Abdominal Trauma

Introduction

The abdominal trauma is a serious and disguising condition. In this case, the mode of injury can distract attention from more serious problems that are undiagnosed at presentation.

There are 2 types of abdominal trauma

1. Blunt trauma

It can result from either compression as a result of direct blow or impact against a fixed external object. Deceleration forces can also result in blunt trauma. The liver and spleen are the most frequently damaged solid organs.

1. Penetrating trauma

This trauma results from a gunshot wound, other high-velocity missile/fragments as in bomb explosion, a sharp object, or a stab wound which enter the abdominal cavity and passing through the internal structures.

Assessment

History and examination should be delayed till resuscitation is done and patient is stable.

History

Brief history can be known from the bystanders, police or close relatives who bring the patient to hospital. The questions should be directed to find out:

1. Previous medical history

2. Any medications being taken

3. History of known allergies

4. Last intake of food or other beverages.

5. Events leading to injury.

Examination

Primary survey of injury needs to be done as the patient is admitted to determine whether an urgent surgery is needed. The findings can be grouped as follows:

Inspection

1. External signs of injury on the abdomen like abrasions or patterned bruises should be noted.

2. Injury patterns can sometimes predict the potential for intra-abdominal trauma such as lap belt abrasions, steering wheel-shaped contusions. Lap belt injury is commonly associated with small intestinal rupture.

3. Abdominal breathing can indicate spinal cord injury. Also, abdominal distention and any discoloration should be inspected.

4. Bradycardia can indicate the presence of free intraperitoneal blood in case of blunt abdominal injuries.

5. Flank bruising and swelling can indicate injury behind the peritoneum.

6. Inspect genitals and perineum for diagnosing bleeding, hematoma and soft tissue damage.

Palpation

1. Any abnormal masses, tenderness and deformities can be diagnosed.

2. Lower rib fractures or instability is associated with splenic or hepatic injury.

3. Instability and fractures in the pelvic region is serious complication and can be associated with pelvic hemorrhage. These are life-threatening injuries.

4. Rectal and vaginal examination should be done to rule out bleeding and injury.

5. Neurological examination is needed to diagnose spinal cord injury.

6. Signs of peritonitis like guarding and rigidity indicate leakage of intestinal contents in abdomen.

Percussion

Tenderness on percussion is a sign of peritonitis.

Investigations

1. Complete blood count: it is done to diagnose haematocrit values for evidence of shock. However, it should not hamper blood transfusion or plasma expansion in patients of shock and having serious injuries. Platelet transfusions can be done in patients with thrombocytopenia due to ongoing hemorrhage.

2. Serum chemistry: Bed side glucose test using sticks can be done. If patient is on diuretics, electrolytes need to be tested.

3. Liver function tests may be deranged in blunt abdominal trauma. Digestive enzymes are determined to rule out pancreatic trauma.

4. Urinalysis is indicated in pelvic or flank injury to determine gross as well as microscopic hematuria.

5. Coagulation profile is needed for patients on anticoagulants and with liver disease.

6. Blood grouping and cross matching is very essential in all suspected abdominal trauma cases. At least 4 units of cross matched blood should be kept ready especially for hemodynamically unstable patients.

Management

1. Airway and breathing of the patient is very important before any procedure. Secure airway by orotracheal intubation if needed immediately.

2. Patients who display apnea or hypoventilation require respiratory support. All patients are given supplemental oxygen from a device capable of delivering a high FiO2.

3. For patients in shock, 2 large bore peripheral IV lines are secured. Central line is needed to monitor right atrial pressure. Venous cut down should be done for patients in whom peripheral veins are collapsed due to shock. A rapid bolus of crystalloid followed by colloid and cross-matched blood can be given.

4. Solid organ injury can be managed conservatively in hemodynamically stable patients.

5. Definitive surgery is done depending on injury like removal of bullets, reconnection or suturing of hollow organs, urological procedures, and major reconstructions of gut, splenectomy, or orthopedic procedures. Peritoneal washes are given and abdomen is closed after putting drains.

6. Patient is monitored in intensive care unit after the surgery till stability is achieved.