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2. Pelvic abdomen: it is defined by the bony pelvis. its content include
the urinary bladder, urethra, rectum, small intestine.and in females
the ovaries, fallopian tubes and uterus. Injury to these structures may
be extraperitoneal in nature and therefore difficult to diagnosis.
3. Retroperitoneal abdomen: which contains the kidneys, ureters,
pancreas, aorta, and vena cava. Injuries to these structures are very
difficult to diagnose, based on physical examination findings.
Evaluation of the structures in this region may require a CT scan,
angiography, and an intravenous pyelogram.
4. True abdomen: which contains the small and large intestines, the
uterus (if gravid), and the bladder (when distended). Perforation of
these organs is associated with significant physical findings and
usually manifests with pain and tenderness from peritonitis.
Plain x-ray films are helpful if free air is present. Additionally, DPL is
a useful step.
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Proper and accurate management of abdominal trauma should decrease
the incidence of morbidity and mortality and unnecessary death.
Immediate appropriate resuscitation, diagnosis and definitive management
should also reduce the incidence of post-injury septicemia, pulmonary
insufficiency, renal failure and malnutrition.
Such trauma patients with life-threatening injuries require urgent
medical attention. These patients benefit most from rapid transportation
to a hospital that provides facilities and personnel to cope with a wide
spectrum of injuries. It is vitally important to suspect abdominal injury
in this group of unstable patients with life-threatening conditions, as
one-fifth of post injury deaths are due to abdominal injuries associated
with blunt and penetrating trauma.
Factors requiring a high degree of suspicion for intra-abdominal injury
because there is a highest correlation with multiple injuries;
1- Revised Trauma Score of less than 12
2- Glasgow Coma Scale of less than 13
3- Rapid deceleration injury
4- High-velocity penetrating injury.
5- Falls from more than 4.5 m.
6- Massive blunt soft tissue injury.
7- Combination of blunt and penetrating trauma e.g. bomb blast.
8- Crush injury, e.g. burial alive .
9- Penetrating trauma between nipples and midthigh.
10- Traumatic amputation of arm or leg.
11- Limb paralysis – partial or complete.
12- Road traffic accidents involving :
-- prolonged extraction .
-- passenger compartment “ invaded” by 30 cm or more.
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-- vehicle roll over
-- backward displacement of the front axle.
-- ejection or death of another occupant,
-- pedestrians struck at more than 20 m.p.h.
Pathophysiology
Injury to intra-abdominal structures can be classified into 2 primary
mechanisms of injury–compression forces and deceleration forces.
Compression or concussive forces may result from direct blows or
external compression against a fixed object (eg, lap belt, spinal column).
Most commonly, these crushing forces cause tears and subcapsular
hematomas to the solid viscera. These forces also may deform hollow
organs and transiently increase intraluminal pressure, resulting in
rupture. This transient pressure increase is a common mechanism of
blunt trauma to the small bowel. Deceleration forces cause stretching
and linear shearing between relatively fixed and free objects. These
longitudinal shearing forces tend to rupture supporting structures at
the junction between free and fixed segments. Classic deceleration
injuries include hepatic tear along the ligamentum teres and intimal
injuries to the renal arteries. As bowel loops travel from their mesenteric
attachments, thrombosis and mesenteric tears, with resultant splanchnic
vessel injuries, can result.
The liver and spleen seem to be the most frequently injured organs.
Small and large intestines are the next most injured organs, respectively.
Recent studies show an increased number of hepatic injuries, perhaps
reflecting increased use of CT scanning and concomitant identification
of more injuries.
Sex:
The male-to-female ratio is 60:40, according to international data.
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Age:
Most studies indicate that peak incidence occurs in persons aged 1430 years. Patients with blunt abdominal trauma reveal equal incidence
of hollow viscus injuries in both children ≤14 y and adults.
