Abdominal TraumaAbdominal Trauma

Soheil Azimi , Student Of MedicineSoheil Azimi , Student Of Medicine Islamic Azad UniversityIslamic Azad University Tehran Medicine UnitTehran Medicine Unit

The abdomen is frequency The abdomen is frequency injured after both blunt and injured after both blunt and penetrating trauma.penetrating trauma.

Approximately 25% of all Approximately 25% of all trauma victims will require trauma victims will require an abdominal exploration.an abdominal exploration.

The PlanThe Plan

Abdominal AnatomyAbdominal Anatomy Mechanisms of Mechanisms of

InjuryInjury Common PathologyCommon Pathology EvaluationEvaluation ManagementManagement

Part 1:Part 1:Abdominal Abdominal AnatomyAnatomy

Abdominal Anatomy Abdominal Anatomy BasicsBasics

Many organs receiving substantial Many organs receiving substantial blood flowblood flow

Potential spaces that can hide Potential spaces that can hide hemorrhagehemorrhage

Hollow organ damageHollow organ damage > Peritonitis> Peritonitis

Abdominal Anatomy Abdominal Anatomy BasicsBasics

Many organs receiving substantial Many organs receiving substantial blood flowblood flow

Potential spaces that can hide Potential spaces that can hide hemorrhagehemorrhage

Hollow organ damage > PeritonitisHollow organ damage > Peritonitis

Abdominal Anatomy Abdominal Anatomy BasicsBasics

Many organs receiving substantial Many organs receiving substantial blood flowblood flow

Potential spaces that can hide Potential spaces that can hide hemorrhagehemorrhage

Hollow organ damage > PeritonitisHollow organ damage > Peritonitis

Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants

Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants

Abdominal AnatomyAbdominal Anatomy

Abdominal AnatomyAbdominal Anatomy

Abdominal AnatomyAbdominal Anatomy

Alternative DivisionsAlternative Divisions

Lower Abdomen CTLower Abdomen CT

Retroperitoneal Retroperitoneal

External Anatomy of AbdomenExternal Anatomy of Abdomen

Part 2:Part 2:Mechanisms andMechanisms and

PathologyPathology

Abdominal InjuriesAbdominal Injuries

Blunt vs. PenetratingBlunt vs. Penetrating

Often both occur simultaneouslyOften both occur simultaneously

Blunt is the most common Blunt is the most common mechanism in USmechanism in US

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or

movement of organsmovement of organs Compressive, stretching Compressive, stretching

or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood

LossLoss Hollow Organs > Blood Hollow Organs > Blood

Loss and Peritoneal Loss and Peritoneal ContaminationContamination

Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially

Mechanism of Injury: Mechanism of Injury: PenetratingPenetrating

● Stab● Low energy, lacerations

● Gunshot● Kinetic energy transfer

● Cavitation, tumble● Fragments

A missed abdominal injury can cause a preventable death.

Abdominal InjuryAbdominal Injury

Factors that Compromise the Exam

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

Caution

Techniques for Techniques for EvaluationEvaluation

Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and

reliable ptreliable pt

Plain FilmsPlain Films Abd films little or no use, pelvis are the Abd films little or no use, pelvis are the

standardstandard

ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams)Ultrasound: FAST (serial exams)

DPL: ProcedureDPL: Procedure

Diagnostic Peritoneal Diagnostic Peritoneal LavageLavage

Introduced by Root (1965)Introduced by Root (1965) Indications for DPL in blunt trauma:Indications for DPL in blunt trauma:

1.1. HypotensionHypotension with evidence of abdominal injury with evidence of abdominal injury

2.2. Multiple injuries Multiple injuries and unexplained shockand unexplained shock

3.3. Potential abdominal injury in patients who are Potential abdominal injury in patients who are unconscious, intoxicated, or paraplegicunconscious, intoxicated, or paraplegic

4.4. Equivocal physical findings in patients who have Equivocal physical findings in patients who have sustained sustained high-energy forces to the torsohigh-energy forces to the torso

5.5. Potential abdominal injury in patients who will Potential abdominal injury in patients who will undergo prolonged general anesthesia for another undergo prolonged general anesthesia for another injury, making continued reevaluation of the abdomen injury, making continued reevaluation of the abdomen impractical or impossibleimpractical or impossible

Contraindications of DPLContraindications of DPL Absolute :Absolute :

PeritonitisPeritonitis Injured diaphragmInjured diaphragm Extraluminal air by x-rayExtraluminal air by x-ray Significant intraabdominal injury by CT scanSignificant intraabdominal injury by CT scan Intraperitoneal perforation of the bladder by cystographyIntraperitoneal perforation of the bladder by cystography

