Evaluation of Abdominal Trauma

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Evaluation of Abdominal Trauma
Principles of Surgery

• Anand Pandya MD FRCSC
• Trauma Surgery and Critical Care Medicine
• Clinical Associate
• St. Michaels Hospital, University of Toronto

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Objectives

• Evaluation of Abdominal Trauma
• Mechanisms of Injury
• Assessment of Unstable Patients
• Assessment of Stable Patients
• Case Discussions
• Diagnostic tests
• Decision making

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External Anatomy of Abdomen
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Mechanism of Injury Blunt

• Compression, crush, or sheer injury to abdominal
  viscera deformation of solid or hollow organs,
  rupture (e.g. small bowel, gravid uterus)
• Deceleration injuries differential movements of
  fixed and non-fixed structures (e.g. liver and
  spleen laceration at sites of supporting
  ligaments)

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Pattern of Injury in Blunt Abdominal Trauma
Spleen 40.6 Colorectal 3.5
Liver 18.9 Diaphragm 3.1
Retroperitoneum 9.3 Pancreas 1.6
Small Bowel 7.2 Duodenum 1.4
Kidneys 6.3 Stomach 1.3
Bladder 5.7 Biliary Tract 1.1
Rosen Emergency Medicine (1998)
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Mechanism of Injury Penetrating

• Stab
• Low energy, lacerations
• Gunshot
• Kinetic energy transfer
• Cavitation, tumble
• Fragments

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Assessment History

• AMPLE
• Mechanism
• MVC
• Speed
• Type of collision (frontal, lateral, sideswipe,
  rear, rollover)
• Vehicle intrusion into passenger compartment
• Types of restraints
• Deployment of air bag
• Patient's position in vehicle

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Assessment Physical Exam

• Inspection, auscultation, percussion, palpation
• Inspection abrasions, contusions, lacerations,
  deformity
• Grey-Turner, Kehr, Balance, Cullen
• Auscultation careful exam advised by ATLS.
  (Controversial utility in trauma setting.)
• Percussion subtle signs of peritonitis tympany
  in gastric dilatation or free air dullness with
  hemoperitoneum
• Palpation elicit superficial, deep, or rebound
  tenderness involuntary muscle guarding

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Abdominal Injury
Factors that Compromise the Exam

• Alcohol and other drugs
• Injury to brain, spinal cord
• Injury to ribs, spine, pelvis

A missed abdominal injury can cause a
preventable death.
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Case 1

• 40 yo male, MVC driver
• GCS7, Airway
• 100 on 15L face mask
• BP80/50, P140
• Diagnosis?
• Management?

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Decision Making

• Airway
• Breathing
• Circulation

S H O C K
Hemodynamically Stable
Hemodynamically Unstable
Transient Responder
How are you going to assess?
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Shock

• Scalp
• Chest clinically vs. chest x-ray
• Abdomen
• FAST
• DPL
• Pelvic X-ray
• Extremities Femur
• Other causes of shock cardiogenic, obstructive,
  anaphylactic, septic

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FAST
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Focused Abdominal Sonography for Trauma (FAST)

• Demonstrate presence of free intraperitoneal
  fluid
• Evaluate solid organ hematomas
• Advantages
• No risk from contrast media or radiation
• Rapid results, portability, non-invasive, ability
  to repeat exams.
• Disadvantages
• Cannot assess hollow visceral perforation
• Operator dependent
• Retroperitoneal structures are not visualized

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FAST

• Four View Technique
• Morrisons pouch (hepatorenal)
• Douglas pouch (retropelvic)
• Left upper quadrant (splenic view)
• Epigastric (View pericardium)

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Diagnostic Peritoneal Lavage

• Introduced by Root (1965)
• Indications for DPL in blunt trauma
• Hypotension with evidence of abdominal injury
• Multiple injuries and unexplained shock
• Potential abdominal injury in patients who are
  unconscious, intoxicated, or paraplegic
• Equivocal physical findings in patients who have
  sustained high-energy forces to the torso
• Potential abdominal injury in patients who will
  undergo prolonged general anesthesia for another
  injury, making continued reevaluation of the
  abdomen impractical or impossible

