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232 Part II Abdominal Wall
TABLE 11-6: CAUSES OF LOWER GI
BLEEDING
Causes
Colonic
bleeding (95%)
Small intestinal
bleeding (5%)
Diverticular disease
Angiodysplasia
Ischemia
Anorectal disease
Neoplasia
Infectious colitis
Polyps
In ammatory bowel disease
Radiation proctitis
Other
Unknown
Angiodysplasias
Neoplasia
Meckel’s diverticulum
Erosions/ulcers
Crohn’s disease
Radiation
Frequency
(%)
30–40
40
6–18
6–16
3–11
3–29
5–13
2–4
1–3
1–9
6–23
Colonoscopy remains the most useful diagnostic and therapeutic investigation for diverticular bleeding ( Fig. 11-13 ),
and can be combined with adrenaline injection, mechanical
clipping, or thermal or electrical coagulation to achieve hemostasis. A recent meta-analysis showed embolization to be successful at arresting diverticular bleeding in 85% of patients.
50
Surgery is indicated in refractory bleeding, and a limited
resection may also be considered as a management option in
patients with multiple episodes of self-limiting bleeding.
Angiodysplasia. Angiodysplastic lesions in the intestine
are degenerative vascular lesions that develop as a result
of progressive dilation of submucosal vessels. Bleeding
from these lesions can account for up to 40% of lower GI
104
bleeds.
Angiodysplastic lesions are frequently found in the
elderly and associated with aortic stenosis and renal failure.
e majority of cases present with anemia and cease bleeding spontaneously; however, 50% will rebleed in 5 years.
Massive bleeding may occur in up to 15% of cases.
In the colon, angiodysplastic lesions are predominantly
located in the cecum and ascending colon, particularly in
elderly patients. Colonoscopy reveals red stellate lesions
with a rim of pale mucosa, while angiographic criteria include early prolonged lling of the draining vein,
clusters of small arteries, and a visible vascular tuft ( Fig.
11-14 ). First-line treatment options include injection
with intra-arterial vasopressin, selective Gelfoam embolization, endoscopic electrocoagulation, or injection with
sclerosing agents. Bleeding refractory to these treatments
requires a segmental colectomy, usually in the form of a
right hemicolectomy.
FIGURE 11-14 Telangiectatic lesions ( black arrows ) characteristic
of colonic angiodysplasia, seen on colonoscopy.
from Dr Nicola Simmonds, Luton and Dunstable Hospital, UK.)
(Used with permission
Neoplasia. Neoplasia is a rare cause of lower GI bleed-
ing, accounting for only 2–9% of all hematochezia, but
is signi cant due to the relatively high incidence of col-
53
orectal cancer in developed countries.
Neoplasia-induced
hemorrhage presents as chronic painless bleeding, usually
53
associated with iron de ciency anemia.
is is particularly frequent in tumors of the right side of the colon,
while tumors of the left side often present with obstructive symptoms and occasionally ulcerate to produce bright
red bleeding ( Fig. 11-15 ). Colonic polyps are the cause
of bleeding in 5–11% of patients and of anemia in 3–7%
of patients; however, this is most often the case in polyps
105
exceeding 1 cm in diameter ( Fig. 11-16 ).
A common cause of lower GI bleeding is postpolypec-
tomy bleeding, where the site may bleed for up to 14 days
FIGURE 11-15 Colonoscopic views of a large ulcerated neoplastic
lesion.
(Used with permission from Dr Nicola Simmonds, Luton and Dunstable
Hospital, UK.)
Chapter 11 Gastrointestinal Bleeding 233
large amounts of blood loss. Inspection of the anal margin
is usually diagnostic and can be made painless following
injection of local anesthetic. Bleeding from ssures usually
ceases spontaneously. Conservative management includes
the use of stool bulking agents, stool softeners, increased
uid intake, and topical nitroglycerin or diltiazem, which
facilitate healing of the ssure by reducing sphincter spasm.
Hemorrhoids account for lower GI bleeding in 2–9% of
105
patients.
Fresh red blood is seen on the tissue paper, in the
bowl, and around the stool, and is usually painless in nature.
Bleeding usually derives from painless internal hemorrhoids
and is associated with prolapse of these hemorrhoids, often
requiring manual reduction. Management includes stoolbulking agents and increased consumption of bre and water.
