Abdominal trauma

Abdominal trauma

Assessment of abdominal trauma Assessment of patients with abdominal trauma can be difficult due to Altered sensorium (head injury, alcohol) Altered sensation (spinal cord injury) Injury to adjacent structures (pelvis, chest) Pattern of injury will be different between penetrating and blunt trauma Indications for laparotomy Unexplained shock Rigid silent abdomen Evisceration Radiological evidence of intraperitoneal gas Radiological evidence of ruptured diaphragm Gunshot wounds Positive result on diagnostic peritoneal lavage Imaging Either CT or ultrasound can be used for the assessment of abdominal trauma CT scanning is preferred method but requires patient to be cardiovascularly stable Ultrasound has high specificity but low sensitivity for the detection of: Free fluid Visceral damage FAST Focused assessment for the sonographic assessment of trauma Is the use of ultrasound to rapidly assess for intraperitoneal fluid Probe is placed on the: Right upper quadrant Left upper quadrant Suprapubic region Fluid in subphrenic, subhepatic spaces or Pouch of Douglas in hypotensive patient Confirms likely need for emergency laparotomy Peritoneal lavage Indications Equivocal clinical examination Difficulty in assessing patient Persistent hypotension despite adequate resuscitation Multiple injuries Stab wounds where the peritoneum has been breached Method Ensure that a catheter and nasogastric tube are in-situ Under LA make vertical sub-umbilical incision and divide linea alba Incise peritoneum and insert peritoneal dialysis catheter Aspirate any free blood or gastric content If no blood seen - infuse 1litre of normal saline an allow 3 min. to equilibrate Place drainage bag on floor and allow to drain Send 20 ml to laboratory for measurement of RBC, WCC and microbiological examination Positive result Red cell count > 100,000 / mm3 White cell count > 500 / mm3 Presence of bile, bacteria or faecal material Damage Control Surgery Following multiple trauma poor outcome is seen in those with Hypothermia Coagulopathy Severe acidosis Prolonged surgery can exacerbate these factors As a result the concept of 'damage control' surgery has been developed Initial operation Early management of major abdominal trauma surgery should aim to: Control haemorrhage with ligation of vessels and packing Remove dead tissue Control contamination with clamps and stapling devices Lavage the abdominal cavity Close the abdomen without tension A plastic sheet or 'Bogata bag' may be useful Picture provided by Mr. J C Campbell, Derriford Hospital Plymouth Intensive care unit Early surgery should be followed by a period of stabilisation on the intensive care unit During this period the following should be addressed Rewarming Ventilation Restoration of perfusion Correction of deranged biochemistry Commence enteral or parenteral nutrition 'Second look laparotomy' Planned re-laparotomy at 24 - 48 hours allows: Removal of packs Removal of dead tissue Definitive treatment of injuries Restoration of intestinal continuity Closure of musculofacial layers of abdominal wall This approach has been shown to be associated with a reduced mortality Gastrointestinal injury Small bowel perforations can invariably be primarily closed The management of colonic perforations is more controversial Used to common practice to excise damaged segment Proximal stoma was then fashioned Perforation could also be exteriorised as a stoma Increasingly recognised that primary repair of colonic injuries is safe Now recommended method, especially in the absence of significant contamination Bibliography Brookes A J,  Rowlands B J.  Blunt abdominal injuries.  Brit Med Bull 1999;  55:  844-855. Curran T J,  Borzotta A P.  Complications of primary repair of colon injuries:  literature review of 2,964 cases. Am J Surg 1999;  177:  42-47.  Hoey B A,  Schwab C W.  Damage control surgery.  Scand J Surg 2002;  91:  92-103 Nelson R,  Singer M.  Primary repair for penetrating colon injuries.  Cochrane Database Syst Rev 2002;  CD002247. Offner P J,  De Souza A L,  Moore E E et al.  Avoidance of abdominal compartment syndrome in damage control laparotomy after trauma.  Arch Surg 2001;  136;  676-81. Parks R W,  Chrysos E,  Diamond T.  Management of liver trauma.  Br J Surg 1999:  86:  1121-1135. Stengel D,  Bauwens J,  Sehouli J et al.  Systemic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma.  Br J Surg 2001;  88:  901-912.

Alameda County Medical Center / Highland General Hospital Trauma Service
Abdominal Stab Wound Evaluation
These guidelines apply only to those patients stabbed in the anterior abdomen (see anatomic  boundaries in box below), who meet all three of the following criteria: hemodynamically normal (i.e.. are not hypotensive, tachycardic or diaphoretic) have no evidence of peritonitis have no bowel or omental evisceration through the wound The presence of any one or more of the above mandates immediate abdominal exploration - without delay for further investigative maneuvers or x-rays.
	Boundaries of the anterior abdominal wall: 1.       Superior: costal margins 2.       Lateral: mid axillary line 3.       Inferior: inguinal ligaments
I.  Local Wound Exploration:  In stable patients, a stab wound within the boundaries of the anterior abdominal wall (see above) will first be examined for evidence of violation of the anterior abdominal fascia.  This procedure is performed under sterile conditions (gown/glove/mask, prepping and draping), using adequate lighting, local anesthesia (1% lidocaine + epi) and instrumentation to extend the margins of the stab wound so as to visually and digitally explore its depth.  Cotton-tipped applicators ("Q-tips") are not to be used to probe the wound. A.  If the local wound exploration demonstrates no fascial violation, the wound is irrigated copiously and closed, and the patient may be discharged from the emergency department.  Prophylactic antibiotics are not indicated. B.  If the local wound exploration demonstrates violation of the anterior abdominal wall fascia, it should be assumed that the knife entered the peritoneal cavity.  The wound is closed in layers after adequate irrigation.  The patient will then undergo diagnostic peritoneal lavage (DPL) to determine indications for exploration (see 2. below).  Should there be strong contraindications to DPL (multiple prior abdominal operations, ascites, third trimester pregnancy, refusal of procedure by patient),  the patient will be observed for a period of no less than 48 hours.  Immediate exploration is also an acceptable alternative, after discussion with the patient and the attending trauma surgeon.
II.  Diagnostic Peritoneal Lavage:  Any of the following "(+) DPL results"  mandates abdominal exploration: A.  gross blood > 10 ml or any feces or any bile on initial paracentesis B.  RBC count > 50,000 RBC / mm3 C.  WBC count > 500 / mm3 D.  Bacteria, food or vegetable particles on gram stain / microscopic exam Patients whose DPL results are negative will be admitted for a minimum of 24 hours.  During this period of observation they will undergo monitoring of vital signs, frequent abdominal examinations (q 2 hr x 12hrs, then q 4 hr) and repeat CBC at 12 and 24 hours.  They will be fed ad lib.  Prompt abdominal exploration will be indicated for any patient developing peritoneal irritation, unexplained fever, leukocytosis or hemodynamic instability.  Prophylactic antibiotics are not indicated during the observation period.  Analgesia will consist of intramuscular NSAIDs while NPO, followed by oral agents once oral intake is tolerated. If none of the abnormalities above are noted after the 24 hour period of observation, the patient may be discharged home under the care of a responsible adult.  Follow-up to the Trauma Surgery Clinic should be scheduled for within one week.