdominal trauma ppt

Abdominal TraumaCheryl Pirozzi, MD

Fellow’s Conference 5/4/11

Abdominal Trauma

• Penetrating Abdominal Trauma– Stabbing 3x more common than firearm wounds– GSW cause 90% of the deaths– Most commonly injured organs: small intestine > colon > liver

• Blunt Abdominal Trauma– Greater mortality than PAT (more difficult to diagnose,

commonly associated with trauma to multiple organs/systems) – Most commonly injured organs: spleen > liver, intestine is the

most likely hollow viscus.– Most common causes: MVA (50 - 75% of cases) > blows to

abdomen (15%) > falls (6 - 9%)

Rosen’s Emergency Medicine, 7th ed. 2009

Pathophysiology of injury

Penetrating Abdominal Trauma• Stab Wounds

– Knives, ice picks, pens, coat hangers, broken bottles

– Liver, small bowel, spleen

• Gunshot wounds– small bowel, colon and liver– Often multiple organ injuries,

bowel perforations

Blunt Abdominal Trauma• Rupture or burst injury of a hollow organ by sudden rises in

intra-abdominal pressures • Crushing effect • Acceleration and deceleration forces → shear injury• Seat belt injuries

– “seat belt sign” = highly correlated with intraperitoneal injury

Physical Exam

• Generally unreliable due to distracting injury, AMS, spinal cord injury

• Look for signs of intraperitoneal injury– abdominal tenderness, peritoneal irritation, gastrointestinal

hemorrhage, hypovolemia, hypotension– entrance and exit wounds to determine path of injury. – Distention - pneumoperitoneum, gastric dilation, or ileus– Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's

sign) - retroperitoneal hemorrhage– Abdominal contusions – eg lap belts– ↓bowel sounds suggests intraperitoneal injuries– DRE: blood or subcutaneous emphysema

Diagnostic studies

• Lab tests: not very helpful• May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox

screen

Imaging

• Plain films: – fractures – nearby visceral damage– free intraperitoneal air – Foreign bodies and missiles

Imaging

• CT– Accurate for solid visceral lesions and intraperitoneal hemorrhage – guide nonoperative management of solid organ damage– IV not oral contrast– Disadvantages : insensitive for injury of the pancreas, diaphragm,

small bowel, and mesentery

Imaging

• Angiography– To embolize bleeding vessels or solid visceral hemorrhage

from blunt trauma in an unstable pt– Rarely for diagnosing intraperitoneal and retroperitoneal

hemorrhage after penetrating abdominal trauma

• Focused assessment with sonography for trauma (FAST) – To diagnose free intraperitoneal blood after blunt trauma– 4 areas:

• Perihepatic & hepato-renal space (Morrison’s pouch)• Perisplenic• Pelvis (Pouch of Douglas/rectovesical pouch)• Pericardium (subxiphoid)

– sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid

• Extended FAST (E-FAST): – Add thoracic windows to look for pneumothorax.– Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

Trauma.orgRosen’s Emergency Medicine, 7th ed. 2009

FAST• Morrison’s pouch (hepato-renal space)

trauma.org

• Perisplenic view

trauma.org Rosen’s Emergency Medicine, 7th ed. 2009

FAST• Retrovesicle (Pouch of Douglas)

• Pericardium (subxiphoid)

trauma.orgRosen’s Emergency Medicine, 7th ed. 2009

FAST• Advantages:

– Portable, fast (<5 min),– No radiation or contrast– Less expensive

• Disadvantages– Not as good for solid parenchymal damage, retroperitoneum,

or diaphragmatic defects. – Limited by obesity, substantial bowel gas, and subcut air.– Can’t distinguish blood from ascites. – high (31%) false-negative rate in detecting hemoperitoneum in

the presence of pelvic fracture

Diagnostic Peritoneal Lavage

• Largely replaced by FAST and CT• In blunt trauma, used to triage pt who is HD unstable

and has multiple injuries with an equivocal FAST examination

• In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury

• In GSW, not used much

Diagnostic Peritoneal Lavage

• 1. attempt to aspirate free peritoneal blood – >10 mL positive for intraperitoneal injury

• 2. insert lavage catheter by seldinger, semiopen, or open

• 3. lavage peritoneal cavity with saline• Positive test:

– In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3

– In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm3

Local Wound Exploration

• To determine the depth of penetration in stab wounds• If peritoneum is violated, must do more diagnostics

• Prep, extend wound, carefully examine (No blind probing)

• Indicated for anterior abdominal stab wounds, less clear for other areas

Laparoscopy • Most useful to eval penetrating wounds to

thoracoabdominal region in stable pt– esp for diaphragm injury: Sens 87.5%, specificity 100%

• Can repair organs via the laparoscope– diaphragm, solid viscera, stomach, small bowel.