Rubber band ligation, injection sclerotherapy, and infrared
coagulation may also be employed, and in refractory cases
FIGURE 11-16 Colonoscopic view of a large pedunculated polyp
with associated bleeding.
Luton and Dunstable Hospital, UK.)
(Used with permission from Dr Nicola Simmonds,
surgical hemorrhoidectomy can be performed.
Other rarer anorectal causes of lower GI bleeding include
solitary rectal ulcers and anorectal varices. Solitary rectal
ulcers are postulated to arise as a result of local ischemia,
due to internal rectal prolapsed or lack of inhibition of the
following polypectomy (Fig. 11-17). Several factors inuence the risk of postpolypectomy bleeding, including size
of polyp, inadequate electrocautery, comorbidity, bowel
106
preparation, and experience of the endoscopist.
Delayed
postpolypectomy bleeding in particular was more likely in
large polyps and in polyps in the right side of the colon,
and in patients in whom anticoagulant therapy had been
107
resumed within 1 week of polypectomy.
Colonic polyps
and neoplasia are covered in more detail in Chap. 36.
puborectalis muscle on straining. Bleeding is rare with solitary rectal ulcers but in contrast can be severe with anorectal
varices. ese arise in patients with portal hypertension and
can bleed in 18% of those patients.
108
An important point to note is that anorectal causes of
bleeding such as ssures and hemorrhoids are relatively common incidental ndings and should not be considered the
only source of bleeding until more proximal colonic neoplasia has been excluded, particularly in the elderly. Benign
anorectal conditions are discussed further in Chap. 39.
Anorectal Disease. Anorectal pathology that can cause
lower GI bleeding includes anal ssures, hemorrhoids, and
colorectal neoplasia. Fissures are associated with signicant pain on defecation and examination but rarely cause
Colitis. Bleeding associated with colitis may be multifacto-
rial in origin.
Bleeding From Inflammatory Bowel Disease. Bleeding
from colonic inammation may be a feature of inammatory bowel disease. Lower GI hemorrhage has been reported
in the majority of patients with ulcerative colitis and in up
109
to a third of patients with Crohn’s disease.
Most bleeding
stops spontaneously, but 35% of patients experience rebleed-
110
Both ulcerative colitis and Crohn’s disease are associ-
ing.
ated with abdominal pain and increased bowel movements.
While ulcerative colitis predominantly involves the mucosal layer and begins at the rectum then spreads proximally,
Crohn’s disease is associated with transmural thickening of
the bowel wall, skip lesions, and strictures, and classically
involves the terminal ileum (Fig. 11-18). Both Crohn’s disease and ulcerative colitis are diagnosed on endoscopy and
managed with 5-aminosalicylic acid (5-ASA) compounds,
immunomodulatory agents, steroids, and antibiotics as
needed. Surgical therapy for ulcerative colitis is needed if
the rare complication of toxic megacolon develops or in the
event of refractory life-threatening hemorrhage. Surgery is
FIGURE 11-17 Colonoscopic views of bleeding from the base of
a polyp postpolypectomy.
Luton and Dunstable Hospital, UK.)
(Used with permission from Dr Nicola Simmonds,
avoided as much as possible in Crohn’s disease because of the
natural relapsing and remitting nature of the disease and the
tendency of the lesions to aect any region of the GI tract.
234 Part II Abdominal Wall
FIGURE 11-18 Colonoscopic view of Crohn’s colitis. Note the
cobblestone appearance of the mucosa and the associated edema
and erythema.
Dunstable Hospital, UK.)
(Used with permission from Dr Nicola Simmonds, Luton and
Crohn’s disease and ulcerative colitis are discussed further in
Chaps. 33 and34.
Infectious Colitis. Causes of infectious colitis that may
cause bloody diarrhea include CMV colitis, Escherichia
coli, Shigella, Salmonella, and Campylobacter. Patients with
infectious colitis typically present with bloody diarrhea
with positive stool cultures. CMV colitis typically aects
the immunocompromised.
Patients with HIV are particularly at risk of GI bleeding and, because of the immune deciency, are particularly
at risk from opportunistic organisms. Causes of GI bleeding
in the colon of HIV-positive patients include CMV colitis,
lymphoma, colonic histoplasmosis, Kaposi’s sarcoma of the
colon, and bacterial colitis, with an overall average mortality
111
of 14%.
