Slide 1

Patient with Abdominal Pain

Following Trauma

ZAI N RI ZVI
2 018 - 103

Slide 2 Trauma - Types

 Trauma is the most common cause of death between the ages of

1 – 44 years worldwide.

 It can be classified in type by causation and by effect

 Blast
 Blunt
 Crush
 Penetrating
 Thermal

Slide 3 Following Major Trauma:

“Trimodal Distribution of Death”

 Immediate – Within seconds to minutes - 50% of all deaths

 Massive head injury or severe cardio-pulmonary insult

 Early – Within minutes to the first few hours

 Subdural hematoma, pneumothorax, blood loss

 Late – After several days/weeks - 20% of deaths

 Multi organ failure & sepsis
Slide 4 ATLS

 ATLS – Acute Trauma Life Support

 Used worldwide as a standardized form of trauma care

 Aimed primarily at the ”early” group of patients

 Optimize the speed and accuracy of the initial assessment and

management
 Reduces subsequent morbidity & mortality

Slide 5 Case #1

A 27 year old lady was involved in a motor vehicle accident. She was
driving the vehicle and was not wearing her seatbelt. On arrival to the
emergency department, she is mildly disoriented, her blood pressure is
110/60 mmHg and her heart rate is 100 per minute.

Physical examination reveals ecchymosis and tenderness in the left

lower chest area. Her abdomen is non tender.

CXR shows 8th and 9th rib fractures on the left.

Slide 6 Questions

 What injuries are likely in this scenario?

 How will you manage it in the ER?

Slide 7 Initial Assessment & Management

The same initial steps are followed, regardless of which part/system of

the body is involved in trauma.

Slide 8 Initial Assessment & Management

 Primary survey and resuscitation

 Adjuncts to primary survey
 Secondary survey (head-to-toe evaluation and patient history)
 Adjuncts to secondary survey
 Consideration of the need for patient transfer
 Continued post resuscitation monitoring and re evaluation
 Definitive care

Slide 9 Primary Survey & Resuscitation

 A traditional surgical approach with
history taking, clinical examination,
ABCD of trauma care
 Traditional approach is inappropriate in major trauma patients investigation & treatment is
inappropriate in major trauma
A - Airway (with cervical spine protection)
B - Breathing (and ventilation) patients.
C - Circulation (with haemorrhage control)  Although the Steps of the ‘ABC’
D - Disability (Neurological status assessment)
E - Exposure (undress the patient and assess for other injuries).
approach are presented here
sequentially, the trauma team
performs & constantly reassess all
of these aspects simultaneously.
Slide 10 Adjuncts to Primary Survey

 Blood Tests = CBC, electrolytes, urea, coagulation profile, cross match

 ECG, pulse oximetry, ABG

 Two wide-bore cannulae for IV fluids

 Urinary and Gastric Catheters

 Radiographs of cervical spine, chest and pelvis

Slide 11 Secondary Survey

 Identify all other injuries and perform a more thorough head to toe examination.

 It is here that patient’s history is reviewed - ‘AMPLE’

 Allergies
 Medications (tetanus status)
 Past medical history
 Last meal
 Events of the incident

Slide 12 Re-Evaluation

 It shouldn’t be stopped until the patient leaves the ER

 Continuous monitoring (vital signs and urinary output)

Slide 13 Damage Control or Damage Limiting Surgery
 Once these goals are achieved, the
operation is suspended & the
 Minimum surgery needed to stabilise the patient’s condition
 Ligation of vessels, drainage, therapeutic packing, etc abdomen temporarily closed.
 Two goals
Patient’s resuscitation then



Stopping active surgical bleeding
Controlling any contamination continues.
 Definitive surgery is performed within 24-72 hours  Ligation of vessels, shunting of
major arteries & veins, drainage ,
temporary stapling off of bowel &
therapeutic packing.
 Definitive Surgery performed within
24 – 72 hours.

Slide 14
Indications for
Damage Control
Surgery

Slide 15 Organ Classification

 Hollow - Stomach, Gall bladder, Large and Small intestines, Ureters

and Urinary Bladder
 Spillage leading to inflammation of peritoneum

 Solid - Liver, Spleen, Kidney, Pancreas

 Bleed heavily and cause shock

 Major Vessels - Aorta, IVC, Major branches

 Bleeding out and leading to shock
Slide 16 Investigations

 FAST (Focused Assessment with Sonography for Trauma)

 DPL

 CT

 Diagnostic Laparoscopy

Slide 17 Focused Assessment with Sonography for Trauma (FAST)

 Doesn’t identify injury to hollow
 Detects presence of free fluid in abdomen viscus
or pericardium; not hollow viscera injury

 Can be done at bedside

 Cannot exclude injury in
 Detects >100 ml of free blood penetrating trauma
 Scans are obtained for:
 pericardial sac
 hepatorenal fossa
 splenorenal fossa
 pelvis or pouch of Douglas

