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Abdominal Trauma Cheryl Pirozzi, MD Fellow’s Conference 5/4/11
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Abdominal Trauma Penetrating Abdominal Trauma Stabbing 3x more common than firearm wounds GSW cause 90% of the deaths Most commonly injured organs: small intestine > colon > liver Blunt Abdominal Trauma Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) Most commonly injured organs: spleen > liver, intestine is the most likely hollow viscus. Most common causes: MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%) Rosen’s Emergency Medicine, 7th ed. 2009
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Pathophysiology of injury Penetrating Abdominal Trauma Stab Wounds Knives, ice picks, pens, coat hangers, broken bottles Liver, small bowel, spleen Gunshot wounds small bowel, colon and liver Often multiple organ injuries, bowel perforations Rosen’s Emergency Medicine, 7th ed. 2009
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Pathophysiology of injury Rosen’s Emergency Medicine, 7th ed. 2009
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Pathophysiology of injury Blunt Abdominal Trauma Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures Crushing effect Acceleration and deceleration forces → shear injury Seat belt injuries “seat belt sign” = highly correlated with intraperitoneal injury Rosen’s Emergency Medicine, 7th ed. 2009
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Physical Exam Generally unreliable due to distracting injury, AMS, spinal cord injury Look for signs of intraperitoneal injury abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension entrance and exit wounds to determine path of injury. Distention - pneumoperitoneum, gastric dilation, or ileus Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhage Abdominal contusions – eg lap belts ↓bowel sounds suggests intraperitoneal injuries DRE: blood or subcutaneous emphysema Rosen’s Emergency Medicine, 7th ed. 2009
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Diagnostic studies Lab tests: not very helpful May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox screen Rosen’s Emergency Medicine, 7th ed. 2009
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Imaging Plain films: fractures – nearby visceral damage free intraperitoneal air Foreign bodies and missiles Rosen’s Emergency Medicine, 7th ed. 2009
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Imaging CT Accurate for solid visceral lesions and intraperitoneal hemorrhage guide nonoperative management of solid organ damage IV not oral contrast Disadvantages : insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery Rosen’s Emergency Medicine, 7th ed. 2009
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Imaging Angiography To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable pt Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma Rosen’s Emergency Medicine, 7th ed. 2009
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FAST Focused assessment with sonography for trauma (FAST) To diagnose free intraperitoneal blood after blunt trauma 4 areas: Perihepatic & hepato-renal space (Morrison’s pouch) Perisplenic Pelvis (Pouch of Douglas/rectovesical pouch) Pericardium (subxiphoid) sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid Extended FAST (E-FAST): Add thoracic windows to look for pneumothorax. Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%) Trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
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FAST Morrison’s pouch (hepato-renal space) trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
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FAST Perisplenic view trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
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FAST Retrovesicle (Pouch of Douglas) Pericardium (subxiphoid) trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
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FAST Advantages: Portable, fast (<5 min), No radiation or contrast Less expensive Disadvantages Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air. Can’t distinguish blood from ascites. high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture Rosen’s Emergency Medicine, 7th ed. 2009
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Diagnostic Peritoneal Lavage Largely replaced by FAST and CT In blunt trauma, used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examination In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury In GSW, not used much Rosen’s Emergency Medicine, 7th ed. 2009
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Diagnostic Peritoneal Lavage 1. attempt to aspirate free peritoneal blood >10 mL positive for intraperitoneal injury 2. insert lavage catheter by seldinger, semiopen, or open 3. lavage peritoneal cavity with saline Positive test: In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3 In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm3 Rosen’s Emergency Medicine, 7th ed. 2009
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Local Wound Exploration To determine the depth of penetration in stab wounds If peritoneum is violated, must do more diagnostics Prep, extend wound, carefully examine (No blind probing) Indicated for anterior abdominal stab wounds, less clear for other areas Rosen’s Emergency Medicine, 7th ed. 2009
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Laparoscopy Most useful to eval penetrating wounds to thoracoabdominal region in stable pt esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel. Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation Rosen’s Emergency Medicine, 7th ed. 2009
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Management General trauma principles: airway management, 2 large bore IVs, cover penetrating wounds and eviscerations with sterile dressings Prophylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal perf/spillage (eg zosyn 3.375 g IV) In general, leave foreign bodies in and remove in the OR Rosen’s Emergency Medicine, 7th ed. 2009
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Management of penetrating abdominal trauma forsurenot.com