Colonoscopy and biopsy conrms the diagnosis,
and treatment should be commenced as appropriate.
NSAID-Associated Lower GI Bleeding. NSAIDs are also
able to induce and exacerbate lower GI bleeding. NSAIDs
can themselves induce mucosa damage and colonic inammation, erosions, and ulcers. In addition, they can exacerbate existing colitis and increase the tendency of preexisting
lesions such as polyps or angiodysplasia to bleed. NSAIDinduced lesions appear as at, irregularly shaped erosions and
ulcerations with otherwise normal mucosa.
53
Radiation Proctitis. Radiation therapy in the pelvic region is
another cause of lower GI bleeding, producing a chronic radiation proctopathy due to the neovascularization resulting from
radiation-induced endarteritis obliterans. Bleeding occurs in
4–13% of patients receiving radiation therapy for prostatic
112
carcinoma.
Patients typically present with bloody diarrhea,
cramping pelvic pain, and tenesmus. Endoscopy reveals multiple
FIGURE 11-19 Colonoscopic view of radiation-induced proctitis,
with the characteristic appearance of multiple telangiectasia on a background of otherwise pale mucosa.
Simmonds, Luton and Dunstable Hospital, UK.)
(Used with permission from Dr Nicola
telangiectasias on an otherwise pale mucosa and can be coupled
with argon plasma coagulation for treatment (Fig. 11-19). Other
treatment options include antidiarrheals and hydrocortisone
enemas. Ablation with 4% formalin solution may be considered
for refractory bleeding.
113
Mesenteric Ischemia. Mesenteric ischemia, or ischemic
colitis, results from a sudden reduction in blood ow to
the intestine due to either reduced blood pressure or vasoconstriction. is is particularly frequent in elderly patients
with a background of cardiovascular disease; other risk
factors include recent abdominal vascular surgery, hypercoagulable states, and vasculitis. Patients on inotropes
and vasoconstrictors are particularly prone to mesenteric
ischemia due to splanchnic vasoconstriction. e splenic
exure of the colon and the rectosigmoid junction are
vascular watershed areas and are especially susceptible to
ischemia. Patients present with abdominal pain and bloody
diarrhoea. e diagnosis is suspected with the identication of a thickened bowel wall on CT and is conrmed
on endoscopy showing bleeding, edematous mucosa
with a demarcation between ischemic, and normal bowel
(Fig.11-20). Ulcerations may appear on endoscopy in the
later stages ofdisease progression. Despite the self-limiting
nature of the disease in most patients, mesenteric ischemia
114
is associated with a high morbidity and mortality.
Conservative management is usually employed, with bowel
rest, intravenous antibiotics, and cardiovascular support
and normalization of the hemodynamic state. In 15% of
patients, ischemia is followed by gangrene and perforation, the patient develops sepsis, acidosis, and peritonitis,
and requires urgent laparotomy with resection of ischemic
bowel and the creation of an end colostomy.
115
Chapter 11 Gastrointestinal Bleeding 235
FIGURE 11-20 Ischemic colitis as viewed on colonoscopy,
with evidence of ulceration and submucosal hemorrhage.
permission from Dr Frederick Makrauer MD, Brigham and Women’s Hospital,
Boston, MA.)
(Used with
FIGURE 11-21 Meckel’s diverticulum seen intraoperatively. Meckel’s
diverticulum (black arrow) can be seen on the antimesenteric border of
the ileum.
OBSCURE LOWER GI BLEEDING
Bleeding persisting or recurring after negative esophagogastroscopy and colonoscopy occurs in approximately 5% of cases
is termed obscure bleeding, often the result of angiodysplastic
lesions, Meckel’s diverticula, Dieulafoy’s lesions, and small bowel
116
neoplasms.
Bleeding in these cases may be visible (termed
obscure-overt bleeding) or only detected by the presence of
guaiac-positive stools (obscure-occult bleeding). Further investigation in the form of capsule enteroscopy, deep enteroscopy,
angiography, or red cell labeling is often necessary in these cases.
Angiodysplasia. Angiodysplasia is the most common cause
of small bowel hemorrhage, accounting for up to 40% of
cases in elderly patients and 10% of cases in younger patients.
e jejunum is the most common site for these lesions.