Mortality/Morbidity
Bunt abdominal trauma is a leading cause of morbidity and mortality
among all age groups. According to several studies 7-9% of pediatric
patients with blunt abdominal trauma died. Of these, only 22% were
reported as having intra-abdominal injuries as the likely cause of death.
BLUNT TRAUMA.
This is the most common cause of abdominal injury and is usually
associated with multiple system injury. Blunt traumas result from motor
vehicle, auto / pedestrian and industrial accidents as well as sporting
injuries.
Blunt trauma causes damage by direct impact, rapid deceleration, or
by shearing and rotational forces. All of these mechanisms could be
present and operative in motor vehicle and auto / pedestrian accidents.
Deceleration injury causes usually detachment and tear of the vessels
and tissue of solid and hollow organs. Rotational forces produce similar
injuries of fixed or mobile structures. Shearing and crushing forces may
compromise blood supply to organs and cause massive soft tissue
injury to the anterior and posterior abdominal wall.
The most commonly affected abdominal organs in blunt trauma are
the spleen, liver and kidneys with bleeding into the peritoneal cavity
or in the retroperitoneal tissue.
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Stab wound of abdomen left side.
PENETRATING TRAUMA.
These traumas are commonly less frequent and occur as stab wounds
or gunshot injuries . Stab knife wounds are relatively clean with rarely
life-threatening conditions. Exceptions include injuries to major abdominal
vessels or the stabbing injury is between the nipples and costal margin
so that the mediastinum and pleural cavity are traversed and injured.
Gunshot injury are more serious and cause varying degrees of injury
and tissue destruction depending on the type of weapon, the velocity
of the bullet and the distance between the assailant and victim. Gunshot
injuries may involve several organs and cause massive soft tissue
necrosis. All gunshot wounds should be explored.
Extensive traumas due to bombs and explosive devices could cause a
combination of penetrating and blunt injuries resulting in massive soft
tissue injury, blast effects and loss of limb and life sometimes .
Such severely injured patients require exploration of the peritoneal
cavity and extensive debridement of necrotic tissue and removal of
foreign bodies . Penetrating trauma cause bowel injuries and major vessel
injury more common than injury of solid organs.
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Incidence of injuries in blunt and penetrating abdominal trauma.
Anatomical site Blunt Penetrating
Spleen 25 % 6 %
Liver 15 % 16 %
Retroperitoneal haematoma 13 % 1 %
Kidney 12 % 5 %
Small bowel 9 % 30 %
Bladder \ ureter 6 % 2 %
Mesentery \ omentum 5 % 18 %
Large bowel 4 % 9 %
Pancreas 3 % 3 %
Urethra 2 % -Diaphragm 2 % 8 %
Vascular 2 % 4 %
Stomach 1 % 7 %
Duodenum 1 % 2 %
Biliary tree -- 1 %
INITIAL ASSESSMENT AND RESUSCITATION.
Random studies indicate that nearly 25% of deaths that occur as a result
of blunt abdominal trauma could be prevented through proper and
effective initial management.
Initial evaluation and treatment require simultaneous physical examination,
resuscitation and diagnostic principles.
Golden hour: it is the period immediately following injury in which
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the patient may appear physiologically stable but may have a lifethreatening injury .
Rapid resuscitation, diagnosis and treatment during this period can prevent
the trauma patient from b/c trauma victim.
Intra-abdominal injury should be suspected in any patient who is
unconscious, has respiratory difficulty and evidence of hypovolaemia.
After admission of the trauma patient, rapid physical examination and
resuscitation should proceed simultaneously and external evidences of
trauma such as penetrating wounds, soft tissue injury, limb deformity,
haematoma formation and bruising should be assessed.
Clinical History
· Initially, evaluation and resuscitation occur simultaneously.
· In general, do not obtain a detailed history until life-threatening
injuries have been identified and therapy has been initiated. However,
to better predict injury patterns and to identify potential pitfalls,
ascertain the mechanism of injury from bystanders, paramedics, or
police.
· AMPLE is often useful as a mnemonic for remembering key elements
of the history.