Slide 18 Direct Peritoneal Lavage

 Gastric tube is placed to empty the
 Used to assess the presence of
stomach & urinary catheter is inserted
blood in the abdomen
 Stomach and bladder must be empty to drain the bladder.
 Cannula is aspirated for blood  Free aspiration of blood,
 (>10 ml is deemed positive)

gastrointestinal contents, vegetable

 Then 1000 ml of warmed Ringer’s
Lactate is allowed to run in the
abdomen & drained out
fibres, or bile through the lavage
 (>100,000 red cells/uL or >500
white cells/uL is deemed positive) catheter in patients with hemodynamic
abnormalities mandates laparotomy.
Slide 19

DPL
It’s especially useful in
hypotensive, unstable
patient with multiple injuries
as a means of excluding intra
abdominal bleeding

Free aspiration of blood,

gastrointestinal contents,
vegetable fibres, or bile
through the lavage catheter
in patients with
hemodynamic abnormalities
mandates laparotomy.

Slide 20 CT Scan
 Blue arrow – Intraparenchymal
 Gold standard for intra-abdominal
haematoma in spleen
diagnosis of injury in the stable
patient  Red arrow – Active extravasation of
 Scan should be performed using IV
blood
contrast

 It’s sensitive for blood, individual

organ injury & retroperitoneal
injury

Slide 21 Indications for a Emergency Laparotomy in Adults

 Gunshot wounds traversing the
peritoneal cavity or
1. Blunt abdominal trauma with hypotension with a positive FAST or
clinical evidence of intra-peritoneal bleeding or positive DPL visceral/vascular retroperitoneum
2. Hypotension with a penetrating abdominal wound
3. Gunshot wounds  Bleeding from the stomach, rectum,
4. Evisceration
5. Peritonitis or genitourinary tract from
6. Free air, retroperitoneal air, or rupture of the hemidiaphragm
7. Contrast-enhanced CT that demonstrates ruptured GIT, penetrating trauma
intraperitoneal bladder injury, renal pedicle injury, or severe visceral
parenchymal injury after blunt or penetrating trauma
Slide 22 Case #1

A 27 year old lady was involved in a motor vehicle accident. She was
driving the vehicle and was not wearing her seatbelt. On arrival to the
emergency department, she is mildly disoriented, her blood pressure is
110/60 mmHg and her heart rate is 100 per minute.

Physical examination reveals ecchymosis and tenderness in the left

lower chest area. Her abdomen is non tender.

CXR shows 8th and 9th rib fractures on the left.

Slide 23

Slide 24 Individual Structure/Organ Treatment - Spleen

In Stable Patient:
 50-80% of splenic injuries in
stable adults do not require
surgery
 Patients being nonsurgical
managed should be monitored in
ICU
 High-grade injury or ongoing
bleeding on CT is an indication for
surgical repair
 Splenectomy patients receive the
In Unstable Patient:
vaccine for Pneumococcus,
 Age >55 years, presence of other
injury, physiological instability –
Meningococcus and Haemophilus
consider splenectomy
 Spleen can be packed, repaired or
influenza type b.
placed in a mesh bag.
 These vaccines usually are given 14
days prior to an elective
splenectomy or 14 days after the
surgery.
Slide 25 Grading of Splenic Injury - AAST
American Association for the Surgery
of Trauma (AAST) splenic injury scale
 Capsular tear 1-3 cm parenchymal
 Free blood can irritate the depth – Subcapsular 10-50%
diaphragm and cause a radiating
left shoulder pain (known
as Kehr’s sign).
surface area, or intraparenchymal
<5cm – Grade 2

Slide 26 Case #2

A 27 year old male was brought to ER with history of RTA. He was

conscious, oriented, tachypnoeic with pulse rate of 110/min and BP of
80/60mmHg.

Examination of abdomen revealed diffuse tenderness. Guarding was

present in the entire abdomen. Neurological examination was normal.

Despite adequate resuscitation with crystalloids and whole blood,

patient didn’t improve.

Slide 27 Questions

 What injuries are likely in this scenario?

 What is the next course of action?

Slide 28 Case

 Internal bleeding should be suspected in this scenario

 Ultrasound was done which revealed free fluid in abdomen and solid
viscera were normal

 Emergency Laparotomy was done when liver laceration 5 x 3 x 2 cm

on anterolateral surface with active haemorrhage was noted.

