260. Abdominal Trauma

Blunt Abdominal Trauma

MCC MVCs. Intraabdominal injuries rare with falls though if they do occur, they are usually hollow organ injuries. Also retroperitoneal injuries can occur.

CT not very good at diagnosing pancreatic, duodenal, mesentery, hollow viscous, diaphragm injuries.

Abdominal exams can be benign initially. Can have 50-60% of blood volume dumped in abdomen before symptoms noted. 35% of blunt trauma have initially ‘benign’ abdomen. Single exam is insensitive. Serial exams are important.

FAST > DPL though not perfect. 28% of negative FASTs have solid organ injuries without hemoperitoneum. DPL insensitive, invasive. No longer recommended though can be preferred in unstable patient unable to get to CT scan. Aspirate two finger breaths under umbilicus. Aspirate and if >10mL bright red blood, need laparotomy. Ultrasound can detect at least 100mL of blood. CT is snapshot, not dynamic imaging. CT not great for pancreas, diaphragm, small bowel, or mesentery.

Gray Turner sign: flank discolorization and Cullen’s sign: umbilicus discoloration are seen with retroperioteal bleeding though usually delayed signs.

Hepatic Injuries: 90% non-operative management if vitals stable. Grade I-III usually non-operative. Higher grade usually fail non-operative management. Angioembolization with stent/coiling useful for large hemoparioteum or contrast blush.

Splenic Injury: most common organ injured with blunt trauma. Failure rate 10-15% in non-operative management. Only non-op if patient < 55 and grade < IV. Proximal embolization can be useful and spleen will do well with collateral circulation.

Penetrating Abdominal Trauma

Small bowel most common organ injured followed by colon and liver. Liver most common injured in stabs though.

Stabs: LWE (local wound exploration) for anterior abdominal stabs is preferred over immediate laparotomy. CT also helpful. If no visualization of anterior fascia and likely negative CT with benign abdominal exam, can likely discharge. If hypotension, peritonitis or evisceration, will need laparotomy.

GSW: transabdominal GSW almost always need surgery. + FAST in 90%, though 1/3 of negative FAST will still need laparotomy. CT reliable in hemodynamic stable patient. Laparotomy for hypotension, abdominal wall disruption, or peritonitis.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 260: Abdominal Trauma

Rosens, Chapter 39: Abdominal Trauma

260. Abdominal Trauma