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Contraindications of DPL

• Absolute 
• Peritonitis
• Injured diaphragm
• Extraluminal air by x-ray
• Significant intraabdominal injury by CT scan
• Intraperitoneal perforation of the bladder by
  cystography
• Relative 
• Previous abdominal operations (because of
  adhesions)
• Morbid obesity
• Gravid Uterus
• Advanced cirrhosis (because of portal
  hypertension and the risk of bleeding)
• Preexisting coagulopathy

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DPL Procedure
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Evaluation of DPL

• Fluid is sent for cell count, amylase, alk phos,
  presence of bile

Index Positive value
Aspirate Blood gt10 mL
Fluid Enteric content
Lavage RBC gt 100,000/mL
WBC gt 500/mL
Amylase gt175 U/dL
Alk Phos gt 3 IU
Bile Confirmed
Negative RBC lt 50,000/mL
WBC lt 100/mL
Amylase lt 75 U/dL
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Diagnostic Peritoneal Lavage
RBC Count Incidence of visceral damage
gt100,000 95
20,000-100,000 15-25 Warrant further investigation
lt20,000 lt 5

• Complications of DPL Perforation of small bowel,
  mesentery, bladder and retroperitoneal vascular
  structures.
• Limitation offers no information about status of
  retroperitoneal organs nor allow determination of
  which organ has been injured.

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Indications for Laparotomy Blunt Trauma

• Hemodynamically abnormal with suspected abdominal
  injury (DPL / FAST)
• Free air
• Diaphragmatic rupture
• Peritonitis
• Positive CT

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On Route to OR

• ABC
• Chest x-ray, Pelvis x-ray
• IV access
• Resuscitation
• What is the goal?
• Group and Match
• Notify OR, Surgeon, Anaesthesia
• Request OR equipment
• Consent
• Antibiotics

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Case 1 Learning Points

• Recognize Shock
• Hemodynamically unstable OR
• Role of FAST, DPL
• Permissive hypotension in resuscitation until
  bleeding controlled

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Case 2

• 40 yo male, MVC Driver
• Airway
• Breathing 100 on 5L NP
• Circulation 130/70, P100
• Disability, GCS14
• Exposure
• Management?

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How do you investigate the Abdomen?

• Hemodynamically stable
• ABCDE, secondary survey
• FAST
• CT Scan
• Lab work

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Imaging in Blunt Abdominal Trauma CT Scan

• Sensitivity
• Solid organ injury 97 II,III
• Identify Contrast extravasation
• Guide Operative vs. Non-operative management
• Enteric injury 64 94 III
• Diaphragmatic injury 61 III
• Pancreatic injury 30 III

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CT Scan
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CT Scan
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CT Scan
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Role of Laboratory Tests

• Amylase
• B-HCG

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In Pregnancy

• X-rays
• Ultrasound
• Abdominal
• Fetal
• Circumferential Lead Shield
• Caution with Radiation exposure

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Decision Making

• Stable patient
• CT Scan
• Operative
• Solid organ injury, hypotensive
• Hollow viscus organ injury
• Intraperitoneal bladder injury
• Diaphragmatic injury
• Non-operative management
• Observation
• Interventional Radiology

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Learning Points Case 2

• CT scan is helpful for decision making in a
  stable patient
• Poor detection of hollow viscus, pancreatic and
  diaphragmatic injury
• Be worried of free fluid in abdomen
• Repeat CT Scan and close clinical observation

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Case 3

• 30 yo male
• GSW to buttock
• Airway
• Breathing
• Circulation
• What injuries are you concerned about?
• How are you going to investigate?