While angiodysplasias of the small intestine often present
with obscure bleeding, patients with bleeding angiodysplastic lesions may also present with occult bleeding and iron
deciency anemia. Unlike colonic angiodysplasia, angiography is rarely helpful in small intestinal angiodysplasia, and
deep enteroscopy or capsule enteroscopy are the investigative
modalities of choice. Optimal management involves on-table
endoscopy with segmental resection of the aected length of
small bowel; however, it is important to note that a signicant
number of patients may spontaneously cease bleeding.
117
Meckel’s and Other Small Intestinal Diverticula. A
Meckel’s diverticulum is the incomplete obliteration of the
remnant of the embryonic vitelline duct, the communication
between the yolk sac and the fetal gut, and occurs in
approximately 2% of the population. Meckel’s diverticulum
is usually found within 100 cm of the ileocecal valve and usu-
118
ally ranges from 1 to 10 cm in length (Fig. 11-21).
Up
to 60% of Meckel’s diverticula contain heterotopic mucosa,
usually of gastric or pancreatic origin. Hemorrhage is a common complication of a Meckel’s diverticulum in both adults
and children, occurring in 38% of adults and 31% of children,
and results from ulceration of the normal mucosa adjacent
119
to the acid-producing heterotopic mucosa.
Radionuclide
scans may assist in the diagnosis of Meckel’s diverticulum
but is much less accurate in the adult population compared
to the pediatric population. e use of cimetidine, which
decreases peptic acid secretion without aecting radionuclide
uptake, slows the release of the pertechnetate into the lumen
120
and increases the sensitivity of the scan to 95%.
Laparoscopy may be used for the diagnosis as well as the treatment
of Meckel’s diverticulum. Operative management hinges on
removal of the Meckel’s diverticulum and associated bands as
well as resection of the adjacent aected bowel.
e incidence of nonmeckelian intestinal diverticulosis
is low, ranging from 0.06 to 4.6% on autopsy studies.
121
ese are particularly common in the elderly but may present in any age group. e pathophysiology of small bowel
diverticula is similar to that of colonic diverticula—these
are pseudodiverticula involving only mucosa and submucosa, unlike a Meckel’s diverticulum that is a true diverticulum. e majority of small intestinal diverticula occur
in the jejunum, corresponding with the greatest frequency
of vasa rectae in the small intestine. Upper GI contrast
series or CT scans may reveal diverticula as contrast-lled
sacculations; however, these lack sensitivity. Enteroclysis
is a double- contrast radiographic modality involving the
use of duodenojejunal intubation and intraluminal distension, allowing even small diverticula to be lled. e
lack of cost-eectiveness, however, makes this modality
236 Part II Abdominal Wall
FIGURE 11-22 CT image of an ileal adenocarcinoma, obvious as
a mass in the left midabdomen.
only appropriate if standard radiographic modalities have
proved unsuccessful. e incidence of bleeding from jeju-
121
nal diverticulosis ranges from 5 to 33%.
Enteroscopy
(particularly deep enteroscopy) is suitable for diagnosis
of diverticula complicated by bleeding, inammation, or
obstruction, but laparotomy remains the gold standard for
diagnosis and management, particularly in the unstable
patient. Operative management involves resection of the
aected segment of small bowel with a primary end-toend anastomosis. Rarely a large proportion of the bowel
is involved (panjejunoileal diverticulosis), and conservative
management may be tried to avoid massive small bowel
resection and resultant short bowel syndrome. Selective
mesenteric angiography and embolization may assist in the
control of hemorrhage in these cases.
Neoplasia. Although small bowel tumors account for only
5% of all GI tumors, they are the second most common
122
cause of small intestinal bleeding.
Patients may present
either with melena or with fecal occult blood. Leiomyomas
and leiomyosarcomas are the most common tumors to bleed
and may bleed briskly due to tumor necrosis and mucosal
ulceration. ese are highly vascular tumors, and hence
angiography has an 86% rate of detection for these lesions.
Other tumors in the small intestine include adenocarcinoma,
carcinoid, and lymphoma. Tumors can be diagnosed on enteroscopy, small bowel contrast series, or CT (Fig. 11-22),
and treatment involves surgical resection of the tumor.
