1. 6/5//2010 MBChB V Lecture
AbdominalAbdominal
TraumaTrauma
Prof. J. A. AdwokProf. J. A. Adwok
MBChB, MMED (Surg.), FICS,MBChB, MMED (Surg.), FICS,
FCS(ECSA), FRCSFCS(ECSA), FRCS
Dept. of Surgery, U.o.NDept. of Surgery, U.o.N

2. Abdominal TraumaAbdominal Trauma
• Frequent cause of preventable deathFrequent cause of preventable death
• Peritoneal signs often masked by:Peritoneal signs often masked by:
– Pain from associated extra-abdominalPain from associated extra-abdominal
traumatrauma
– Head injuryHead injury
– IntoxicantsIntoxicants
• Significant deceleration injury or aSignificant deceleration injury or a
penetrating torso woundpenetrating torso wound

3. Abdominal RegionsAbdominal Regions
 Peritoneal cavity:Peritoneal cavity:
–Upper abdomenUpper abdomen
–Lower abdomenLower abdomen
 Retroperitoneal spaceRetroperitoneal space
 PelvisPelvis

5. Mechanism of AbdominalMechanism of Abdominal
TraumaTrauma
BluntBlunt
PenetratingPenetrating
GeographicalGeographical
location andlocation and
demographicsdemographics
affect pattern ofaffect pattern of
injuryinjury
SocioeconomicSocioeconomic
environmentenvironment
influencesinfluences
prevalence andprevalence and
ratioratio

6. Muzzle Velocity of GunsMuzzle Velocity of Guns
 Low velocityLow velocity
 <1200ft./Sec.(<366m/sec.)<1200ft./Sec.(<366m/sec.)
 Hand gunsHand guns
 Medium velocityMedium velocity
 >1200-2000ft./Sec.(366-609m/sec)>1200-2000ft./Sec.(366-609m/sec)
 High velocityHigh velocity
 >2000ft./Sec.(>609m/sec.)>2000ft./Sec.(>609m/sec.)
 Military, assault and high-power huntingMilitary, assault and high-power hunting
riflesrifles
 Usually automatic and semiautomaticUsually automatic and semiautomatic
weaponsweapons

7. Blunt Trauma
•Direct impact
•Compression injury
•Shearing forces

8. Blunt Trauma-Blunt Trauma-
AssessmentAssessment
 HistoryHistory
 Physical examination:Physical examination:
 Inspection: Evidence of injuryInspection: Evidence of injury
 Palpation: GuardingPalpation: Guarding
 Auscultation: Bowel soundsAuscultation: Bowel sounds
 Percussion: TendernessPercussion: Tenderness

9. Blunt Trauma--Blunt Trauma--
AssessmentAssessment
Nasogastric tubeNasogastric tube
Aspiration minimizationAspiration minimization
Upper GIT bleedingUpper GIT bleeding
Caution : facial injuriesCaution : facial injuries

10. Blunt Trauma—PelvicBlunt Trauma—Pelvic
AssessmentAssessment
 Penile:Penile:
 Scrotum:Scrotum:
 Vaginal:Vaginal:
 Rectal:Rectal:
 Gross bloodGross blood
 HaematomaHaematoma
 Gross blood,Gross blood,
fracture fragmentsfracture fragments
 Sphincter tone,Sphincter tone,
prostate position,prostate position,
fracture fragmentsfracture fragments
and gross bloodand gross blood

11. Pelvic--AssessmentPelvic--Assessment
Transurethral CatheterTransurethral Catheter
 Rectal/genital exam firstRectal/genital exam first
 Decompress bladder, monitor urinaryDecompress bladder, monitor urinary
outputoutput
 Diagnostic: haematuriaDiagnostic: haematuria
 Caution: pelvic fracturesCaution: pelvic fractures
 Contraindicated: suspected urethralContraindicated: suspected urethral
injuryinjury

12. Blunt Trauma--AssessmentBlunt Trauma--Assessment
• Positive exam---Positive exam---
• Negative exam--Negative exam--
• Negative exam--Negative exam--
Re-evaluate !Re-evaluate !
SignificantSignificant
Does notDoes not
preclude injurypreclude injury
May becomeMay become
positive with timepositive with time