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Management of penetrating abdominal trauma Mandatory laparotomy vs Selective nonoperative management Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of penetrating abdominal trauma Mandatory laparotomy standard of care for abdominal stab wounds until 1960s, for GSWs until recently Now thought unnecessary in 70% of abdominal stab wounds Increased complication rates, length of stay, costs Immediate laparotomy indicated for shock, evisceration, and peritonitis Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of penetrating abdominal trauma Selective management used to reduce unnecessary laparotomies Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair Strategy depends on abdominal region: Thoracoabdomen Nipple line to costal margin Anterior abdomen Xiphoid to pubis Flank and back Posterior to anterior axillary line Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of penetrating abdominal trauma Thoracoabdomen Big concern is diaphragmatic injury 7% of thoracoabdominal wounds Diagnostic evaluation: CXR (hemothorax or pneumothorax) Diagnostic peritoneal lavage FAST Thoracoscopy Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Thoracoabdomen Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of penetrating abdominal trauma Anterior abdomen Only 50-70% of anterior stab wounds enter the abdomen of these, only 50-70% cause injury requiring OR 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required? Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of PAT Anterior abdomen Rosen’s Emergency Medicine 7th ed
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Management of penetrating abdominal trauma Back/Flank Risk of retroperitoneal injury Intraperitoneal organ injury 15-40% Difficulty evaluating retroperitoneal organs with exam and FAST In stable pts, CT scan is reliable for excluding significant injury: Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
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Management of penetrating abdominal trauma Gunshot wounds Much higher mortality than stab wounds Over 90% of pts with peritoneal penetration have injury requiring operative management Most centers proceed to lap if peritoneal entry is suspected Expectant management rarely done Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617 Rosen’s Emergency Medicine 2009
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Management of PAT Gunshot wounds assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) Rosen’s Emergency Medicine, 7th ed. 2009
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Management of Blunt abdominal trauma ashwinearl.blogspot.com
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Management of Blunt abdominal trauma Exam less reliable Diagnostic studies to determine if there is hemoperitoneum or organ injury requiring surgical repair FAST, CT, DPL In HD stable pts, CT is preferred Rosen’s Emergency Medicine, 7th ed. 2009
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Management of Blunt abdominal trauma Clinical Indications for Laparotomy after Blunt Trauma Rosen’s Emergency Medicine, 7th ed. 2009
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Damage Control Patients with major exsanguinating injuries may not survive complex procedures Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Damage Control 0. initial resuscitation 1. Control of hemorrhage and contamination Control injured vasculature, bleeding solid organs Abdominal packing 2. back to the ICU for resuscitation Correction of hypothermia, acidosis, coagulopathy 3. Definitive repair of injuries 4. Definitive closure of the abdomen Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Damage Control Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Damage Control Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Damage Control Resuscitation in the ICU IVF (crystalloid, not colloid) Transfusion ?1:1:1 PRBC/plt/FFP Recombinant activated factor VII Increased thromboembolic complications Rewarming if hypothermic Correction of metabolic abnormalities Low tidal volume ventilation recommended (4-6 ml/kg) Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Damage Control Open abdominal wounds and definitive closure 40-70% can’t have primary closure after definitive repair. Temporary closure methods Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
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Abdominal Compartment Syndrome Common problem with abdominal trauma Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure ± APP below 50 mm Hg Primary ACS: associated with injury/disease in abdomen Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
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Abdominal Compartment Syndrome Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29
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Abdominal Compartment Syndrome Effects of elevated IAP Renal dysfunction Decreased cardiac output Increased airway pressures and decreased compliance Visceral hypoperfusion Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
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Abdominal Compartment Syndrome Management Surgical abdominal decompression Nonsurgical: paracentesis, NGT, sedation Staged approach to abdominal repair Temporary abdominal closure Sugrue M. Curr Opin Crit Care 2005; 11:333-338 Bailey J. Crit Care 2000, 4:23–29
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Conclusions Watch out for implements and missiles violating the abdomen Laparotomy is mandatory if shock, evisceration, or peritonitis Diagnostic studies used to determine need for laparotomy in PAT and BAT FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood Damage Control is a principle of staged operative management with control and resuscitation prior to definitive repair Abdominal compartment syndrome is a common problem in abdominal trauma
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References Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617 Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S421-30. Marx: Rosen’s Emergency Medicine, 7th ed. 2009 Mosby Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338 Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29