• Disadvantages:– poor sensitivity for hollow visceral injury, retroperitoneum– Complications from trocar misplacement. – If diaphragm injury, PTX during insufflation

Management

• General trauma principles: – airway management, 2 large bore IVs, cover penetrating

wounds and eviscerations with sterile dressings

• Prophylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal perf/spillage– (eg zosyn 3.375 g IV)

• In general, leave foreign bodies in and remove in the OR

Management of penetrating abdominal trauma

forsurenot.com

• Mandatory laparotomy vs• Selective nonoperative management

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

• Mandatory laparotomy – standard of care for abdominal stab wounds until 1960s,

for GSWs until recently– Now thought unnecessary in 70% of abdominal stab

wounds– Increased complication rates, length of stay, costs– Immediate laparotomy indicated for shock, evisceration,

and peritonitis

• Selective management used to reduce unnecessary laparotomies

• Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair

• Strategy depends on abdominal region:– Thoracoabdomen

• Nipple line to costal margin

– Anterior abdomen• Xiphoid to pubis

– Flank and back• Posterior to anterior axillary line

Thoracoabdomen• Big concern is diaphragmatic injury

– 7% of thoracoabdominal wounds

• Diagnostic evaluation:– CXR (hemothorax or pneumothorax)– Diagnostic peritoneal lavage– FAST– Thoracoscopy

Thoracoabdomen

• Anterior abdomen– Only 50-70% of anterior stab wounds enter the abdomen– of these, only 50-70% cause injury requiring OR– 1. is immediate lap indicated ?– 2. Has peritoneal cavity been violated?– 3. Is laparotomy required?

Management of PAT

• Anterior abdomen

Rosen’s Emergency Medicine 7th ed

• Back/Flank– Risk of retroperitoneal

injury– Intraperitoneal organ

injury 15-40%– Difficulty evaluating

retroperitoneal organs with exam and FAST

– In stable pts, CT scan is reliable for excluding significant injury:

Gunshot wounds• Much higher mortality than stab wounds• Over 90% of pts with peritoneal penetration have

injury requiring operative management• Most centers proceed to lap if peritoneal entry is

suspected• Expectant management rarely done

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617Rosen’s Emergency Medicine 2009

Management of PAT

Gunshot wounds• assess peritoneal

entry by missile path, LWE, CT, US, laparoscopy (all limited)

Management of Blunt abdominal trauma

ashwinearl.blogspot.com

• Exam less reliable• Diagnostic studies to determine if there is

hemoperitoneum or organ injury requiring surgical repair– FAST, CT, DPL– In HD stable pts, CT is preferred

• Clinical Indications for Laparotomy after Blunt TraumaMANIFESTATION PITFALL

Unstable vital signs with strongly indicated abdominal injury Alternative sources, shock

Unequivocal peritoneal irritation Unreliable

Pneumoperitoneum

Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy)

Evidence of diaphragmatic injury Nonspecific

Significant gastrointestinal bleeding Uncommon, unknown accuracy

Damage Control

• Patients with major exsanguinating injuries may not survive complex procedures

• Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control

• 0. initial resuscitation• 1. Control of hemorrhage and contamination

– Control injured vasculature, bleeding solid organs– Abdominal packing

• 2. back to the ICU for resuscitation– Correction of hypothermia, acidosis, coagulopathy

• 3. Definitive repair of injuries• 4. Definitive closure of the abdomen

Damage Control

Resuscitation in the ICU• IVF (crystalloid, not colloid)• Transfusion

– ?1:1:1 PRBC/plt/FFP

• Recombinant activated factor VII– Increased thromboembolic complications

• Rewarming if hypothermic• Correction of metabolic abnormalities• Low tidal volume ventilation recommended (4-6 ml/kg)

Damage Control

Open abdominal wounds and definitive closure• 40-70% can’t have primary closure after definitive repair. • Temporary closure methods

Abdominal Compartment Syndrome

• Common problem with abdominal trauma• Definition: elevated intraabdominal pressure (IAP) of

≥20 mm Hg, with single or multiple organ system failure– ± APP below 50 mm Hg

• Primary ACS: associated with injury/disease in abdomen

• Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak)

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

• Effects of elevated IAP– Renal dysfunction– Decreased cardiac output– Increased airway

pressures and decreased compliance

– Visceral hypoperfusion

Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

• Management– Surgical abdominal decompression– Nonsurgical: paracentesis, NGT, sedation– Staged approach to abdominal repair– Temporary abdominal closure

Sugrue M. Curr Opin Crit Care 2005; 11:333-338Bailey J. Crit Care 2000, 4:23–29

Conclusions

• Watch out for implements and missiles violating the abdomen• Laparotomy is mandatory if shock, evisceration, or peritonitis• Diagnostic studies used to determine need for laparotomy in

PAT and BAT• FAST is noninvasive, quick and accurate way to evaluate for

intraperitoneal blood• Damage Control is a principle of staged operative

management with control and resuscitation prior to definitive repair

• Abdominal compartment syndrome is a common problem in abdominal trauma

References

• Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

• Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S421-30.

• Marx: Rosen’s Emergency Medicine, 7th ed. 2009 Mosby• Sugrue M. Abdominal compartment syndrome. Curr Opin Crit

Care 2005; 11:333-338• Bailey J, Shapiro M. Abdominal compartment syndrome. Crit

Care 2000, 4:23–29

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