13. AssessmentAssessment
Blood SamplingBlood Sampling
 Group and crossmatchGroup and crossmatch
 TbcTbc
 Pregnancy testPregnancy test
 AmylaseAmylase
 Alcohol/drug levelsAlcohol/drug levels

14. AssessmentAssessment
Screening RadiographsScreening Radiographs
Based on patientBased on patient
status/mechanism ofstatus/mechanism of
injuryinjury
Free air/extraluminal airFree air/extraluminal air
Loss of psoas shadowLoss of psoas shadow
Associated bony injuryAssociated bony injury

16. Special DiagnosticSpecial Diagnostic
StudiesStudies
 Done for multiply injuredDone for multiply injured
patient if abdominal exampatient if abdominal exam
is :is :
– EquivocalEquivocal
– UnreliableUnreliable
– ImpracticalImpractical
 Do not delay treatment orDo not delay treatment or
transporttransport

17. Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage
 Operative procedureOperative procedure
 Performed by surgeonPerformed by surgeon
 Perform early if hypotensivePerform early if hypotensive
 98% sensitive for98% sensitive for
intraperitonealintraperitoneal bleedingbleeding

18. Computed TomographicComputed Tomographic
ScansScans
Stable patients onlyStable patients only
ContrastContrast
Include lower thorax andInclude lower thorax and
pelvispelvis

23. Indications forIndications for
LaparotomyLaparotomy
Low BP + Abdominal injuryLow BP + Abdominal injury
Extraluminal airExtraluminal air
Injured diaphragmInjured diaphragm
Intraperitoneal injury (+DPL orIntraperitoneal injury (+DPL or
+CT)+CT)
Peritoneal signsPeritoneal signs

24. Grade III
Injury to
Spleen

26. SummarySummary
 Two major types ofTwo major types of
abdominal traumaabdominal trauma
occur: Penetrating andoccur: Penetrating and
blunt.blunt.
 In either case, earlyIn either case, early
evaluation by a surgeonevaluation by a surgeon
is essentialis essential

27. Penetrating traumaPenetrating trauma
 A surgeon must evaluate allA surgeon must evaluate all
penetrating injuries of thepenetrating injuries of the
abdomen.abdomen.
 Penetrating trauma to flanks,Penetrating trauma to flanks,
buttocks, and lower chest maybuttocks, and lower chest may
produce intra-abdominal injuriesproduce intra-abdominal injuries
as well as should be regardedas well as should be regarded
with a high degree of suspicion.with a high degree of suspicion.

28. Blunt TraumaBlunt Trauma
 Blunt Trauma : Intra-abdominalBlunt Trauma : Intra-abdominal
visceral damage must stronglyvisceral damage must strongly
be suspected following bluntbe suspected following blunt
trauma to the abdomen,trauma to the abdomen,
especially because evidence isespecially because evidence is
frequently subtle and misleading.frequently subtle and misleading.
 Diagnosis of such injuries isDiagnosis of such injuries is
often difficult, and an aggressiveoften difficult, and an aggressive
approach is mandatoryapproach is mandatory

29. Blunt Trauma
 Multiple injuries are common, and
common signs and symptoms
guide diagnosis.
 If the above are absent or
obscured by other injuries, special
techniques must be applied.
 Peritoneal lavage is a valuable
diagnostic tool. A specific organ
injury diagnosis is not necessary-
only the finding of an acute
abdominal injury.

30. ManagementManagement
 Re-establish vital function andRe-establish vital function and
optimizing oxygenation and tissueoptimizing oxygenation and tissue
perfusion.perfusion.
 Delineating injury mechanism.Delineating injury mechanism.
 Maintaining a high index of suspicionMaintaining a high index of suspicion
related to occult vascular andrelated to occult vascular and
retroperitoneal injuries.retroperitoneal injuries.
 Repeating a meticulous physicalRepeating a meticulous physical
examination, assessing for changesexamination, assessing for changes
 Selecting adjunctive diagnosticSelecting adjunctive diagnostic
maneuvers as needed, performed withmaneuvers as needed, performed with
a minimal loss of timea minimal loss of time ..