© ACS

1

Budi Irwan

Bagian Bedah FK USU – RSUP H.Adam Malik - Medan

© ACS

2

Objectives

� Describes the significance of the anatomic

regions of the abdomen

� Recognize the difference between blunt

and penetrating injury patterns

© ACS

3

Anatomy

External

� Anterior abdomen

� Flank � Flank

� Back

© ACS

4

ANTERIOR ABDOMEN

• As the area between the transnipple line

superiorly

• Inguinal ligaments and Symphysis pubis • Inguinal ligaments and Symphysis pubis

inferiorly

• And the anterior axillary lines laterally

© ACS

5

FLANK

• This is the area between the anterior and

posterior axillary lines from the sixth

intercostal space to the iliac crestintercostal space to the iliac crest

© ACS

6

BACK

• This is the area located posterior to the

posterior axillary lines from the tip of

scapulae to the iliac crests.scapulae to the iliac crests.

© ACS

7

Anatomy

© ACS

8

Peritoneal cavity

• Upper Peritoneal cavity :

Covered by the lower aspect of the bony

thorax, and includes the diaphragm, liver, thorax, and includes the diaphragm, liver,

spleen, stomach, and transverse colon

© ACS

9

Pelvic Cavity :

• Which is surrounded by the pelvic bones

It contains the rectum, bladder, iliac vessel,

and in women, internal reproductive organs. and in women, internal reproductive organs.

© ACS

10

Retroperitoneal space

• This potential space is the area posterior the

peritoneal lining of the abdomen, and

contains the abdominal aorta, inferior vena contains the abdominal aorta, inferior vena

cava, most of the duodenum, the pancreas,

kidneys and ureters and the posterior

aspects of the ascending colon and

descending colon.

© ACS

11

Blunt Trauma

• A direct blow, eg, contact with the lower rim of the steering wheel

• May cause a compression or crushing injury to the abdominal visceraabdominal viscera

• These forces deform solid or hollow organs and may cause rupture

• Shearing injury to the abdominal viscera are a form of crushing that may result when a restraint device is worn improperly

� Deceleration (fixed organs)

© ACS

12

Blunt Trauma

The organ most frequently injured include :

• Spleen (40% - 50%)

• Liver (35% - 45%)• Liver (35% - 45%)

• Small bowel (5%-10%)

• 15% incidence of retroperitoneal hematoma

© ACS

13

Penetrating Trauma

• Stab wounds and low velocity gunshot

wounds cause tissue damage by laceration

or cuttingor cutting

• High velocity gunshot wounds transfer

more kinetic energy to abdominal viscera

© ACS

14

Penetrating Trauma

Stab wounds

Most commonly involved :

• Liver (40%)• Liver (40%)

• Small bowel (30%)

• Diaphragm (20%)

• Colon (15%)

© ACS

15

Penetrating Trauma

Gunshot wounds

Most commonly involved :

• Small bowel (50%)• Small bowel (50%)

• Colon (40%)

• Liver (30%)

• Abdominal vascular structures (25%)

© ACS

16

Initial Assesment

• Objective :

Apply the diagnostics and therapeutic

procedures specific to abdominal traumaprocedures specific to abdominal trauma

© ACS

17

Initial Assessment

• History

Blunt

♦ Speed of the vehicle

Penetrating

♦ Type of Weapon ♦ Speed of the vehicle

♦ Type of collision (Point of impact)

♦ Vehicle intrusion to the passenger

compartement

♦ Safety devices

♦ The patient’s position in the vehicle

♦ Ejection

♦ Type of Weapon

♦ Distance from the

assailant

© ACS

18

Assessment : Physical Exam

� Inspection

� Auscultation � Auscultation

� Pecussion

� Palpation

© ACS

19

Inspection

• The patient must be fully undressed

• Inspected for :

- Abrasions

- Contussion- Contussion

- Lacerations

- Penetrating wounds

- Foreign bodies

- Evisceration of omentum and small bowel

- Pregnant state

© ACS

20

Auscultation

• To confirm of bowel sounds

• Injuries to adjacent structures (rib,spine, or

pelvis) may produce an ileuspelvis) may produce an ileus

• Absence of bowel sounds is not diagnostic

of intra abdominal injuries

© ACS

21

Percussion

• May demonstrate:

- the tympanitic sounds over an acute

gastric dilatation in the left upper quadrantgastric dilatation in the left upper quadrant

- diffuse dullness when a hemoperitoneum

is present.

© ACS

22

Palpation

- The goal of palpation is to elicit and

localize superficial, deep, or rebound

tenderness.tenderness.

- The presence of a pregnant uterus, as well

as estimation of fetal age, also can be

determined

© ACS

23

Evaluation of penetrating wounds

� Local wound exploration by surgeon

Assessing Pelvic Stability : � Assessing Pelvic Stability :

Manual compression of the anterosuperior iliac spines or iliac crest may elicit abnormal movement or bony pain (suggest a pelvic fracture)

© ACS

24

Evaluation of penetrating wounds

♦ Penile, perineal:

The presence of blood at the urethral meatus,

ecchymoses or a hematoma at scrotum and

perineum strongly suggest a urethral tear.perineum strongly suggest a urethral tear.

♦ Rectal Examination :

To assess sphincter tone, Position of the prostate

and to determine wether fractures of the pelvic

bones.

© ACS

25

Evaluation of penetrating wounds

♦ Vaginal examination :

Laceration of the vagina may occur from bony fragments from pelvic fracture(s) or from penetrating wounds.bony fragments from pelvic fracture(s) or from penetrating wounds.

♦ Gluteal examination :

Penetrating injuries to this area are associated with up to 50% incidence of significant intraabdominal injuries.

© ACS

26

Pelvic fracture

© ACS

27

Insertion Gastric Tube

1. Relieves dilatation

2. Decompresses stomach before DPL

Caution :

• Basilar skull / facial fractures

• May induce vomiting / aspiration

© ACS

28

Insertion Urinary Catheter

� Monitors urinary output

� Decompresses bladder before DPL Decompresses bladder before DPL

� Diagnostic

Caution :

Urethral injury

© ACS

29

Blood and Urin Sampling

♦ Blood :

- Complete blood count (CBC)

- Potassium- Potassium

- Glucose

- Amylase (for blunt trauma)

- Blood alcohol levels

© ACS

30

Blood and Urin Sampling

♦ Urin :

Urine specimens are sent for a urinalysis

and urine drug screen if indicated.and urine drug screen if indicated.

“A blood test or urine pregnancy test is

indicated in all females of childbearing age”

© ACS

31

Diagnostic Peritoneal Lavage (DPL)

A DPL is a rapidly performed, invasive

procedure that significantly alters

subsequent examinations of the patient and subsequent examinations of the patient and

is considered 98 % sensitive for

intraperitoneal bleeding.