Management of blunt abdominal trauma in ED.

1. BLUNT ABDOMINAL
TRAUMA
BY: ANNE E. ODARO (MCM/2017/69852)
FACILITATOR: DR. NYAGA

2. INTRODUCTION
• Abdominal trauma is an injury to the abdomen.
• Abdominal trauma is divided into:
 Penetrating abdominal trauma (PAT), usually
diagnosed based on clinical signs.
Blunt abdominal trauma is more likely to be
delayed or altogether missed because clinical
signs are less obvious.
Blunt injuries predominate in rural areas, while
penetrating ones are more frequent in urban
settings.

3. EPIDEMIOLOGY
• Motor vehicle accidents are responsible for
75% of all blunt trauma abdominal injuries
• More common in elderly due to less resilience.
• Blunt injuries causes solid organ trauma
(spleen, liver and kidneys) more often than
hollow viscera.
• Multi organ injury and multiple system injury
are also more common in blunt injury than in
other types.

4. MECHANISMS OF INJURY
• CRUSHING: Direct application of a blunt force to the
abdomen
• SHEARING: Sudden decelerations apply a shearing
force across organs with fixed attachments.
• BURSTING: Raised intraluminal pressure by
abdominal compression accurately in hollow organs
can lead to rupture
• PENETRATION: Disruption of bony areas by blunt
trauma may generate bony spicules that can cause
secondary penetrating injury

5. BRIEF ANATOMY

13. PRESENTATION
• Varies widely from hemodynamic stability with minimal
abdominal signs to complete cardiovascular collapse and
may change from one to the other with alarming rapidity.
• Injuries are often categorized by type of structure that is
damaged:
a) Abdominal wall
b) Solid organ (liver, spleen, pancreas, kidneys)
c) Hollow viscus (stomach, small intestine, colon,
ureters, bladder)
d) Vasculature

14. • Spleen is the most common cause of massive bleeding in
blunt abdominal trauma to a solid organ. Spleen is the
most commonly injured organ. The spleen is the second
most commonly injured intra-abdominal organ in children.
A laceration of the spleen may be associated with
hematoma. Because of the spleen's ability to bleed
profusely, a ruptured spleen can be life-threatening,
resulting in shock.

16. ORGAN INJURIES
SOLID ORGANS
• Solid organs most commonly injured in blunt traumas
• In decreasing incidence of injury
i. Spleen
ii. Liver
iii. Kidneys
iv. Intraperitoneal small bowel
v. Bladder
vi. Colon
vii. Diaphragm
viii. Pancreas and duodenum

17. HOLLOW VISCERA
• Duodenum commonly injured
• Small bowel injured at relatively fixed areas
(duodenojejunal flexure and ileocaecal junction)
by shearing force
• Colon relatively protected.
→Gaseous distension of caecum – most
vulnerable part as fixed.
• Stomach rarely injured – compression cause
esophagogastric junction bursting

18. RETROPERITONEUM AND UROGENITAL
TRACT
• Kidney injury - common next to spleen and liver
• Pancreatic injury - 4% cases of trauma
• Bladder - most commonly injured extra-
peritoneally by shearing at the vesico-urethral
junction.
→intraperitoneally by blunt force on distended
bladder
• Rupture of prostatic urethra by shear forces is
commonly seen with hemorrhage

19. INITIALASSESSMENT
• Determine if the patient is hemodynamically stable.
• Use a systematic approach based on ABCDE to assess
and treat an acutely injured patient. Unless there are
associated injuries, most patients with abdominal trauma
generally present with a patent airway. Alterations found in
breathing, circulation and disability assessments generally
correspond to the degree of shock. The goal is to manage
any immediate threats to life and identify any emergent
concerns that may require activation of retrieval services
and early transfer.
•

20. PRIMARY SURVEY: AIRWAY
Assess for airway stability
• Attempt to elicit a response from the patient.
• Look for signs of airway obstruction (use of accessory
muscles, paradoxical chest movements, see-saw
respirations).
• Listen for any upper-airway noises, breath sounds. Are
they absent, diminished or noisy? Noisy ventilations
indicate a partial airway obstruction by either the tongue
or foreign material.
Assess for soiled airway
• Hemorrhage and vomiting are common causes of airway
obstruction in trauma patients. These should be removed
with suction.

