abdominal trauma

1. VARUN KUMAR VARSHNEY

2. Introduction
 Abdominal trauma is regularly encountered
in the emergency department
 One of the leading cause of death and
disability
 Identification of serious intra-abdominal
injuries is often challenging
 Many injuries may not manifest during the
initial assessment and treatment period

3. Epidemiology
Peak incidence Abdominal Trauma
15 - 30yr
 More than 1.5 Lac people die every year as
a result of injuries by motor vehicle
accident , fall, suicide and homicide
Injury accounts for 10% of all deaths
Estimates indicate that by 2020, 8.4
million people will die yearly.
Prevalence: 13%

4.  Uncontrolled haemorrhage is the major acute
cause of death immediately following abdominal
trauma.
 Most common delayed cause of mortality and
morbidity following abdominal trauma is sepsis.

5. Classification of Abdominal Trauma
Trauma
Blunt
Crush injury
Blast injury
Seat Syndrome
Penetrating
Stab Wound
Gun Shot Wound
Iatrogenic
Endoscopic
External cardiac massage
Peritoneal dialysis
Per-cutaneous trans-
hepatic cannulation
Guided liver biopsy

6. Mechanism of injury
 Blunt trauma:
MVC
Seatbelt injury
fall from ht
crash injury
sport injury
 Penetrating injuries.

7. Blunt trauma
 associated with severe trauma to multiple
intraperitoneal organs and extra-abdominal systems
 altered mental status, intoxication
 Peritoneal signs are often subtle and may be obscured by
other painful injuries
 Up to 20% of patients with hemoperitoneum have benign
abdominal exams on initial presentation.

8. liver (40-55%)
spleen (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%

10. Seat belt injuries
Unrestrained front and rear seat passengers are at
unequivocally greater risk of intra-abdominal injury than
their restrained counterparts.
The three-point shoulder-lap belt is the most effective
restraining system and is associated with the lowest
incidence of abdominal injuries.
However, abdominal injuries are still ascribed to shoulder-lap
and lap-belt systems.

11.  Clinically, two symptom patterns emerge.
 1/4 of pt develop evidence of a hemoperitoneum
secondary to mesenteric lacerations.
 In the remainder, the intestinal injury most commonly
involves the jejunum contusion or perforation.
 Rare cases of acute abdominal aortic dissection with
incomplete or complete occlusion have also been described,
and injuries to the lumbar spine are not uncommon.

12. Penetrating trauma
 Stab wound
 gunshot

13. Stab wounds
 Knives are not the sole implement used in stabbings.
 Ice picks, pens, coat hangers, screwdrivers, and broken
bottles.
 most commonly in the upper quadrants, the left more
commonly than the right

14.  multiple in 20% of cases
 involve the chest in up to 10% of cases.
 Most stab wounds do not cause an intraperitoneal injury
 the incidence varies with the direction of entry into the
peritoneal cavity
 The liver, followed by the small bowel, is the organ most
often damaged by stab wounds.

15. Gunshot wounds
 the degree of injury depends :
 amount of kinetic energy imparted by the bullet to the
victim
 mass of the bullet and the square of its velocity
 Distance

17. Anaesthesists’ responsibility in
trauma care
1.Prehospital care
2.Emergency department
Trauma team leader
Trauma team member
Anaesthesiologist
3.Operating room
Anaesthesia
4. Postoperative care
 Intensive care unit
 High-dependency unit
 Acute pain team
5. Transportation

18. PRE-HOSPITAL INFORMATION AND
HANDOVER
M-I-S-T
 MECHANISM OF INJURY
 INJURIES SUSTAINED OR SUSPECTED
 SIGNS- VITALS ON SCENE AND DURING TRANSPORT
 TREATMENT INITIATED

19. Prehospital Care
The goal of prehospital is to deliver the
pt to hospital for definitive care as
rapidly as possible. ‘Scoop and Run’
Maintain airway & start I V line
Care of spinal cord
Communicate to medical control
Rapid transport of patient to trauma
centre

