July 7, 2009 | In: TRAUMA
23 BLUNT ABDOMINAL TRAUMA
David J. Ciesla M.D., Ernest E. Moore M.D.
1. What elements of the history are important in evaluating a patient with suspected blunt abdominal trauma (BAT)?
Show answer
First, the mechanism of injury (e.g., motor vehicle collision, automobile-pedestrian accident, fall) is important. In motor vehicle accidents, note the position of the victim in the car, velocity of impact (high, moderate, low), type of accident (front, lateral, or rear impact; side swipe; rollover), and type of restraint used (shoulder restraint, air-bag, lap belt). Information about damage to the vehicle, such as a broken windshield or bent steering wheel, may raise suspicion of cervical and chest injuries. In a fall, it is important to note the distance fallen and the site of anatomic impact. Vertical landing on the feet or in a sitting position causes a different pattern of injury than lateral landing on the side. Serial vital signs and mental status are always important.
2. Is physical examination accurate in the diagnosis of intraabdominal injury?
Show answer
No. The examination results may be normal in up to 50% of patients with acute intraabdominal bleeding. Signs of intraabdominal injury include abrasions and contusions over the lower chest and abdomen; subcutaneous emphysema or palpable rib fracture; clinically evident pelvic fracture; abdominal pain, tenderness, guarding, or rigidity; blood in the urine or urethral meatus; high-riding prostate or blood on rectal examination; and microscopic hematuria.
3. Which organs are most frequently injured in BAT?
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Liver, 50%
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Colon, 5%
|
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Spleen, 40%
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Duodenum, 5%
|
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Mesentery, 10%
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Vascular, 4%
|
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Urologic, 10%
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Stomach, 2%
|
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Pancreas, 10%
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Gallbladder, 2%
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Small bowel, 10%
|
4. What diagnostic studies are helpful in BAT?
Show answer
1. Ultrasound: reliably identifies peritoneal fluid (blood) and pericardial fluid but may miss up to 25% of isolated solid organ injuries.
2. Computed tomography (CT) scan: identifies the presence and severity of solid organ injury (liver and spleen), detects intraabdominal air and fluid (blood, mucus, urine), and aids in evaluation of pelvic fractures. CT scanning can also identify bowel, pancreatic, renal, and bladder injuries.
3. Diagnostic peritoneal lavage (DPL): grossly positive DPL (> 10 mL blood returned by aspiration of the catheter) indicates significant hemoperitoneum. Positive by cell count after infusion of 1 L of crystalloid fluid (> 100,000 red blood cells/mm3, presence of bile or fibers) indicates intraabdominal bleeding, injury to hollow viscus, or hepatobiliary system injury. Lavage fluid exiting through a chest tube or urinary catheter indicates diaphragmatic or bladder injury.
5. How has the availability of ultrasound (US) changed the initial evaluation of BAT?
Show answer
The focused abdominal sonography for trauma (FAST) examination has largely supplanted the DPL. The FAST examination can be performed in a hemodynamically unstable patient during the early secondary survey with immediate transfer to the operating room when hemoperitoneum is identified. CT scan is safe in the hemodynamically stable patient. DPL is still useful when US is equivocal or not available and for evaluation of hollow organ injury.
6. How is hollow organ injury diagnosed?
Show answer
CT findings include peritoneal fluid without solid organ injury, extravasation of oral contrast into the peritoneal cavity, and free intraabdominal air. Suggestive signs include mesenteric stranding and hematoma. Peritoneal lavage results suggestive of hollow organ injury include elevated amylase, alkaline phosphatase, or biliribun levels and the presence of particulate matter.
KEY POINTS: USEFUL DIAGNOSTIC MODALITIES IN BAT
1. Primary and secondary surveys are crucial, but further diagnostic testing is required in most patients.
2. FAST: reliably identifies intraabdominal and intrapericardial fluid but is poor at hollow viscus evaluation.
3. DPL: effective for evaluation of hemoperitoneum and a useful adjunct along with FAST exam.
4. CT: excellent modality with 99.97% negative predictive value for BAT.
7. What are the indications for urgent operation in a patient with BAT?
Show answer
Any hemodynamically unstable patient who exhibits significant hemoperitoneum (by US or DPL) requires emergency laparotomy. Other indications for urgent laparotomy include free intraabdominal air and evidence of hollow viscus injury.
8. How does time in the emergency department (ED) impact the mortality of patients requiring emergent operation for BAT?
Show answer
The probability of death from trauma is related to both the extent of hypotension and the interval from the time of injury to definitive surgery. An estimated increase in mortality of 1% is incurred for every 3 minutes spent in the ED up to 90 minutes.
9. What is the role of angiographic embolization?
Show answer
Angiographic embolization may be effective for hemorrhage control in hemodynamically stable patients. Favorable embolization sites include liver, spleen, and kidney injuries; lumbar arteries with retroperitoneal hemorrhage; and pelvic blood vessels associated with pelvic fracture.
10. What is the “bloody viscus cycle”?
Show answer
The bloody viscus cycle is a syndrome of hypothermia, acidosis, and coagulopathy that occurs with profound hemorrhagic shock and massive transfusion. It represents a circular cascade of events in which severe hemorrhagic shock accompanied by metabolic failure provokes a coagulopathy that exacerbates further bleeding.
11. What is a staged or abbreviated laparotomy (damage control surgery)?
Show answer
Staged laparotomy is terminated before all definitive procedures are completed with the intent to return to the operating room to complete the operation at a later (and safer) time. The purpose of this approach is to delay additional surgical stress until the patient is in a more favorable physiologic state. The objectives of the initial operation become to (1) arrest bleeding and correct coagulopathy; (2) limit peritoneal contamination and the secondary inflammatory response (to control gastrointestinal spillage); and (3) enclose the abdominal contents to protect viscera and limit heat, fluid, and protein loss from an open abdomen.
12. When is staged laparotomy used in trauma patients?
Show answer
* Inability to achieve hemostasis because of recalcitrant coagulopathy (pack the bleeding)
* Inaccessible major venous injury (retrohepatic caval injury)
* Demand for control of a life-threatening extraabdominal (e.g., head or thoracic) injury
* Inability to close the abdominal incision because of extensive visceral edema
* Need to reassess the abdominal contents because of questionable viability at the time of the initial operation
References
WEB SITE
http://www.east.org/tpg/bluntabd.pdf
BIBLIOGRAPHY
1. Branney SW, Moore EE, Cantrill SV, et al: Ultrasound based key clinical pathway reduces the use of hosptial resources for the evaluation of blunt abdominal trauma. J Trauma 42:1086-1090, 1997. Medline Similar articles Full article
2. Burch JM, Denton JR, Noble RD: Physiologic rationale for abbreviated laparotomy. Surg Clin North Am 77:779-782, 1997. Medline Similar articles
3. Clarke JR, Trooskin SZ, Doshi PJ, et al: Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 52:420-425, 2002. Similar articles Full article
4. Davis KA, Fabian TC, Croce MA, et al: Improved success in management of blunt splenic injuries: Embolization of splenic artery pseudoaneurysms. J Trauma 44:1008-1013, 1998.
5. Livingston DH, Lavery RF, Passannante MR, et al: Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy. Am J Surg 182:6-9, 2001. Medline Similar articles Full article
6. Miller MT, Pasquale MD, Bromberg WJ, et al: Not so fast. J Trauma 54:52-59, 2003. Medline Similar articles Full article
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