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Transpelvic GSW

• Rectal injury
• Extraperitoneal rigid sigmoidoscopy
• Intraperitoneal CT scan with rectal contrast or
  laparotomy
• Bladder injury
• Hematuria
• Cystogram
• Urethral injury
• Retrograde urethrogram

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Transpelvic GSW

• Vascular injury
• FAST
• CT Scan
• Pelvic fracture
• X-ray
• Female Uterine injuries
• CT Scan

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Decision Making

• Low threshold for laparotomy with GSW
• Bowel injury sigmoidoscopy
• Intraperitoneal repair/resect
• Extraperitoneal diversion
• Bladder injury cystogram
• Intraperitoneal surgical repair
• Extraperitoneal foley catheter

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Learning Points Case 3

• Think of associated injuries
• GSW have blast effect, variable trajectory
• Diagnostic tests guide treatment
• Early laparotomy

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Case 4

• 30 yo male
• Stab wounds to abdomen
• Airway
• Breathing
• Circulation
• What is your management?

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Options for Management
Diffuse Abdominal Tenderness
Yes
No
Laparotomy
Hemodynamic Stability?
Indications for Laparotomy Penetrating Trauma

• Hemodynamically abnormal
• Peritonitis
• Evisceration
• Positive DPL, FAST, or CT
• Violation of peritoneum

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Options for Management

• Hemodynamically stable penetrating injury

• Serial Observation
• Wound Exploration
• DPL
• CT scan /- Contrast
• Laparoscopy
• Laparotomy
• Ultrasound/echo cardiac box
• Pericardial window cardiac box

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Stab Wounds
Shorr RM, Gottlieb MM, et al. Selective
management of abdominal stab wounds Importance
of the physical examiantion. Arch Surg 1988,
123(9)1141-5.
330 patients over 12 months154 (47) acute
abdomen, underwent immediate celiotomy Even of
these, 31 negative 176 (53) observed 3 (1.7)
injuries required celiotomy (no adverse effects)
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The Value of Serial Observation
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Learning Points Case 4

• Injury from stab wounds are different from GSW
• Indications for early surgery
• Consider diagnostic options
• Value of serial exam

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Case 5

• 50 yo male, MVC driver
• Airway
• Breathing
• Circulation
• 100/70, P130
• What is the next step?

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Priorities

• ABC
• Consider associated injuries with pelvic trauma
• Blood vessels arterial and venous
• Bone
• Bladder and urethral
• Bowel
• Baby (Uterus)
• Other Body injuries

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Vascular Anatomy

1. Abdominal Aorta
2. Common Iliac Artery
3. Internal Iliac
4. External Iliac
5. Superior Gluteal
6. Obturator Artery

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AP Pelvic with bladder injury
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The Pelvic Mantra.

• Unstable Fractures Lead to Unstable Patients
• - stability should be tested by GENTLE
  manipulation
• - stability should only be performed ONCE
• Minimize further hemmorage !

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Young-Burgess Classification System
VS
LC
APC

Unstable
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Decision Making

• Hemodynamically Stable
• CT Scan cystogram
• If blush then observe vs. embolize
• Hemodynamically unstable, Pelvis unstable
• FAST or DPL to rule out intra-abdominal injury
• Bedsheet wrap pelvis, Ex-fix, C-clamp
• If intraperitoneal blood laparotomy
• If no intraperitoneal blood Angiogram

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Angiography and Embolization
Initial Angiogram
Post-Embolization
Right iliac angiogram acute extravasation (left)
from the right superior and inferior lateral
sacral arteries. Post-embolization (right)
showing no evidence of acute arterial bleeding
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Learning Points Case 5

• Unstable vs. Stable patients
• Recognize pelvic fracture
• Rule out bladder injuries
• Angiogram and emobolization of arterial injuries

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Role of Interventional Radiology

• Embolization
• Spleen
• Liver
• Pelvis
• Angioplasty Stent
• Renal artery dissection
• Stent
• Thoracic aortic injuries

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Spleen Embolization
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Renal Artery Dissection
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Blunt Thoracic Aortic Injury
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Summary

• Mechanism of injury Blunt vs. Penetrating
• ABC ? Stability of trauma patients
• Select ppropriate diagnostic imaging
• Think about associated injuries
• Multi-modality
• Clinical
• FAST
• CT Scan
• Interventional Radiology
• Surgical exploration

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Questions