21. PRIMARY SURVEY: AIRWAY
Attempt simple airway maneuvers if required
• Open the airway using a chin lift and jaw thrust.
• Suction the airway if excessive secretions are noted or if
the patient is unable to clear their airway independently.
• Insert an oropharyngeal airway (OPA) if required.
• If the airway is obstructed, simple airway-opening
maneuvers should be performed as described above.
Care should be taken to not extend the cervical spine.
Caution: NPA should not be inserted in patients with a
head injury in whom a base of skull fracture has not been
excluded.

22. PRIMARY SURVEY: AIRWAY
Secure the airway if necessary (treat airway obstruction as a
medical emergency)
• Consider intubation early if there are any signs of:A decreased
level of consciousness GCS <9, unprotected airway,
uncooperative/combative patient leading to distress and further
risk of injury
• Hypoventilation, hypoxia or a pending airway obstruction:
stridor, hoarse voice.
• Assist ventilation with a bag and mask while the provider is
setting up for intubation.
Maintain full spinal precautions if indicated
• Suspect spinal injuries in polytrauma patients, especially where
there is an altered level of consciousness. Ensure cervical
collar, head blocks or in-line immobilisation is maintained
throughout patient care.

23. PRIMARY SURVEY: BREATHING
• Patients with early, compensated shock may have a mild
increase in their respiratory rate, however those with more
severe hypovolemic shock will display marked tachypnea.
Assess the chest
• Count the patient’s respiration rate and note the depth
and adequacy of their breathing. Auscultate the chest for
breath sounds and assess for any wheeze, stridor or
decreased air entry. Be mindful that in the setting of
abdominal trauma, potential thoracic injuries may have
occurred also. Rupture of the hemi diaphragm often leads
to compromise of respiratory function and bowel sounds
may be heard over the thorax when breath sounds are
auscultated.

24. PRIMARY SURVEY: BREATHING
Record the oxygen saturation (SpO2)
• Adequate oxygenation to the brain is an essential element
in avoiding secondary brain injury. Monitor the SpO2 and
maintain it above 95%. Failure to keep saturations above
this rate is associated with poorer outcomes.
Ensure high-flow oxygen is administered to maintain
saturations above 95%.

25. PRIMARY SURVEY: CIRCULATION
Assess circulation and perfusion
Check:
• Heart rate.
• Blood pressure.
• Peripheral circulation and skin (pale, cool, clammy).

26. PRIMARY SURVEY: CIRCULATION
• Shock from intra-abdominal haemorrhage may range from
mild tachycardia with few other findings to severe
tachycardia, marked hypotension and pale, cool, clammy
skin. The most reliable indicator of intra-abdominal
haemorrhage is the presence of hypovolemic shock from
an unexplained source.
In immediate trauma care aim for a blood pressure
greater than 90 mmHg systolic or a shock index less than
1 (HR/SBP).
Insert x 2 large bore peripheral IV cannulas. If access
is difficult, consider a central or intraosseous
insertion if the equipment / skills are available.

27. PRIMARY SURVEY: CIRCULATION
Commence fluid resuscitation as indicated
• Initial treatment of hypovolemia with crystalloid fluids
(normal saline) is recommended, up to 20–30 mL/kg.
Blood pressure goals for penetrating trauma or
uncontrollable hemorrhage are generally lower than for
blunt trauma in the absence of a major head injury. (SBP
values less than 90 mmHg may be acceptable if cerebral
perfusion is maintained – that is, if conscious state is
normal). Early consultation about such patients is
required.

28. PRIMARY SURVEY: DISABILITY
• Assess level of consciousness
• Perform an initial Glasgow Coma Scale (best eye
opening, motor response and verbalisation).
• Check pupil size and reactivity if conscious state
is altered.
• Test blood sugar levels
• Ensure that any alterations in level of
consciousness are not related to a metabolic
cause.