- A llergies
- M edications
- P ast medical history
- L ast meal or other intake
- E vents leading to presentation
· A history of out-of-hospital hypotension is a predictor of more
significant intra-abdominal injuries. Even if normotensive upon
ED arrival, consider the patient as having an increased risk.
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The initial examination must include rapid assessment of the airways,
chest, abdomen and neurological status together with pulse and blood
pressure.
The first immediate priority is the establishment and maintenance of
adequate airways and respiratory function. If the patient is conscious
with spontaneous breathing, oxygen could be given by mask. In an
unconscious patient the airways should be cleared of blood, saliva or
foreign bodies and oropharyngeal or tracheal intubation may be
indicated with mechanical ventilation sometimes.
The second vital priority is the assessment of the cardiovascular system
with the vital signs, pulse, blood pressure and skin temperature.
Intravenous cannula should be inserted either percutaneously or by
venous cut down and isotonic saline could be infused rapidly, followed
by colloid infusion of dextrans, albumins or plasmas and blood transfusions.
After the clearance of the airways and fluid resuscitation, the trauma
patient should be examined properly, particularly the chest and abdomen.
The chest wall is examined for movement, evidence of fractured ribs,
bruising and penetrating injury. A chest x-ray should be taken and
pneumothorax or haemothorax treated with tube thoracostomy.
The abdomen should be examined properly and carefully to exclude
abdominal distension and voluntary guarding. Any evidence of penetration,
bruising and haematoma formation on the anterior abdominal wall and
flanks should be noted. The pelvis is compressed to assess pelvic stability
and possible fracture and the external genetalia and rectum are examined
for blood and pelvic haematoma.
The assessment of the severity of an injury is an estimate using trauma
scoring systems to identify the patient with fatal injuries, those at
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greatest risk of dying or developing complications and those expected
to make an uneventful and full recovery.
The Glasgow coma scale gives an assessment of the level of consciousness,
motor and verbal response and when combined with the systolic pressure
blood pressure and respiratory rate, can be used to generate the Revised
Trauma Score.
Diagnostic steps in abdominal trauma.
The patient should be admitted to the trauma receiving area in the
accident and emergency department, with proper equipment like
ventilator support, monitoring, venous access and diagnostic
evaluation, as well as with resuscitation fluids.
General diagnostic principles:
1. History:
a. Time of trauma. b. Medication and alcohol.
c. Vomiting. d. Psychiatric problems.
Clue from history: a.Rapid deceleration. b. Use of seat belt.
c. History of ejection. d. Fall from great height.
2.Examination: (Exposure of patient body)
Inspection contusions/abrasions
seat belt sign
abdominal distension.
Palpation tenderness (50% associated injury rate) guarding
Auscultation diminished bowel sounds
P/R bleeding............ruptured viscus
loss of tone.........spinal cord injury
Nasogastric aspirate: Blood
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3. Blood analysis:
Initial laboratory evaluation must include blood for typing and cross
matching, complete blood count and viral screen.
Electrolytes, blood urea as well as toxicology and arterial blood gases
Urinanalysis could reveal haematuria.
4.Radiology (x-ray):
A. Abdominal x-ray:
1. Air under diaphragm, free gas may be found in some cases of
bowel perforation and retroperitoneal gas bubble associated with
duodenal perforation is characteristic.
2. Fracture of spine
3. Loss of psoas shadow: Blurring of the psoas shadow suggests
retroperitoneal blood or fluid.
4. Foreign body, in gunshot wound: bullets, bullet fragments.
5. Loss of kidney shadow
B. Pelvic x-ray:
1. Fracture of pelvic ring
2. Foreign body
C. Intravenous pyelogram should be performed if haematuria is
found to assess excretion from both kidneys and ureters.
5. Investigative Techniques:
Diagnostic Peritoneal Lavage
Computer Tomography
Ultrasound Scanning
Laparoscopy
Laparotomy
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