20. TRAUMA TEAM
RADIOGRAPHER
AIRWAY DOCTOR
AIRWAY NURSE
CIRCULATION DOCTOR
CIRCULATION NURSE
ORTHO REGISTRAR
WARDSPERSON
SCRIBE NURSETEAM LEADERSOCIAL WORKER

21. Initial assessment
 Preparation & Triage
 Primary survey
 Resuscitation
 Adjuncts to primary survey and resuscitation
 Secondary survey
 Adjuncts to secondary survey
 Post resuscitation monitoring and reevaluation
 Definitive care

22. The use of the following protective devices is
recommended
 Goggles
 Gloves
 Fluid-impervious gowns or aprons
 Shoes covers and fluid- impervious leggings
 Mask
 Head covering

23. PRICIPLES OF INITIAL ASSESSMENT
APPLY APPROPRIATE
MONITORING
DEVICES

24. PRICIPLES OF INITIAL ASSESSMENT
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
AMPLE
ALLERGY
MEDICATION
PAST HISTORY
LAST FOOD
EVENTS

25. PRICIPLES OF INITIAL ASSESSMENT
PERFORM DETAILED
SECONDARY
SURVEY(HEAD TO TOE)

26. PRICIPLES OF INITIAL ASSESSMENT
TRANSFER FOR
DEFINITIVE CARE

27. PRICIPLES OF INITIAL ASSESSMENT
APPLY APPROPRIATE
MONITORING
DEVICES
OBTAIN HISTORY
A-M-P-L-E
&
TETANUS STATUS
RAPID PRIMARY
SURVEY
SIMULTANEOUS
MANAGEMENT OF LIFE
THREATNING INJURIES
PERFORM DETAILED
SECONDARY
SURVEY(HEAD TO TOE)
TRANSFER FOR
DEFINITIVE CARE

28.  Primary survey
A Airway maintenance with cervical spine protection
B Breathing and ventilation
C Circulation with hemorrhage control
D Disability : Neurological status
E Exposure/Environmental control : completely undress the
patient, but prevent hypothermia

29. Airway
 During resuscitation of any severely injured patient,
the initial priorities are to ensure a clear, secure airway
and to maintain adequate oxygenation.
 If the airway obstructed, immediate basic maneuvers
such as chin lift or jaw thrust along with suction may
temporarily relieve the obstruction.
 In semiconscious patient, an oropharyngeal or
nasopharyngeal airway may help while preparing for
more definitive management.

30. Intubation of the trachea with a cuffed
tube remains the gold standard

31. BREATHING AND VENTILATION
 Do not confuse airway problem for ventilation problem
 Patent airway does not equal adequate ventilation.
 Need good gas exchange
 Oxygen in
 CO2 out
Rapid assessment of
 RR
 SPO2
 TRACHEA
 CHEST EXPANSION
 PERCUSSION
 AUSCULTATION

32. CIRCULATION AND HEMORRHAGE
CONTROL
 ASSESS-
 PULSE RATE AND CHARACTER
 SKIN COLOUR AND TEMPERATURE
 CONSCIOUS LEVEL(GCS)
 CAPILLARY REFILL TIME
 DECREASED URINE OUTPUT
 HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME LOST.
 Stopping the bleeding : most important priority

33. MANAGEMENT OF CIRCULATION
 Control bleeding with direct pressure
 Splint limb fractures
 Insert 2 large bore IV cannulas in adults or cut down on
long saphenous v
 Send off blood-cross match,coagulation screen,Hb,
hct,biochemistry,blood alcohol level if req
 Intraosseous needle in children upto 10 yrs

34. DISABILITY AND NEUROLOGIC STATUS
Disability assessed by AVPU scale
 A. Alert i.e. obeys commands
 V. Vocalizes-inappropriate or
incomprehensible
 P. Responds to pain
 U. Unresponsive
 GLASGOW COMA SCORE