Slide 29 Individual Structure/Organ Treatment - Liver

In Stable Patient:
 Majority of it is better treated non-
operatively as long as it stays &
continues to stay hemodynamically
stable.
• Intra-hepatic bile collections usually
In Unstable Patient:
resolve spontaneously over months.
 Operative management can be
summarised as ‘the 4 Ps’
• Extra-hepatic bile collections should
 Push

 Pringle
be drained percutaneously.
 If more than 2 units of packed RBCs
are required then arteriography with
embolization should be considered.
 Plug

 Pack
• (1) Suture ligation (2) Surgical clips
 Repeat CT scans should be considered
in patients to rule out parenchymal
 If hemodynamic instability or
continuous bleeding – Laparotomy (3) Electrocautery (4) Microfibrillar
infarction, hematoma and biloma.
collagen (diffuse capillary bleeding)
(5) Haemostatic gelatin foam
sponges soaked in thrombin (diffuse
capillary bleeding) (6) Fibrin glue (7)
Surgical packing with angiographic
embolization

Slide 30  Liver is constituted as best as

possible as in its normal position &
Pringle Manoeuvre
Inflow from portal triad is
controlled by direct
bleeding is controlled by direct
compression either
digitally or using a soft compression – Push
clamp
Clamping of the
hepatoduodenal ligament
 Penetrating injury can be plugged
interrupts the flow of
blood through the hepatic using silicone tubing or Sengstaken-
artery and the portal vein
Blakemore tube.
Slide 31 Case #3

A 45 year old woman who was wearing a lap seat belt is involved in a
head-on collision 4 hours ago. She is awake & complains of abdominal
pain. She is slightly pale and has a blood pressure of 110/80 mm Hg.

On examination, bruise across her upper abdomen with slight guarding

and moderate tenderness to palpation.

A rapid trauma sonography demonstrated free intraperitoneal fluid.

After giving her the necessary IV fluids the patient was stabilized.

Slide 32 Questions

 What is the next course of action?

Slide 33 Case #3 - Investigations

 Stabilized patient

 Contrast enhanced abdominal CT

 Showed the presence mesenteric
haematoma
Slide 34 Individual Structure/Organ Treatment - Bowel
 Individual loops may be trapped,
causing high pressure rupture of a
Small Bowel
 Need urgent repair
 Injury with non-compromised blood supply can be controlled with simple sutures
loop or tearing of the mesentery
Mesenteric Injury
 The mechanism of mesenteric
 Bowel Injury with compromised blood supply
 Resection
injury in blunt abdominal trauma
 Emphasis should be on preserving as much small bowel as possible. involves compression and
deceleration forces which result in a
spectrum of injuries that range
from contusions, to tearing of the
bowel wall, to shearing of the
mesentery, to loss of vascular
supply

Slide 35 Individual Structure/Organ Treatment - Colon

 Transverse or defunctioning
colostomy may be performed to
 Result mostly from penetrating injury
decompress the bowel obstruction,
 Can be repaired primarily if viability is satisfactory
bypass the diseased bowel or
 Colon should be closed off and defunctioning colostomy should be formed if
patient is unstable or bowel is of doubtful viability protect distal anastomosis

Slide 36 Individual Structure/Organ Treatment - Rectum

 Associated with bladder & proximal
urethral injury
 Generally from penetrating injury or fracture of pelvis

 DRE usually reveals presence of blood

 Hartmann’s procedure - resection
 Treatment for intra peritoneal injury is same as that for colon
of rectosigmoid colon with closure
 Extra peritoneal injury requires either a diverting end colostomy with closure of distal end of anorectal stump & formation of
(Hartmann’s procedure) or loop colostomy.
end colostomy
 Loop Colostomy – stoma in which
entire loop of colon is exteriorized
& both proximal & distal limb open
into the common stoma opening &
not transected
Slide 37 Individual Structure/Organ Treatment
Renal and Urological Tract Injury
 Severe Renal Injury managed
through: (1) Suture repair (2) Partial
 Generally renal injuries are managed non operatively unless patient is
unstable nephrectomy (3) Total
 Uretic Injuries are rare & can be repaired or diverted if necessary
 Intraperitoneal ruptures of bladder require surgical repair
nephrectomy (rare) (4) Pedicle
 Extraperitoneal ruptures of bladder will heal with adequate urine
drainage
grafts of omentum or free
 Uterine injury can be repaired by sutures or by hysterectomy if peritoneal patch grafts to cover
indicated
defects

Slide 38 Individual Structure/Organ Treatment - Pancreas

 An early normal serum amylase level does not exclude major pancreatic
trauma
 Persistently elevated or rising serum amylase levels should prompt further evaluation of the
pancreas and other abdominal viscera.

 Closed suction drainage with distal pancreatectomy if duct is involved

 Damage control surgery with packing and drainage

 Referred for definitive surgery once stabilized

Slide 39 Individual Structure/Organ Treatment - Biliary Injuries

 Partial or total pancreatectomy
 Rarely injured, occur mainly from
penetrating trauma

 CBD can be repaired over a

T-tube or drained

 Avulsion (due to duodenal)

 May require choledochojejunostomy
Slide 40 Antibiotics

 They should be used in all cases of penetrating abdominal

trauma.

Slide 41
After the Resuscitation Room & Necessary Surgical Intervention

 After the patient has been stabilised , further investigations can be undertaken beyond the
resuscitation room prior to definitive surgical or intensive care unit admission.

 Senior Anaesthetic and Surgical Staff must accompany the patient in these situations.

Slide 42

Thank You