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MANAGEMENT OF ABDOMINAL TRAUMA
L. D. Britt • Robert A. Maxwell
MANAGEMENT OF PENETRATING
ABDOMINAL TRAUMA
Introduction
e management of penetrating abdominal trauma parallels
the evolution of diagnostic modalities. In the 19th century,
expectant (observation) management was the approach of
choice worldwide. In 1880, Paule Reclese, a French surgeon,
advocated supportive care only for penetrating abdominal injuries. Sir William McCormick, chief Army Surgeon
during this same period, coined the McCormick aphorism
regarding the management of gunshot wounds to the abdomen that stated “if a man undergoes surgery after being shot
he dies and lives if left in peace.” Even with a mortality rate
that was exceedingly high, such dogma was the standard of
care during this era for any penetrating abdominal trauma.
is management approach was, unfortunately, applied
when President James A. Gar eld sustained a gunshot wound
to the abdomen. e observational management, called the
“Gar eld Death Watch,” by the President’s medical team
resulted in the demise of President Gar eld. ere were very
few voices that challenged this surgical dogma of nonoperative management, with Dr Marion Simms, a prominent
Southern surgeon who became president of the American
Medical Association, being the most vocal.
ably overwhelming morbidity/mortality associated with
these injuries, it became apparent that a more aggressive,
interventional approach was needed for penetrating injuries
to the abdomen, and, as a result, mandatory exploration,
or celiotomy, became the prevailing management option of
choice and essentially the standard of care.
Shafton and Nance’s landmark articles, which emphasized surgical judgment in the management of penetrating
wounds of the abdomen, changed the approach to penetrating abdominal injuries from mandatory celiotomy to a more
1
With predict-
selective management.
greatly assisted in making the nonoperative/selective management a more reliable and acceptable treatment option in
penetrating abdominal trauma.
Initial Trauma Management
Before focusing on the speci c anatomical region where
there is an obvious traumatic injury, an initial assessment
of the entire patient is imperative. e concept of initial
assessment includes the following components: (1) rapid primary survey, (2) resuscitation, (3) detailed secondary survey
(evaluation), and (4) reevaluation. Such an assessment is the
cornerstone of the Advanced Trauma Life Support (ATLS)
program.
speci c adjuncts. Such adjuncts include the application of
electrocardiographic monitoring and the utilization of other
monitoring modalities such as arterial blood gas determination, pulse oximetry, the measurement of ventilatory rate
and blood pressure, insertion of urinary and/or gastric catheters, and incorporating necessary x-rays and other diagnostic
studies, when applicable, such as focused abdominal sonography for trauma (FAST) examination, other diagnostic
studies (plain radiography of the spine/chest/pelvis and computed tomography [CT]), and diagnostic peritoneal lavage
(DPL). Determining the right diagnostic study depends on
the mechanism of injury and the hemodynamic status of the
patient.
expeditiously address immediate life-threatening injuries.
Only after the primary survey is completed (including the
initiation of resuscitation) and hemodynamic stability
is addressed, should the secondary survey be conducted,
which entails a head-to-toe (and back-to-front) physical
examination, along with a more detailed history.
4
Integrated into primary and secondary surveys are
e focus of the primary survey is to both identify and
12
2,
3 Enhanced diagnostic imaging has
239
240 Part II Abdominal Wall
PRIMARY SURVEY
Only the emergency care disciplines of medicine have a twotier approach to their initial assessment of the patient, with
primary and secondary surveys being integral components.
As highlighted previously, the primary survey is designed to
quickly detect life-threatening injuries.
erefore, a universal approach has been established with
the following prioritization:
•
•
•
•
•
Such a systematic and methodical approach (better known
as the ABCDEs of the initial assessment) greatly assists the
surgical/medical team in the timely management of those
injuries that could result in a poor outcome.
A. Airway assessment management (along with cervical
spine protection): Because loss of a secure airway could
be lethal within 4 minutes, airway assessment/manage-
ment always has the highest priority during the primary
survey of the initial assessment of any injured patient,
irrespective of the mechanism of injury or the anatomical
wound. e chin lift and jaw thrust maneuvers are occa-
sionally helpful in attempting to secure a patient airway.
However, in the trauma setting, the airway management
of choice is often translaryngeal, endotracheal intubation.
