1. Bukenya Ali
1

2. Introduction
• In relation to trauma, the abdomen is
divided into 4 sections internally:
intrathoracic
true abdomen
pelvic
retroperitoneal
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3. Abdominal trauma
Classification
• Blunt: Usually due to RTA, blow, fall
• Penetrating: Mainly due to stab wounds,
gun shots, anything piercing or Sharp
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4. Factors that influence severity of
injury in RTAs
• Size of car; smaller is worse
• Position of victim in car
• Morphology of victim: more weight is better
• Use and type of restraint: seat-belts, airbags
• Type of RTA:
Lateral impact: least bad
Frontal impact: bad
Rollover and ejection: worst
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5. Difficulties in abdominal injuries.
• Non clear history in a walking pt.
• closed injury can occur without any obvious
sign
• Obvious injuries like # may disrupt your
attention.
• Alcohol or head injury make diagnosis hard.
• Anesthesia and analgesia make diagnosis
hard
• Muscle pain vs. peritoneal irritation may be
difficult to distinguish.
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6. Making a Diagnosis
• History of trauma, nature + site of impact
• Pain; site, severity, progression,
• Examination; pallor, Anxiety, cold
extremities, breathing, abdominal tenderness,
bowel sounds, rib fractures, rectal exam and
vaginal exam, orthostatic hypotension
• Physical exam can be unreliable
– compensated hemoperitoneum, retroperitoneal,
pelvic injuries
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7. Physical Exam: Eponyms
• Grey-Turner sign:
– Bluish discoloration of lower flanks, lower back; associated
with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
• Cullen sign:
– Bluish discoloration around umbilicus, indicates peritoneal
bleeding, often pancreatic hemorrhage.
• Kehr sign:
– L shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
• Balance sign:
– Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.
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8. Special methods.
• Measuring increasing girth 2-3cm significant
• Paracentesis (4 quadrant tap) can repeat 2-
3hrs later. Negative not always negative
• Diagnostic Peritoneal lavage.
• Culdocentesis
• Urine for blood, FBC
• X-ray
• CT, MRI
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9. Diagnostic peritoneal lavage
• Standard criteria
– 10cc gross blood
– RBC>100,000/mm2 (5% miss)
– WBC>500/mm2
– Amylase>175 IU/dL
– Bile, bacteria, or food
• Contraindications
– Clear indication for ex lap
– Prior abdominal surgeries
– Pregnancy
– Obesity
• Sensitive to intraperitoneal bleed
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10. FAST
• Pros
– Noninvasive
– Fast
– Low cost
• Cons
– User dependent
– Obesity, gas interposition
– Misses retroperitoneal/hollow viscus injury
– May not detect free fluid <50-80 cc
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11. CT Scan
• Hemodynamically stable patient
• Pros
– Retroperitoneal assessment
– Nonoperative management of solid organ
injury
– High specificity
• Cons
– Hardware, cost, radiation
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12. Management
• Depends on whether the pt is stable or not
• The critical decision is whether to do a
laparotomy or not
• Ensure patent airway and ventilation
• Correct hypovolaemia*
• Rapid assessment of injuries
• Immediate surgery or conservative for
stable pt
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13. Indications for laparotomy.
• Hemodynamic instability.
• Increasing guarding and tenderness.
• All bullet and grenade wounds.
• Herniation of viscera thru diaphragm or
abdominal wall.
• Thoraco-abdominal wounds.
• Hematemesis or rectal bleeding.
• Penetrating anal or vaginal injuries.
• Positive findings on paracentesis*
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14. Splenic Injury
• Most frequently injured intra-abdominal
organ in blunt trauma.
• Splenic preservation when possible
•Risk of overwhelming post-
splenectomy infections
• More than 70% can be treated non-
operatively
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15. Splenic Injury Cont…
• Non-operative criteria
–Hemodynamic stability
–Negative abdominal examination
–No other clear indications for ex lap
–No coagulopathy
–Low grade injuries (1-3)
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16. 16

17. Liver Trauma
• Frequently injured in both blunt & penetrating
trauma.
• Control of profuse bleeding from deep lacerations a
formidable challenge.
– Simple suture, mattress sutures, packing,
debridement, resection, mesh hepatorrhaphy,
absorbable hemostats
• Nonoperative treatment (blunt trauma)
– Stable without peritoneal signs  U/S  CT
– Low-grade liver lesions (1-3, 95% success)
– ICU monitoring 17

18. 18

19. Retroperitoneal hematoma
• Zone 1
– Explore regardless of
mechanism.
• Zone 2
– Explore penetrating trauma.
– Observe blunt trauma
(nonexpanding,
nonpulsatile, no urologic
indications)
• Zone 3
– Explore penetrating.
– Observe blunt. 19

20. Gastric Injury
• Mostly penetrating trauma.
• <1% from blunt trauma
–Including iatrogenic injury from CPR
• NGT + aspirate for blood
• Most penetrating wounds treated by
debridement and primary closure in
layers.
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21. Small Intestine Injury
• Most common organ injured
after penetrating trauma
• Blunt trauma
– Crushing injury against
vertebral bodies
– Shearing at fixed points
– Closed loop rupture
• Seat-belt sign should raise
suspicion.
• DPL/CT not reliable
21