29. PRIMARY SURVEY: EXPOSURE
• By the end of the primary survey the patient should have been
fully exposed so as to ensure no injuries posing an immediate
life threat are missed.
• Consideration must be given to the patient’s age, gender and
culture when exposing them for a trauma examination.
• Exposure may need to be done sequentially, uncovering one
body region at a time to maintain patient dignity.
• Trauma patients are prone to hypothermia, so upon completion
of the primary survey, they should be covered with dry, warm
blankets.
• External warming devices may be required if the patient is even
mildly hypothermic. All intravenous fluid or blood should be
warmed prior to administration if a fluid warmer is available.

30. SECOND PRIORITIES
HISTORY
• To know injury mechanism (mode of injury) – to anticipate
injury patterns and raise the index of suspicion for occult
injury.
• Events preceding the injury
• General principles :
Serial examinations by the same examiner improves
sensitivity
Spinal cord injury masks clinical findings
Tenderness blunted by intoxicants

31. PHYSICAL EXAMINATION
General Examination : relating to hemodynamic
stability Abdominal findings :
Inspection
for abdominal distension
for contusions or abrasions
lap belt ecchymosis – mesenteric, bowel, and
lumbar spine injuries
periumblical (Cullen sign) and flank (Grey Turner
Sign) ecchymosis – retroperitoneal haematoma

32. • The classical ‘seatbelt’
sign. The bruising on
the left breast is from
the shoulder belt and
the low bruising to the
abdominal wall is from
the lapbelt.

34. Palpation
• for tenderness, guarding and/or rigidity, rebound
tenderness – hemoperitoneum
Percussion
• Dullness/ shifting dullness – intrabdominal collection
Auscultation
• Presence or absence of bowel sounds

35. Rectal findings
• Check for gross blood - pelvic fracture
• Determine prostate position – high riding prostate –
urethral injury
• Assess sphincter tone – neurologic status
Distal pulses
• Assess for absence or asymmetry
• Assessment of other associated injuries i.e. multiple
fractures, spinal injuries etc.

36. DIAGNOSTIC STRATEGY
•To identify those with injuries
•To decide which ones need
laparatomies
•To determine how fast this should be
done

37. • Base line investigations
• Four quadrant tap
• Diagnostic peritoneal lavage (DPL)
• Ultrasound – FAST (focused assessment
with sonography for trauma)
• Abdominal CT scan
• Diagnostic laparoscopy
• Laparotomy

39. BASELINE INVESTIGATIONS
• Hemogram with hematocrit
• ABG
• Electrocardiogram
• Renal function tests
• Urine analysis – +nce of hematuria – genito urinary injury
• -nce of hematuria – does not rule out it
Serum amylase / lipase or liver enzymes - increase -
suspicion of intraabdominal injuries

40. CHEST RADIOGRAPH
• Pneumothorax/hemothorax
• Raised left/right hemidiaphragm –
perisplenic/hepatic hematoma.
• Lower ribs fracture – liver/spleen injury.
• Abdominal contents in the chest –ruptured
hemidiaphragm

41. ABDOMINAL: RADIOGRAPHS
• Pneumoperitoneum – perforation of hollow viscus
• Ground glass appearance – massive
hemoperitoneum
• Dilated gut loops- retroperitoneal hematoma or
injury
• Retroperitoneal air outlining the right kidney –
duodenal injury
• Double wall sign – air inside and outside the
bowel
• Distortion or enlargement of outlines of viscera –
hematoma in relation to respective organs

42. ABDOMINAL RADIOGRAPH
• Medial displacement of stomach – splenic
hematoma
• Obliteration of Psoas shadow – retroperitoneal
bleeding
• Pelvic bone fracture – bladder/urethral/rectal
injury
• Fracture vertebra – ureter injury / retroperitoneal
hematoma

43. INDICATIONS FOR FURTHER TESTING
• Unexplained hemorrhagic shock
• Major chest or pelvic injuries
• Abdominal tenderness
• Diminished pain response due to:
Intoxication
Depressed level of consciousness
Distracting pain
Paralysis
• Inability to perform serial examination

44. FOUR QUADRANT TAP
• Overall accuracy – about 90%
• Positive tap – obtaining 0.1 ml or more of non clotting
blood Negative tap does not rule out hemorrhage
DIAGNOSTIC PERITONEAL LAVAGE
Criteria for positive tap
Gross bloody tap
>1,00,000 RBCs per mm
500 white blood cells per mm
Elevated amylase level
Presence of bile or bacteria or feces

