Abdominal - pelvic Trauma

ABDOMINAL TRAUMA

Dr. Abdulaziz Alrabiah

Classification of Abdominal Trauma

• Blunt
• Penetrating

Blunt Abdominal Trauma

• Common mechanisms: Road traffic crashes, falls, sports injuries, and assaults.
• Organs most affected: Spleen > Liver > Small and large intestine.
• Management: Often managed conservatively, though interventional radiology and surgery are indicated for severe injuries.

Penetrating Abdominal Injury

Liver

• Definition: Any wound between the nipple line (T4) and the groin creases anteriorly, and from T4 to the curves of the iliac crests posteriorly is potentially a penetrating abdominal injury.

Assessment of Abdominal Trauma

• Primary Survey: ABCDE
• Secondary Survey:
  • Inspection:
    • Abrasions, wounds.
    • Bruising.
    • Seat belt marks: Indicate bad sign.
    • Lap belt: 30% chance of mesenteric or intestinal injury (not used anymore).
    • Retroperitoneal haemorrhage: Ecchymosis of the periumbilical area (Cullen’s sign) and the flanks (Grey-Turner’s sign).
    • Genital and perineum examination.
  • Palpation:
    • Fullness: Suggests haemorrhage.
    • Crepitation of lower rib cage: Suggests hepatic or splenic injury.
    • Peritonism: Ruptured viscus with leakage.
    • Rectal or vaginal examination.

Investigations

• Trauma Series: e.g., CXR, pelvis XR (c-spine XR).
• Trauma Blood Panel: e.g., FBC, UEC, LFTs, lipase, coags, group and hold, BHCG.
• Imaging: Bedside FAST scan, +/- CT abdomen if haemodynamically stable and imaging warranted.

FAST Scan (Focused Assessment with Sonography for Trauma)

Protocol:

• Positive (+) & Patient Stable → CT scan.
• Positive (+) & Patient Unstable → Operation.

Details:

• Sensitivity: 70-95%.
• 4 Regions Analyzed:
  1. Subxiphoid: Pericardial space + rough assessment of contractility and filling.
  2. RUQ (Right Upper Quadrant).
  3. Splenorenal Recess.
  4. Pelvis.

Pros:

• Quick to perform with immediate results.
• Repeatable.
• Patient doesn’t have to leave Emergency Department.
• Sensitivity approaching 96% in detecting >800mls blood.

Cons:

• Requires >250 mL free fluid to collect in Morison’s pouch for a positive result.
• Operator dependent.
• Doesn’t specify anatomical structures injured.
• Does not distinguish other causes of intraperitoneal fluid (e.g., ascites, residual fluid after DPL, bladder rupture).
  • Shows only intraperitoneal bleed; does not show retroperitoneal bleed.
• Doesn’t look at solid organs, hollow viscera, or retroperitoneal structures.
• Can be technically difficult in obese patients, those with lots of bowel gas, or if subcutaneous emphysema is present.

Diagnostic Peritoneal Lavage (DPL) y

• Rarely performed; minor surgical procedure.
• Pros:
  • Highly sensitive for intraperitoneal hemorrhage (>97%).
  • Rapid.
  • Performed at the bedside.
• Cons:
  • Invasive.
  • Doesn’t specify anatomical structures injured.
  • False positives may result from trauma during the procedure (up to 25% negative laparotomy rate).
  • Rarely performed, practitioners have become deskilled.
  • Residual fluid following DPL makes subsequent FAST scans unreliable.
  • Modified technique required if pregnant, pelvic fracture, or midline scarring.

CT Abdomen and Pelvis

• Prerequisite: Patient must be stable.
• Indications:
  • Trauma patients with abdominal tenderness.
  • Trauma patients with altered sensorium.
  • Distracting injuries or injuries to adjacent structures.
• Pros:
  • Identifies specific anatomical structures injured, allows grading of severity, and helps guide management.
  • Concurrent imaging of other body compartments is frequently indicated.
  • Images retroperitoneal structures.
  • Provides imaging of the thoracolumbar vertebrae and other skeletal structures.
  • Blush of IV contrast: Strong predictor of failure of non-interventional management.
• Cons:
  • Patient usually has to leave the ED.
  • Patient transfers are time-consuming.
  • Requires IV contrast and risk of adverse reactions.
  • Radiation exposure.
  • Less sensitive with pancreatic, diaphragmatic, and hollow viscus injuries.
  • Poor access to patient during the scan should they deteriorate.
  • Requires additional skilled staff (CT radiographers and radiologists).

Management

• Address ABCDE.
• IV lines (i.e., 16G, 18G).
• Fluids, Bloods +/- Vasopressors.

Laparotomy

✓ Indications:

• Peritonism.
• Free air.
• Evisceration.
• Penetrating abdominal trauma + hypotension (unstable).
• Gunshot wound traversing peritoneum or retroperitoneum.
• GI bleeding following penetrating trauma.
• Penetrating object is still in situ (risk of precipitous haemorrhage on removal).
• Blunt abdominal trauma + hypotension with positive FAST scan, positive DPL, or peritonism.

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(Note: Assess before laparotomy)

Interventional Radiology

• Main Role: Stop bleeding without the physiological stress of surgery.
• Sources of Bleeding: Typically spleen, liver, pelvis, retroperitoneal, or gastrointestinal haemorrhage.
• Techniques: Embolisation and balloon occlusion.
• May be performed in conjunction with operative intervention in some centres.

Damage Control Surgery

• Concept: Open the area, apply packing and gauze, then send to tertiary care or ICU.
• Integral to Damage Control Resuscitation (along with permissive hypotension and hemostatic resuscitation). is integral to the concept of damage control resuscitation
• Derived from military experience and increasingly adopted into civilian trauma management.

Pelvic Trauma

Classification: Open Book Fracture

Pelvic X-ray showing a large separation (diastasis) between the pubic bones, characteristic of an open book pelvic fracture (>3cm).

Treatment

• ✓ Pelvic Binder
• ✓ Blood Transfusion (Blindly/Empirically)
• ✓ Call for Interventional Radiology

Medical brace/pelvic binder.

Medical support belt.

Patient with surgical drain and IV line.

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Thank You aalrabiah@ksu.edu.sa