22. Small Intestine Injury Cont…
• 13% w/ perforated
small bowel have a
normal CT scan
• Suggestive findings
include free air, free
fluid w/o solid organ
injury, thickening of
small bowel wall or
mesentery
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23. Operative management
• Bleeding initially
controlled/leakage clamped
• Penetrating injuries by firearms
should be debrided.
• Small tears closed primarily.
• Adjacent holes connected and
closed transversely.
• Extensive lacerations and
devascularization require
resection and reanasatomosis.
• Explore mesenteric hematomas
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24. Colon Injury
• Second most frequent injured organ, usually
from penetrating trauma
• Repair within 2 hours dramatically reduces
infectious complications.
• Pre-operative antibiotics important adjunct.
• O/E: blood per rectum, stab to flanks or back
• CT w/rectal contrast, XR- pneumoperitoneum
• Mgt: primary repair/ colostomy
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25. Colon Injury Cont…
• Primary repair criteria
– Early diagnosis (within 4-6 hours)
– Absence of prolonged shock/hypotension
– Absence of gross contamination
– Absence of associated colonic vascular
injury
• Extensive wounds
– Right colon  hemicolectomy +/- ileostomy
– Left colon  resection + colostomy 25

26. Rectal Injury
• Most from Gun Shot Wound
• Other causes - foreign body, impalement,
pelvic fractures, and iatrogenic
• Lower abdomen/buttock penetrating injury
should raise suspicion.
• May be intra- or extraperitoneal
• Rectal exam may reveal blood or laceration
• Work-up includes anoscopy and rigid
sigmoidoscopy. 26

27. Rectal Injury Cont…
• Extraperitoneal injury
– Primary closure
– Diverting colostomy
– Washout of rectal stump
• Intraperitoneal injury
– Primary closure
– Diverting colostomy
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28. Renal trauma
• MOI: blunt or penetrating
• CFs:
–Flank pain/ mass/ ecchymosis
–Hematuria
–Shock
• Ix
–Ultrasound, IVU, contrast CT
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29. Mgt of Renal trauma…
• Conservative
–Usually indicated in grade I-III patients
who are hemodynamically stable
• Surgery
–Nephrectomy in grade IV & V
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30. 30
Renal injury
scale
Injury Description
I Contusion Microscopic or gross hematuria; urologic studies normal
Hematoma Nonexpanding perirenal hematoma confined to the renal
retroperitoneum
II Hematoma Subcapsular, nonexpanding without parenchymal
laceration
Laceration <1 cm parenchymal depth of renal cortex without urinary
extravasation
III Laceration >1 cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation
IV Laceration Parenchymal laceration extending through the renal
cortex, medulla, and collecting system
Vascular Main renal artery or vein injury with contained
hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum that devascularizes the kidney

31. 31

32. Ureteric injury
• Because of their size, location, and
mobility, the ureters are uncommonly
injured by trauma
• Usually damaged during pelvic or
endoscopic surgery.
• CFs: hematuria, flank pain/ mass
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33. Ureteric injury Cont…
• Ix: contrast CT, IVU
• Mgt:
–Re-anastomosis
–Implantation into the bladder
• Complications
–Urinoma
–Ureterocutaneous fistula 33

34. Bladder trauma
Types of bladder rupture
• Extraperitoneal (65-85%)
– Most common
– Usually associated with pelvic #
• Intraperitoneal (15-35%)
– Extravasation of urine in abdomen
– Sudden force to full bladder
– Associated injuries +++
– Mortality (20%)
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35. Bladder trauma: CFs
• Bruising or edema of the lower abdomen,
perineum, or genitalia
• Inability to retrieve all fluid used to irrigate
the bladder through a Foley catheter
• 98% : Gross hematuria
• 2%: Microscopic hematuria + Pelvic #
• Ix: Retrograde cystogram, CT, USS
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36. Bladder trauma: Mgt
Bladder contusion
• Urethral catheter + follow-up cystography
Penetrating injuries: Operate
Blunt
– Intraperitoneal: operate
– Extraperitoneal: Urethral cath. drainage x 7-10
days + follow-up cystography
• Antibiotics & analgesia
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37. Urethral injuries
• Posterior urethral injuries are often associated
with pelvic fractures
• CFs
– Gross hematuria in 98%
– Inability to void
– Blood at urethral meatus
– Pelvic / suprapubic tenderness
– Penile / scrotal / perineal hematoma
– Boggy / high-riding prostate/ ill-defined mass on
rectal examination.
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38. Posterior urethral rupture
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39. Retrograde urogram
Partial tear Complete tear
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40. Management
• SPC to prevent further extravasation of
urine
• Stabilize the patient and attend to
associated injuries
• Initial urethral repair is not recommended
because of risk of hemorrhage, impotence,
and infection of pelvic hematoma.
• Antibiotics + analgesia
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41. Anterior urethra
• Usually due to direct
trauma
• Usually NO pelvic #
• CFs
– Blood at meatus
– Unable to micturate
– Penile/Scrotal/Perineal
contusion, hematoma,
fluid collection
Mgt:
• No urethral catheter
• Retrograde
Urethrogram
• SPC
• Surgical Rx –
urethroplasty
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