Abdominal trauma

Assessment of abdominal trauma

Assessment of patients with abdominal trauma can be difficult due to
- Altered sensorium (head injury, alcohol)
- Altered sensation (spinal cord injury)
- Injury to adjacent structures (pelvis, chest)
Pattern of injury will be different between penetrating and blunt trauma

Indications for laparotomy

Unexplained shock
Rigid silent abdomen
Evisceration
Radiological evidence of intraperitoneal gas
Radiological evidence of ruptured diaphragm
Gunshot wounds
Positive result on diagnostic peritoneal lavage

Picture provided by Arnold Angelis, Tondo Medical Centre, Philippines

Imaging

Either CT or ultrasound can be used for the assessment of abdominal trauma
CT scanning is preferred method but requires patient to be cardiovascularly stable
Ultrasound has high specificity but low sensitivity for the detection of:
- Free fluid
- Visceral damage

FAST

Focused assessment for the sonographic assessment of trauma
Is the use of ultrasound to rapidly assess for intraperitoneal fluid
Probe is placed on the:
- Right upper quadrant
- Left upper quadrant
- Suprapubic region
Fluid in subphrenic, subhepatic spaces or Pouch of Douglas in hypotensive patient
Confirms likely need for emergency laparotomy

Peritoneal lavage

Indications

Equivocal clinical examination
Difficulty in assessing patient
Persistent hypotension despite adequate resuscitation
Multiple injuries
Stab wounds where the peritoneum has been breached

Method

Ensure that a catheter and nasogastric tube are in-situ
Under LA make vertical sub-umbilical incision and divide linea alba
Incise peritoneum and insert peritoneal dialysis catheter
Aspirate any free blood or gastric content
If no blood seen - infuse 1litre of normal saline an allow 3 min. to equilibrate
Place drainage bag on floor and allow to drain
Send 20 ml to laboratory for measurement of RBC, WCC and microbiological examination

Positive result

Red cell count more than 100,000 / mm³
White cell count more than 500 / mm³
Presence of bile, bacteria or faecal material

Damage Control Surgery

Following multiple trauma poor outcome is seen in those with
- Hypothermia
- Coagulopathy
- Severe acidosis
Prolonged surgery can exacerbate these factors
As a result the concept of 'damage control' surgery has been developed
Damage control surgery should be considered if a patient with multiple trauma has
- Injury severity score greater than 25
- Core temperature less than 34 degree
- Arterial gas pH less than 7.1

Initial operation

Early management of major abdominal trauma surgery should aim to:
- Control haemorrhage with ligation of vessels and packing
- Remove dead tissue
- Control contamination with clamps and stapling devices
- Lavage the abdominal cavity
- Close the abdomen without tension
Options for temporary wound closure include
- Skin-closure only
- Plastic abdominoplasty
- Absorbable mesh
- Non-absorbable mesh with protection of underlying viscera
- Vacuum pack
- Vacuum-assisted wound management
A plastic sheet or 'Bogata bag' may be useful

Picture provided by Mr. J C Campbell, Derriford Hospital Plymouth

Intensive care unit

Early surgery should be followed by a period of stabilisation on the intensive care unit
During this period the following should be addressed
- Rewarming
- Ventilation
- Restoration of perfusion
- Correction of deranged biochemistry
- Commence enteral or parenteral nutrition

'Second look laparotomy'

Planned re-laparotomy at 24 - 48 hours allows:
- Removal of packs
- Removal of dead tissue
- Definitive treatment of injuries
- Restoration of intestinal continuity
- Closure of musculofacial layers of abdominal wall
This approach has been shown to be associated with a reduced mortality

Gastrointestinal injury

Small bowel perforations can invariably be primarily closed
The management of colonic perforations is more controversial
Used to common practice to excise damaged segment
Proximal stoma was then fashioned
Perforation could also be exteriorised as a stoma
Increasingly recognised that primary repair of colonic injuries is safe
Now recommended method, especially in the absence of significant contamination

Bibliography

Brookes A J, Rowlands B J. Blunt abdominal injuries. Brit Med Bull 1999; 55: 844-855.

Curran T J, Borzotta A P. Complications of primary repair of colon injuries: literature review of 2,964 cases. Am J Surg 1999; 177: 42-47.

Hoey B A, Schwab C W. Damage control surgery. Scand J Surg 2002; 91: 92-103.

Loveland J A, Boffard K D. Damage control in the abdomen and beyond. Br J Surg 2004; 91: 1095-110.

Moore A F K, Hargest R, Martin M et al. Intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg 2004; 91: 1101-1110.

Nelson R, Singer M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev 2002; CD002247.

Offner P J, De Souza A L, Moore E E et al. Avoidance of abdominal compartment syndrome in damage control laparotomy after trauma. Arch Surg 2001; 136; 676-81.

Parks R W, Chrysos E, Diamond T. Management of liver trauma. Br J Surg 1999: 86: 1121-1135.

Stengel D, Bauwens J, Sehouli J et al. Systemic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma. Br J Surg 2001; 88: 901-912.