Relative :Relative : Previous abdominal operations (because of adhesions)Previous abdominal operations (because of adhesions) Morbid obesityMorbid obesity Gravid UterusGravid Uterus Advanced cirrhosis (because of portal hypertension and Advanced cirrhosis (because of portal hypertension and

the risk of bleeding)the risk of bleeding) Preexisting coagulopathyPreexisting coagulopathy

FASTFAST

Focused Abdominal Sonography for Focused Abdominal Sonography for Trauma (FAST)Trauma (FAST)

Demonstrate presence of free Demonstrate presence of free intraperitoneal fluidintraperitoneal fluid

Evaluate solid organ hematomasEvaluate solid organ hematomas

AdvantagesAdvantages No risk from contrast media or radiationNo risk from contrast media or radiation Rapid results, portability, non-invasive, ability to Rapid results, portability, non-invasive, ability to

repeat exams.repeat exams.

DisadvantagesDisadvantages Cannot assess hollow visceral perforationCannot assess hollow visceral perforation Operator dependentOperator dependent Retroperitoneal structures are not visualizedRetroperitoneal structures are not visualized

FASTFAST Four View Technique:Four View Technique:

Morrison’s pouch (hepatorenal)Morrison’s pouch (hepatorenal) Douglas pouch (retropelvic)Douglas pouch (retropelvic) Left upper quadrant (splenic Left upper quadrant (splenic

view)view) Epigastric (View pericardium)Epigastric (View pericardium)

Algorithm for the evaluation of Algorithm for the evaluation of penetratingpenetrating abdominal injuriesabdominal injuries

AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound.

Algorithm for the initial evaluation of a patient with Algorithm for the initial evaluation of a patient with suspected suspected bluntblunt abdominal trauma abdominal trauma

CT = computed tomography; DPA = diagnostic peritoneal aspiration; CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocritFAST = focused abdominal sonography for trauma; Hct = hematocrit

Genitourinary Genitourinary TraumaTrauma

GU TraumaGU Trauma

2-5% of adult traumas2-5% of adult traumas Vast majority blunt mechanismsVast majority blunt mechanisms 80% renal injuries80% renal injuries 10% bladder injuries10% bladder injuries Abnormalities (tumor, hydro) Abnormalities (tumor, hydro)

increase susceptibility increase susceptibility Rarely require immediate Rarely require immediate

interventionintervention

EvaluationEvaluation

Rectal - high riding prostateRectal - high riding prostate Perineum - ecchymosis, lacsPerineum - ecchymosis, lacs Genitals - meatal/vaginal bloodGenitals - meatal/vaginal blood Difficult catheter placement (may Difficult catheter placement (may

need suprapubic)need suprapubic) UA – hematuria (poor correlation to UA – hematuria (poor correlation to

degree of injury)degree of injury)

EvaluationEvaluation

U/S and Plain films of little useU/S and Plain films of little use CT is the superior imaging modalityCT is the superior imaging modality Careful with contrast (nephropathy)Careful with contrast (nephropathy) Angiography remains the Angiography remains the gold gold

standard standard IVP/Cystoscopy less usefulIVP/Cystoscopy less useful

GU Injuries: The KidneysGU Injuries: The Kidneys

Kidneys are well protectedKidneys are well protected Most commonly bruisedMost commonly bruised Pts with a shattered kidney become Pts with a shattered kidney become

rapidly unstablerapidly unstable Renal vascular injuries may result in Renal vascular injuries may result in

thrombosed vesselsthrombosed vessels

GU Injuries: The KidneysGU Injuries: The Kidneys

Operative management for:Operative management for: uncontrolled hemorrhageuncontrolled hemorrhage Penetrating injuriesPenetrating injuries Multiple lacsMultiple lacs Shattered kidneyShattered kidney Avulsed vesselsAvulsed vessels

GU Injuries: The BladderGU Injuries: The Bladder

ContusionContusion Rupture: Intra vs. ExtraperitonealRupture: Intra vs. Extraperitoneal Extraperitoneal presents with pain, Extraperitoneal presents with pain,

hematuria and inability to voidhematuria and inability to void Urethral injuries: Anterior vs. Urethral injuries: Anterior vs.

posteriorposterior No Foley for urethral injuriesNo Foley for urethral injuries

In Summary...In Summary...

Basic knowledge of anatomy Basic knowledge of anatomy necessary for initial assessment of necessary for initial assessment of abdominal traumaabdominal trauma

Peritoneal vs. RetroperitonealPeritoneal vs. Retroperitoneal Blunt vs. PenetratingBlunt vs. Penetrating Don’t miss GU injuriesDon’t miss GU injuries

Thank YouThank You