35. EXPOSURE

36. RESUSCITATION
 Protect/Secure airway & protect C-spine
 Breathing/Ventilation/Oxygenation
 Vigorous shock therapy
 At last two large - caliber IV line
 Crystalloid solution ( Ringer’s lactate 2~3 litter)
 Type-specific blood
 Surgical intervention
 Protect from Hypothermia : 39oC warm IV fluid
 Urinary/gastric catheters unless contraindication

37. AIRWAY MANAGEMENT
 CLEAR THE AIRWAY-
 SUCTION –
 FINGER SWEEP –
 HEMLICH’S MANOEUVRE
 HEAD TILT & CHIN LIFT
 ENDOTRACHEAL TUBE

39.  Maintain SBP at 80-100 mmHg
 Maintain hematocrit at 25-30%
 Maintain the PT & PTT in normal ranges
 Maintain the platelet count at >50000/ HPF
 Maintain normal serum ionized calcium
 Maintain core temp higher than 35 C
 Maintain function of the pulse oximeter
 Prevent an increase in serum lactate
 prevent acidosis from worsening
 Achieve adequate anaesthesia and analgesia
Goals for early resuscitation

40.  Maintain SBP>100mmHg
 Maintain hematocrit above individual transfusion
thresold
 Normalize coagulation status
 Normalize electrolyte balance
 Normalize body temperature
 Restore normal urine output
 Maximize CO by invasive or noninvasive means
 Reverse systemic acidosis
 Document decrease in lactate to normal range
Goals of late resuscitation

41. PRIMARY SURVEY ADJUNCTS:-
MONITOR
 VITALS
 ECG
 FOLEY’S CATHETER
 GASTRIC TUBE
 ABG
 PULSE OXIMETER
 URINE OUTPUT

42. PRICIPLES OF INITIAL ASSESSMENT
APPLY APPROPRIATE
MONITORING
DEVICES

43.  Secondary survey
- Secondary survey does not begin until the primary survey
(ABCDEs) is completed, resuscitative efforts are well
established, and the patient is demonstrating normalization
of vital functions.

44. Secondary Survey
 General &Systemic Examination-to identify all occult
injuries .
 Special attention to Back, Axilla , Perineum
 PR - sphincter tone ,bleeding ,perforation , high riding
prostate
 Foley’s catheter- monitor urine out put
 Nasogastric tube

45. Secondary Survey(contd.)
 AMPLE History
 A: Allergy
 M: Medications
 P: Past medical history
 L: Last meal
 E: Event - What happened

46. Examination
 Laceration
 Abrasion
 Entry/Exit wounds
 Involvement chest
& Head injury
 Seat Belt Sign

47. Examination
Cullen’s Sign:1918
Bluish discoloration around umbilicus
Diffusion of blood along periumbilical
tissues or falciform ligament
Hemoperitoneum
Severe pancreatitis

48. Examination
Grey-Turner’s Sign: (1877-1951)
Bluish discoloration of the flanks
Retroperitoneal Hematoma
hemorrhagic pancreatitis.
Kehr’s sign (1862-1916).
Referred pain, Right shoulder
irritation of the diaphragm
(Splenic injury, free air,
intra-abdominal bleeding)

49. Examination
Balance’s Sign
Dullness on percussion of the left upper quadrant
ruptured spleen
Labia and Scrotum : Pooling of blood from
abdominal and pelvic cavities.

50. A- Baseline labs
 They add little value in ruling out the need for surgical
intervention yet they are mainly used for later on
comparison.
1. HB : - quantity of blood to replace.
2. HCT : - confirm massive Hg (6-12 hrs).
3. WBCs : - indicate sepsis or reactive leucocytosis.
4. Serum createnin: - pre-renal shut down.
5. Glucose and electrolytes: - proper fluid resuscitation.
6. Amylase: - gut injury or pancreas (non-specific).
7. Urine analysis: - if RBCs >30 – 50 /mm, radiographic
evaluation of kidneys and urinary bladder is a must.

