Abdominal Blunt

Trauma
Lecturer:
Dr. dr. Bambang Arianto, Sp.B, FINACS
By:
Fajaruddin Maruf
(201510401011051)
Niqma N. Sanad (201510401011052)

Surgery Department of Haji

General Hospital Surabaya
2016

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%)
Rosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injury
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

Rosens Emergency Medicine, 7th ed. 2009

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
Rosens Emergency Medicine, 7th ed. 2009

Diagnostic studies
Lab tests: not very helpful
May have Hct, WBC, lactate, LFTs,
lipase, tox screen

Rosens Emergency Medicine, 7th ed. 2009

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

Rosens Emergency Medicine, 7th ed. 2009

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

Rosens Emergency Medicine, 7th ed. 2009

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

Rosens Emergency Medicine, 7th ed. 2009

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

Perihepatic & hepato-renal space (Morrisons pouch)

Perisplenic
Pelvis (Pouch of Douglas/rectovesical pouch)
Pericardium (subxiphoid)

sensitivity 60 to 95% for detecting 100mL - 500mL 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%)

Rosens Emergency Medicine, 7th ed. 2009

Trauma.org

FAST

Morrisons pouch (hepato-renal space)

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

FAST
Perisplenic view

trauma.org

Rosens Emergency Medicine, 7th ed. 2009

FAST

Retrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)

Rosens Emergency Medicine, 7th ed. 2009

trauma.org

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.
Cant distinguish blood from ascites.
high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture

Rosens Emergency Medicine, 7th ed. 2009

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
Rosens Emergency Medicine, 7th ed. 2009

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
Rosens Emergency Medicine, 7th ed. 2009

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

Rosens Emergency Medicine, 7th ed. 2009

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

Rosens Emergency Medicine, 7th ed. 2009

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
Rosens Emergency Medicine, 7th ed. 2009

Management of Blunt
abdominal trauma

ashwinearl.blogspot.com

Management of Blunt
abdominal trauma
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

Rosens Emergency Medicine, 7th ed. 2009

Management of Blunt
abdominal trauma
Clinical Indications for Laparotomy after
MANIFESTATION
PITFALL
Blunt
Trauma
Unstable vital signs with strongly
Alternative sources, shock
indicated abdominal injury
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

Rosens Emergency Medicine, 7th ed. 2009

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

Damage Control

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

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

Damage Control
Open abdominal wounds and definitive
closure
40-70% cant have primary closure after definitive
repair.
Temporary closure methods

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

CASE REPORT

PATIENT IDENTITY
Name
: Mr. Harlan
Age
: 30 Years Old
Address
: Surabaya
Job
: Employee of apartment
Last education
: Senior High School
Coming to emergency department : 06 October
2016, 12.00

 PRIMARY SURVEY
Airway : Corpus alenium (-)
Maksilofacial trauma (-)
Additional breath sounds (-)
Gaps (-)
Breathing :
I : Normochest, symmetric, retraction (-), RR:
20x/minute
P: Movement of the chestwalls symmetric,
crepitation (-), deviated trachea (-),widened
ICS (-)
P : sonor/ sonor
A : breath sound vesicular +/+, Ronchi -/-,
Wheezing -/-

 Circulatiom :
HR : 88x/mnt
Blood pressure : 120/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability :
GCS : 456
Round pupil isokor 3mm/3mm
Exposure :
(-)

SECONDARY SURVEY
Main complaint : Pain in the right arm and stomach
HISTORY OF PRESENT ILLNESS :
Patient come to the Emergency Department at Hospital of
Haji Surabaya with complain about fall down while in the
night shift duty from the height at least 4 meters and then
the body goes to the right side. He had no idea when he
works upthere, it came a building material that suddenly
went to him closely so he decided to against it. Then the
materials moved fastly but failed to hurt his head but
poorly touched his arm and body a bit in the stomach area.
Before and after it the patient still awake and memorize it
well. He just uncomfortable with pain in the right arm, and
he feels that the stomach still fine just a bit pain.
Unconsiusness (-), nausea (-), vomiting (-), no other
complaints, eat and drink as usual, defecate and urinate
are normally.

 HISTORY OF PAST ILLNESS:

History of such illness is denied, history of any
operation in abdomen is denied.
SOCIAL HISTORY :
The patient is an employee in apartment. His work is
to make sure the building component all good.
ALLERGIES HISTORY : Denied

GENERAL STATUS

General state : Good enough, Weight: + 65 kg

Blood pressure :120/80 mmHg
HR : 88 x/minute
RR : 20x/ minute
Tax : 36,5 oC
Head/Neck :
A-/I-/C-/D-

 Thoraks
I : Normochest, symmetric, retraction (-)
P : Movement of the chestwalls symmetric, crepitation
(-), deviated trachea (-), widened intercostals space
(-)
P
: sonor/ sonor
A
: breath sounds vesicular +/+, Ronchi -/-,
Wheezing -/ COR
I : Ictus does not seem
P : Ictus no palpable, thrill (-)
P : heart border normal
A: S1S2 single, Gallop (-), Murmur (-)

 Abdomen
I : Flat simetris
P : Soepel , tenderness (-), H/L/R no palpable,
P : Meteorismus (+)
A : bowel sounds (+) normal

Ekstremitas
Warm akral

: CRT < 2 dtk

Oedema

Cyanosis

LOCALIST STATUS
Regio abdomen
I : Mass (-), hiperemi (-), swelling (-), oedema (-),
vulnus (-), bleeding (-)
P : tenderness at left lower qauadrant (+), mass (-),
defans (-)
P: timpani (+), shifting dullness (+)
A : Bowel sounds (+)

Regio antebrachii dextra : covered by elastic

bandage

 DIAGNOSIS
Suspect blunt abdominal trauma with close fracture
radius 1/3 distal
PLANNING DIAGNOSIS:
FAST USG
R abdomen and pelvic
R antebrachii
PLANNING THERAPY
Consult to surgeon
Infusion RL 2600 cc/24 hours
Antrain 3x1 amp IV

 PLANNING MONITORING
General state
Vital sign.
Patient complaints.

Edukasi
Describes the patients common condition to the
family.
Describes to the family that the patients must be
treated in the hospital till the condition become
stable.
Describes about the examination and treatments
that choosen for the patient.

The picture of patient:

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: Rosens 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, 4:2329