If this cannot be achieved due to an upper airway obstruc-
tion or some technical diculty, a surgical airway (needle
or surgical cricothyroidectomy) should be the alternative
approach. No other management can take precedence over
obtaining an appropriate airway control. Until adequate
and sustained oxygenation can be documented, adminis-
tration of 100% oxygen is required.
B. Breathing (ventilation assessment): An airway can be
adequately established and optimal ventilation still not be
achieved. For example, such is the case when there is an
associated tension pneumothorax (other examples include
a tension hemothorax, open pneumothorax, or a large
ail chest wall segment). Worsening oxygenation and an
adverse outcome would ensue unless such problems are
expeditiously addressed. erefore, assessment of breath-
ing is imperative, even when there is an established and
secure airway. A patent airway but poor gas exchange will
still result in a poor outcome. Tachypnea, absent breath
sounds, percussion hyperresonance, distended neck veins,
and/or tracheal deviation are all consistent with inadequate
gas exchange. Decompression of the pleural space with a
needle/chest tube insertion should be the initial interven-
tion for a pneumo-/hemothorax. A large ail chest, with
underlying pulmonary contusion, will likely require endo-
tracheal intubation and the administration of positive-
pressure ventilation.
C. Circulation assessment (adequacy of perfusion
management): e most important initial step in
determining adequacy of circulatory perfusion is to quickly
identify and control any active source of bleeding, along
with restoration of the patient’s blood volume with crystalloid uid resuscitation and blood products, if required.
Decreased levels of consciousness, pale skin color, slow
(or nonexistent) capillary rell, cool body temperature,
tachycardia, or diminished urinary output are all suggestive of inadequate tissue perfusion. Optimal resuscitation
requires the insertion of two large-bore intravenous lines
and infusion of crystalloid uids (warmed). Adult patients
who are severely compromised will require a uid bolus
(2L of Ringer’s lactate or saline solution). Children should
receive a 20 mL/kg uid bolus. Blood and blood products
are administered as required. Along with the initiation of
uid resuscitation, emphasis needs to remain on identifying the source of active bleeding and stopping the hemorrhage. For a patient in hemorrhagic shock, the source of
blood loss will be an open wound with profuse bleeding,
or within the thoracic or abdominal cavity, or from an
associated pelvic fracture with venous or arterial injuries.
Disposition (operating room, angiography suite, etc) of
the patient depends on the site of bleeding. For example, a
FAST assessment that documents substantial blood loss in
the abdominal cavity in a patient who is hemodynamically
labile dictates an emergency celiotomy. However, if the
quick diagnostic workup of a hemodynamically unstable
patient who has sustained blunt trauma demonstrates no
blood loss in the abdomen or chest, the source of hemorrhage could be from a pelvic injury that would likely
necessitate angiography/embolization if external stabilization (eg, a commercial wrap or binder) of the pelvic fracture fails to stop the bleeding. Profuse bleeding from open
wounds can usually be addressed by application of direct
pressure or occasionally ligating torn arterial vessels that
can easily be identied and isolated.
D. Disability assessment/management: Only a baseline
neurologic examination is required when performing the
primary survey in order to determine neurologic function
deterioration that might necessitate surgical intervention.
It is inappropriate to attempt a detailed neurologic examination initially. Such a comprehensive examination should
be done during the secondary survey or evaluation. is
baseline neurologic assessment could be the determination of the Glasgow coma scale (GCS), with an emphasis
on the best motor or verbal response, and eye opening.
An alternative approach for a rapid neurologic evaluation
would be the assessment of the pupillary size and reaction,
along with establishing the patient’s level of consciousness
(alert, responds to visual stimuli, responds only to painful stimuli or unresponsive to all stimuli). e caveat that
must be highlighted is the fact that neurologic deterioration can occur rapidly and that a patient with a devastating
injury can have a lucid interval (eg, epidural hematoma).
Because the leading causes of secondary brain injury are
hypoxia and hypotension, adequate cerebral oxygenation
and perfusion are essential in the management of a patient
with neurologic injury.
Chapter 12 Management of Abdominal Trauma 241
E. Exposure/environmental control: In order to perform
a thorough examination of a patient, he/she must be
completely undressed. is often requires cutting o
the garments to safely expedite such exposure. However,
care must be taken to keep the patient from becom-
ing hypothermic. Adjusting the room temperature and
infusing warmed intravenous uids can help establish an
optimal environment for the patient.
