Abdominal trauma

Background

  • Typically divided into penetrating and abdominal trauma
  • Gun shot wounds that penetrate the peritoneum virtually all have intra-abdominal injury requiring surgery
    • Small bowel most commonly injured

Classes of hemorrhagic shock[1]

Class I II III IV
Approximate blood loss <15% 15-30% 30-40% >40%
Heart rate ↔/↑ ↑↑
Blood pressure ↔/↓
Pulse Pressure (mmHg)
Respiratory Rate (per min) ↔/↑
Urine Output (mL/hr) ↓↓
Glasgow coma scale score
Base deficit^ 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 or less mEq/L
Need for blood products Monitor Possible Yes Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Clinical Features

  • Typically, abdominal pain after trauma (blunt or penetrating)

Differential Diagnosis

Abdominal Trauma

Evaluation

ATLS Blunt Abdominal Trauma Algorithm

  • Unstable
    • FAST to search for free fluid (vs. DPL if unavailable)
      • Positive: Exploratory laparotomy
      • Negative: CT scan
  • Stable
    • CT scan
      • Exploratory laparotomy, angiographic embolization, conservative management as indicated

Imaging Tests

  • Ultrasound (FAST)
    • Indicated only for hemodynamically unstable trauma patients
      • Otherwise CT is indicated for primary imaging
        • Ultrasound cannot reliably evaluate retroperitoneum / hollow viscous injury
        • Ultrasound has lower sensitivity in the setting of pelvic fractures
      • If CT is not available (e.g. low resource area, multiple casualty) can consider serial FAST exams, which increases sensitivity
        • For example, serial abdominal exams with two FAST examinations performed at least 6 hours apart
  • CT
    • CT with IV contrast only is typical standard
      • May consider triple-contrast (IV, PO, PR) if specific concern for viscous perforation, although delay to imaging typically prohibits this as the initial study

Management

Nonoperative management is the norm in children, but not necessarily in adults.

  • ATLS algorithm for severe trauma
    • Vascular access
    • Consider blood transfusion (and massive transfusion protocol) + TXA
    • Surgery consult (surgery vs. IR)
    • polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy
    • isolated bleed for angioembolization

Indications for laparotomy

  • Blunt
    • Anterior abdominal injury with hypotension
    • Abdominal wall disruption
    • Peritonitis
    • Free air under diaphragm on chest radiograph
    • Positive FAST or DPL in hemodynamically unstable patient
    • CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury)
  • Penetrating
    • Injury to abdomen, back, and flank with hypotension
    • Abdominal tenderness
    • GI evisceration
    • High suspicion for transabdominal trajectory after gunshot wound
    • CT-diagnosed injury requiring surgery (i.e., ureter or pancreas)

Disposition

Discharge

  • CT scan of the abdomen and pelvis negative, normotensive
  • Penetrating
    • Knife: If local wound exploration shows no violation of anterior fascia, suture laceration and discharge
    • If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation

See Also

References

  • Shah, Essential Emergency Trauma, pgs 143-148
  • Bailitz J, Bokhari F, Scaletta TA, Schaider J. Emergent Management of Trauma. New York: The McGraw-Hill Company, 2011: pg 193.
  1. American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81

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