51. Plain X-Ray Chest & Abdomen
 Pneumotharax, Haemothorax
 Free air under diaphragm
 Nasogastric tube, bowel loops in the chest
 Elevation of the both /Single diaphragm
 Lower Ribs # -Liver /Spleen Injury
 Ground Glass Appearance –
Massive Hemoperitoneum
 Obliteration of Psoas Shadow –Retroperitoneal
Bleeding
 #vertebra

52. Focused Assessment with Sonography in
Trauma (FAST)
 First used in 1996
 Rapid , Accurate
 Sensitivity 86- 99%
 Can detect 100 mL of blood
 Cost effective
 Four different views- Pericardiac
Perihepatic
Perisplenic
Peripelvic space
 Eliminates unnecessary CT scans
 Helps in management plan

53. B- FAST (cont.)
 Advantages: -
1. Fast and non-invasive.
2. Bedside.
3. Portable
 Disadvantages: -
1. Operator dependent.
2. Limited by surgical emphysema and obesity.
It must be clear that in a hemodynamically stable
patient a positive FAST per se doesn’t indicate the
need for surgical exploration.

55. C- Diagnostic peritoneal lavage (DPL)
 It has been the golden standard for the investigation of
blunt abdominal injury for more than 30 years. Its
accuracy is 97.3%. False-positive rate is 1.4%. False-
negative rate is 1.3%.
 DPL is considered positive if: -
1. Return of 10 ml of non-clotting blood on insertion.
2. Lavage count of 100 000 red cells per mm (RCC).
3. 500 white cells per mm.
4. Amylase greater than 200 IU.
5. Presence of bile, faeces, bacteria.

56. C- Diagnostic peritoneal lavage (DPL) (cont.)
 Indications: -
1. Unconscious trauma patient with signs of abdominal
injury.
2. Patient with suspected intra-abdominal injury and
equivocal physical findings.
3. Patients with muitple injuries and unexplained
shock.
4. Patients with spinal cord injury.
5. Intoxicated patients in whome abdominal injury is
suspected.

57. C- Diagnostic peritoneal lavage (DPL) (cont.)
 Disadvantages: -
The most frequent criticism is the rate of non-therapeutic
laparotomy performed for positive cell count due to the
balance between false-negative results and over
sensitivity. Its various estimation is 10 - 15 %.
It does not allow conservation management in the presence
of blood in the abdominal cavity, but CT may be used as an
adjunct in the stable patients.

58. C- Diagnostic peritoneal lavage (DPL) (cont.)
 Contraindications: -
1. Patients with previous abdominal operations.
2. Pregnancy.
3. Morbid obesity.
4. Patients with frank surgical abdomen.
 Complications: -
1. Gut perforation.
2. Hemorrhage.
3. Infection.

61. Paracentasis
 Four quadrant aspiration of abdomen
 A Positive tap – blood , air , bile stained fluid
 Negative tap doesn’t rule out injury.
 False negatives are as high as 22-60%

62. CT Scan
• Gold Standard
• Haemodynamically Stable
• Provides excellent imaging of pancreas, duodenum
and Genitourinary system
• Standard for detection of solid organs injury.
• Determines the source and amount of bleeding
• Can reveal other associated injuries e.g. Vertebral &
Pelvic # & injury in the thoracic cavity .
• High Specificity-95%

63. DPL FAST CT SCAN
Indications Document bleeding if
hypotensive
Document fluid if
hypotensive
Document organ injury
if BP normal
Advantages •Early diagnosis
•All patients
•Rapidly performed
•Sensitivity 98%
•Detects bowel injury
•Transport : No
•Early diagnosis
•All patients
• Rapidly performed
•Non invasive
•86- 97% accurate
•Transport: No
•Most specific for
injury
•Sensitive 92-98%
Disadvantages •Invasive
•Low specificity
•Misses injury to
diaphragm and
retroperitoneum
•Operator dependant
•Bowel gas and
subcutaneous air
distortion
•Misses injury to
diaphragm ,bowel and
pancreas
•Increased cost and
time
•Transport required
•Misses injury to
diaphragm ,bowel and
sometimes pancreas