46. ULTRASOUND; FAST EXAMINATIONS ( focused assessment
with sonography for trauma ).
Advantages
• Inexpensive, noninvasive and portable
• Performed by emergency physicians and surgeons trained in
performing FAST examinations.
• Avoids risks associated with contrast media
• Confirms presence of hemoperitoneum in minutes
a) Deceases time to laparotomy
b) Great adjunct during multiple casualty disasters
• Serial examination can detect ongoing hemorrhage
Differentiates pulseless electrical activity from extreme
hypotension
• With pregnant trauma patients, determines gestational age and
fetal viability

47. Disadvantages
• A minimum of 70 ml of intraperitoneal fluid for positive
study.
• Accuracy is dependent on operator / interpreter skill and
is decreased with prior abdominal surgery.
• Technically difficult with – obese, ileus or subcutaneous
emphysema is present
• Does not define exact cause of hemoperitoneum
• Sensitivity is low for small-bowel and pancreatic injury
Sensitivity – 69%-99%
Specificity – 86%-98%

48. Technique
Four basic transducer positions used to find
abdominal fluid.
Subxiphoied – hemopericardium
Right upper abdominal quadrant - fluid in
Morrison’s pouch
Left upper abdominal quardant –fluid in
perisplenic space
Suprapubic – fluid in Douglas pouch

50. ABDOMINAL CT SCAN
• Latest generation of helical and multislice
scanners provides rapid and accurate
diagnostic information.
• Criterion standard for solid organ injuries.
• Help quantitate the amount of blood in the
abdomen and can reveal individual organs
with precision.

53. LAPAROSCOPY
Advantages
• The extent of organ injuries and determines the need for
laparotomy
• Defines which intraabdominal injuries may be safely
managed non-surgically
• More sensitive than DPL or CT in uncovering
a)Diaphragmatic injuries
b)Hollow viscus injuries
• Surgery can be done in same sitting
a)With laparoscope with minimal trauma
b)Open surgery
• Sampling for HPR can be taken

54. Disadvantages
• Pneumoperitoneum may elevate ICP
• General anesthesia usually necessary
• Patient must be hemodynamically stable
Complications
• Bleeding or injury
• Gas embolism and pneumoperitoneum

55. LAPAROTOMY
INDICATIONS
Absolute criteria
• Peritonitis (gross blood, bile or feces)
• Pneumoperitoneum or pneumoretroperitoneum
• Evidence of diaphragmatic defect
• Gross blood from stomach or rectum
• Abdominal distension with hypotension
• Positive diagnostic test for an injury requiring operative
repair

57. NON OPERATIVE INJURY
MANAGEMENT
General considerations
criteria for non operative management
• Patient hemodynamically stable after initial
resuscitation
• Continuous patient monitoring for 48 hrs
• Surgical team immediately available
• Adequate ICU support and transfusion services
available
• Absence of peritonitis
• Normal sensorium

58. •Angioembolization may be alternative
to surgical intervention
•All patients with solid organ injury
managed non-operatively require
admission for observation, serial
hematocrit measurement, and repeat
imaging

60. MANAGEMENT PROTOCOL

61. COMPLICATIONS
Delayed consequences of abdominal injury include:
• Hematoma rupture
• Intra-abdominal abscess
• Bowel obstruction or ileus
• Biliary leakage and/or biloma
• Abdominal compartment syndrome
• Abscess, bowel obstruction, abdominal compartment syndrome, and
delayed incisional hernia also can be complications of treatment.

62. REFERENCES
• Fitzgerald, J.E.F.; Larvin, Mike (2009). "Chapter 15:
Management of Abdominal Trauma". In Baker, Qassim;
Aldoori, Munther. Clinical Surgery: A Practical Guide. CRC
Press. pp. 192–204. ISBN 9781444109627.
• Jansen JO, Yule SR, Loudon MA (April 2008).
"Investigation of blunt abdominal trauma". BMJ. 336
(7650): 938–42. doi:10.1136/bmj.39534.686192.80. PMC
2335258 Freely accessible. PMID 18436949.
• D'Errico E, Goffre B, Mazza D (2009). "Blunt abdominal
trauma: current management". Chir Ital. 61 (5-6): 601–6.
PMID 20380265.