Patients involved in major trauma should be considered to have an abdominal injury until otherwise excluded. Blunt and penetrating trauma can present with significant abdominal injuries.
Hidden intra-abdominal haemorrhage and other unrecognised intra abdominal injuries are common causes of death following polytrauma, so a high index of suspicion is important.
Assessment[edit | edit source]
The initial assessment of the abdominal trauma patient is the Primary Survey: ABCDE. The assessment of the "Circulation" during the Primary Survey involves careful evaluation of the abdomen and pelvis for possible hidden haemorrhage, especially in hypotensive patients.
Regions[edit | edit source]
There are three distinct regions of the abdomen:
- the peritoneal cavity
- the retroperitoneal space
- the pelvic cavity.
Injuries to the retroperitoneal visceral structures are often difficult to diagnose and traumatic injuries, especially penetrating injuries, can involve more than one intra-abdominal cavity, Trauma does not respect anatomical boundaries and no examination should be taken in isolation – chest and abdominal injuries commonly occur together; repeated evaluation is necessary to ensure injuries are not missed.
The site of injury, energy transfer and mechanism are important factors in the assessment of abdominal trauma. Blunt trauma can often affect solid organs and all viscera are at risk from penetrating injuries. It is important, in the case of knife and gun shot wounds, to attempt to gauge trajectory as this may indicate potential internal injuries.
Mechanism[edit | edit source]
Classification of the mechanism of injury:
- Penetrating trauma e.g. gunshot, knife wounds
- Blunt trauma e.g. compression, crush and deceleration injuries
- Explosions can cause both blunt and penetrating trauma as well as blast
pressure injuries to the lungs and hollow viscera.
Assessment and management of abdominal trauma – is there visceral damage or bleeding?[edit | edit source]
Blunt abdominal trauma can be very difficult to evaluate. This is especially important in patients who are unconscious or intoxicated or in patients with polytrauma to a number of anatomical cavities. The pain from significant rib or pelvic injuries can mask abdominal injury. Ten percent of polytrauma patients with no abnormal clinical signs have evidence of intra-abdominal injury on radiological imaging. Evaluation of the retroperitoneum for injuries to colon, pancreas and kidneys is difficult and these patients should be referred to a surgeon.
Repeating the primary survey and serial physical examinations of the abdomen will identify clinical deterioration and assist in making the diagnosis.
Physical examination includes inspection, auscultation, percussion and palpation of the abdomen as well as examination of:
- Urethra, perineum, and gluteal region
- Rectum (tone, blood, prostate position),
- Vagina
- Pelvis (fractures and stability)
The haemodynamic status of the patient determines the diagnostic and management priorities. Hypotensive patients may need an urgent diagnostic laparotomy.
Diagnostic peritoneal lavage (DPL) and, if available, ultrasound (Focused Assessment Sonography in Trauma or FAST) and abdominal computed tomography (CT) are diagnostically useful but should not delay transfer of the patient for definitive care.
DPL[edit | edit source]
- Sensitive and specific test for intraperitoneal blood, an indication for surgery
- More sensitive than ultrasound for hollow viscus injury
- Does not exclude retroperitoneal injury
- Operator dependent
FAST[edit | edit source]
- Replacing DPL when available
- Sensitive and specific for intraperitoneal and pericardial fluid
- Rapid, repeatable and non invasive
- Ultrasound does not predict the need for surgery
- Negative ultrasound examination does not exclude organ injury
CT[edit | edit source]
- Investigation of choice, when available, for haemodynamically stable patients
- Sensitive and specific for solid organ pathology, less sensitive for hollow viscus
- Normal CT scan has a high negative predictive value
- Diagnostic test of choice for the retroperitoneal space and diaphragm
- However, a surgeon should assess patients and negative CT scanning should be treated with caution.
Other diagnostic aids[edit | edit source]
- Nasogastric tube (not in base of skull and mid face fractures)
- Urinary catheter (caution with pelvic fractures, and urethral meatal bleeding)
- Chest and pelvis x-rays are mandatory if available. Abdomen x-ray is rarely helpful.
- Contrast studies of gastro or genitourinary systems
Assessment and management of pelvic fractures: is there visceral damage, bleeding or pelvic fracture?[edit | edit source]
Pelvic fractures are often complicated by visceral injury and massive haemorrhage. Life threatening haemorrhage is a frequent complication of major pelvic fractures and causes 30% of polytrauma deaths.
Both orthopaedic and general surgeons should assess patients due to the high risk of concurrent bony, vascular and visceral injury.
Physical examination includes[edit | edit source]
- Urethra (meatal blood), perineum (bruises) and gluteal region
- Rectum (laceration, blood, high riding prostate), vagina
- Leg length difference or rotational deformity
- Mechanical instability of the pelvis by gentle compression/distraction
The management of pelvic fractures includes early identification and immobilisation to stop bleeding, using either simple stabilisation with a sheet pulled tight and tied round the hips (femoral greater trochanters) or commercially available pelvic slings.