64. UNSTABLE
INVESTIGATION AVAILABILITY
F A S T D P L
FREE FLUID
BLOOD
NO YES
CONTINUE
RESUSCITATION LAPAROTOMY
HEMODYNAMIC STABILITY ?

65.  Blunt abdominal injuries carry a
greater risk of morbidity and mortality
than penetrating abdominal injuries

68. Indications for laprotomy
 BTA with hypotension, with clinical evidence of
intraperitoneal bleeding
 BTA with positive DPL or FAST
 Hypotension with penetrating wounds
 Gunshot wounds traversing the peritoneal cavity or
visceral/vascular retroperitoneum
 Evisceration
 Bleeding from the stomach, rectum or genitourinary tract
following penetrating trauma

70. PREPARATION FOR ANESTHESIA
AND SURGERY
 Establishing or Confirming Presence of Definitive
Airway
 Intravenous Access.
 Evaluation of Preoperative Volume Status.
A quick evaluation of the patient’s volume status can
be made by measuring the blood pressure, heart rate,
palpating the peripheral pulse, skin color and turgor,
and quality of mucous membranes

71. INDUCTION AND MAINTENANCE
OF ANESTHESIA
 Hypotension at induction of anesthesia for trauma is a
common and important complication to avoid.
 suppression of endogenous catecholamines.
 direct myocardial depressant effects and vasodilator
effects of certain induction drugs.
 once abdominal incision is made, tamponade of
abdominal bleeding is lost and a torrent of bleeding may
occur

72. INDUCTION
 It is frequently quoted that “more soldiers were killed
in World War II by thiopental than by bullets.”
 Comatose patients, those in severe shock, or in full
arrest on admission, require nothing more than oxygen
and possibly a neuromuscular blocking drug until the
patient’s blood pressure and heart rate rebound
enough that anesthetics can be added.
 Awake traumatized patients demonstrating signs of
hypovolemia are generally best induced with
etomidate (0.2 mg/kg).

73. MAINTENANCE
 Drugs should be titrated according to BP.
 Trauma patients with hemorrhagic shock too severe to
tolerate anesthetic drugs (other than neuromuscular
blockade) should receive scopolamine as an amnestic.
 No absolute contraindications of any volatile drug for
abdominal trauma .
 However, halothane and sevoflurane have been historically
avoided due to potential for liver and renal injury,
respectively.
 If possible, nitrous oxide (N2O) should be avoided to limit
bowel and closed space gas accumulation.

74. ADJUNCTIVE MANAGEMENT
AND COMPLICATIONS
 Administration of Shed Abdominal Blood.
 PREVIOUSLY CONTRAINDICATED.
For noncontaminated intraabdominal blood involving
liver, spleen, or retroperitoneal injury, cell saver
technique is considered standard practice for most
TRAUMA CENTRE.
Prevent HYPOTHERMIA
ACID BASE MANAGEMENT.
ANTIBIOTICS.

75. POSTOPERATIVE ICU
CONSIDERATION
1
• ABDOMINAL COMPARTMENT SYNDROME
2
• DEEP VENOUS THROMBOSIS
3
• SEPSIS

76. DAMAGE CONTROL
 Multi trauma pt. triad of coagulopathy, hypothermia,
metabolic acidosis- interfernce with surgical mgt
 Goal- 1.control hmg
2. prevent contamination
3. protect pt. from further
injury
 Proceed to definitive surgery once pt stabilises
 Clear communication between surgeon,
anesthesiologist and intensivist

77. Getting the Right Care, at
the Right Place, at the
Right Time.
Thank you