SECONDARY SURVEY
e secondary survey should not be done until the primary
survey has been completed and resuscitation initiated, with
some evidence of normalization of vital signs. It is imperative
that this head-to-toe evaluation be performed in a detailed
manner in order to detect less obvious or occult injuries.
is is particularly important in the unevaluable (eg, head
injury or severely intoxicated) patient. e physical examination should include a detailed assessment of every anatomical
region, including the following:
•
•
•
•
•
•
•
•
A full neurologic examination needs to be performed,
along with an estimate of the GCS score if one was not done
during the primary survey. e secondary survey and the
utilization (when applicable) of the armamentarium of diagnostic adjuncts, previously mentioned, will allow detection
of more occult or subtle injuries that could, if not found,
account for signicant morbidity and mortality. When possible, the secondary survey should include a history of the
mechanism of injury, along with vital information regarding
allergies, medications, past illnesses, recent food intake, and
pertinent events related to the injury.
It cannot be overemphasized that frequent reevaluation of
the injured patient is necessary in order to detect any deterioration in the patient status. is sometimes requires repeating
both the primary and secondary surveys.
Topography and Clinical Anatomy
e abdomen is often dened as a component of the torso that
has for its superior boundary the left and right hemidiaphragm,
which can ascend to the level of the nipples (fourth intercostal space) on the frontal aspect and to the tip of the scapula
in the back. e inferior boundary of the abdomen is the pelvic oor. For clinical purposes, it is helpful to further divide
the abdomen into four areas: (1) anterior abdomen (below
the anterior costal margins to above the inguinal ligaments
and anterior to the anterior axillary lines), (2)intrathoracic
abdomen (from the nipple or the tips of the scapula to the
inferior costal margins), (3) ank (inferior scapular tip to
the iliac crest and between the posterior and anterior axillary
lines), and (4) back (below the tips of the scapula to the iliac
crest and between the posterior axillary lines). e majority
of the digestive system and urinary tract, along with a substantial network of vasculature and nerves, are contained with
the abdominal cavity. A viscera-rich region, the abdomen can
often be the harbinger for occult injuries as a result of penetrating wounds, particularly in the unevaluable abdomen as
the result of a patient’s compromised sensorium.
Mechanism of Injury
In addition to the hemodynamic status of the patient, important variables in the decision making regarding management
of penetrating abdominal injuries are both the mechanism
and location of injury (see Physical Examination). e kinetic
energy generated by hand-driven weapons, such as knives and
sharp objects, is substantially less than what is caused by rearms. Although not always evident, it is important to know
the length and width of the wound along with the depth
of penetration of the weapon or device that caused the stab
injury. For example, a stab injury usually results in a long,
more shallow wound that does not penetrate the peritoneum.
Local wound management is the primary focus for these
injuries with no concern for any potential intra- abdominal
5
Although there are some stab wounds that do not
injury.
penetrate the peritoneal cavity, such cannot be assumed
without some formal determination or serial abdominal
examinations to assess for worsening abdominal tenderness
or the development of peritoneal signs.
ere is notable variability among the full spectrum of
rearms in the civilian setting, with this arsenal, including
mostly handguns, ries, shotguns, and air guns. e kinetic
energy, which correlates with the wounding potential, is
dependant on mass and velocity (KE = 1/2 mr
the higher the velocity, the greater the wounding potential.
Because the barrel is longer in a rie than a handgun, the bullet has more time to accelerate—generating a much higher
velocity. A high-velocity missile is propelled at 2500 ft/s or
greater. Air guns usually re pellets (eg, BBs) and are associated with a lower velocity and wounding potential. Shotguns
re a cluster of metal pellets, called a shot. e pellets separate
after leaving the barrel, with a rapidly decreasing velocity. At
a distance, the wounding potential is diminished. However,
at close range (<15 ft), because of the increase in aggregate
mass, the tissue destruction is similar to a high-velocity
missile injury.
Although each injury should be handled on an individual basis, there are general principles that will provide some
guidance in the management of penetrating injuries based
on mechanism of injury. Regarding stab wounds, approximately one-third of the wounds do not penetrate the peritoneum and only half of those that do penetrate require
2
). erefore,
6