J.

Trauma 143

CHAPTER OUTLINE
Triage Pancreatic Injury
Spinal Injury Small Bowel Injury
Neck Injuries Colonic Injury
Bullet Injuries Liver Injury
Blast Injuries Splenic Injury
Penetrating Injuries Renal Injury
Abdominal Trauma Urinary Bladder Injury
Blunt Trauma of Abdomen Abdominal Compartment Syndrome
Duodenal Injury Seatbelt Injuries

Trauma is the major public health problem in all countries.

Triage algorithm
Step One (Assess physiological impact)
Measure vital signs and level of consciousness
 By Glasgow coma scale
 Systolic blood pressure
 Respiratory rate
 Revised trauma score. It is based on airway, laryngeal injury,
spine injury, maxillofacial injury
Step Two (Assess anatomical impact)

Trauma
All penetrating injuries to head, neck, thorax, major burns, frac-
ture bones, pelvic fractures, paralysis

Fig. 1.260: Trauma causing large tissue defect exposing the bone. Step Three (Assess mechanism)
Automobile accidents, crash or blast injuries, high energy injuries,
TRIAGE fall from more than 20 feet. Bullet injury

Triage means To sort in French. Step Four (Assess history)

Triage is a system to attend trauma patients, formulated by  Patients age below 5 years or age more than 55 years
Committee of Trauma of the American College of Surgeons.  Cardiac diseases, respiratory and metabolic diseases
Advanced trauma life support (ATLS) is essential for first  Pregnancy
hour care of an injured patient.  Patients with bleeding disorders
Pre-hospital trauma life support (PHTLS) is to prevent  Immunosuppressed individuals
deaths while injured patients are transported to the hospital. BASED ON THESE STEPS CONSIDER TO SHIFT THE PATIENT TO
TRAUMA CENTER and TRAUMA TEAM SHOULD BE KEPT ALERT.
Types of Triage System It is important in multiple and mass casualities (fire, blasts, auto-
mobile accidents, train accidents).
o Multiple casualties: Staff and facilities are sufficient but
priority is given to life-threatening injuries. Management
o Mass casualties: Staff and facilities are not sufficient to
manage. Here those who are likely to have highest chance o Initial evaluation of the patient.
of survival are given priority. o Physiologic stabilisation.
o Control of haemorrhage.
o Management of thoracic and abdominal injury.
Assessment of four components
o Management of cranial injury.
i. Physiologic response
ii. Anatomical injury I. Primary Management
iii. Biomechanical injury o Airway management (blocked by food, vomitus, clot, fallen
iv. Comorbid factors tongue).

During an injury, unsuspected lesions of the spinal cord may cause the most excruciating abdominal pain.
Theodore Schrire
144 o Breathing.
o Circulation.
o Disability and level of consciousness assessment by
Glasgow coma scale.
o Exposure of the patient from head to toe for final assessment.
o Fingers and tubes: Finger evaluation, Foleys catheterisa-
tion.

Goals
o Identify life-threatening conditions.
o Decide and implement appropriate treatment to the area of
trauma.
o First think to salvage the life, then think to salvage the limb. Fig. 1.261: Crush injury leg due to road traffic accident.
o Rapid assessment, rapid resuscitation, rapid stabilisation.
o Optimum, complete care.
o Transport efficiently to higher trauma centre.

Categorise the patient

I: Deceased
II: Walking wounded
III: Immobile wounded
IV: Trapped wounded
Tag the patient accordingly
Red colour : Immediate treatment is required
SRB's Manual of Surgery

Yellow colour : Urgent treatment is required

Green colour : Delayed treatment is required
Blue colour : Expectant treatment is required
Black colour : Deceased
AIRWAY BREATHING
Chin lift 100% oxygen
Jaw thrust Assess bilateral chest raise
Nasal airway Assess breath sounds
Oral airway Use pulse oximetry
Endotracheal intubation Treat flail chest, pneumothorax Fig. 1.262: Ankle injury with open wound.
Tracheostomy Intercostal tube drainage
(assess airway patency)
CIRCULATION DISABILITY EVALUATION
Monitor vitals Neurological examination
Heart sounds Glasgow coma scale
ECG Pupillary reaction
IV fluids blood transfusion
Treatment of shock
Control of external bleed
Use two IV lines14G/16G
EXPOSE THE PATIENT FINGERS AND TUBES
FULLY Examine all orifices like P/R,
Undress the patient P/V, etc.
Hypothermia assessment Use required tubes like catheter,
Assess injuries Ryles tube Fig. 1.263: Degloving injury involving entire left lower limb, perineum,
Examine joints, bones, and left groin. Patient has lost scrotum and both testes. There were
abdomen, other systems no internal injuries and vessels and nerves were intact. Patient
Look for identification marks underwent wound excision extensively and colostomy was done
to promote healing of perineal wound and prevent contamination.

II. Investigations
o X-ray spine, chest, pelvis, extremities.
o CT scan. III. Secondary Survey
o Blood group and cross-matching. Re-evaluate the patient completely again.
o Arterial blood gas analysis.
o Serum electrolytes. IV. Definitive Care
o U/S abdomen. (All discussed under individual topics.)
Mechanism of Trauma o Multidisciplinary approach. 145
o Blunt traumadirect or indirect blunt injury can occur. Seat o Planning, setting up, organizing, team work.
belt reduces the blunt injury in vehicles. o Assess respiratory system; circulation; bleeding areasas
o Penetrating injuryseverity depends on the extent of deeper priority.
injury. o Assess also whether patient is haemodynamically stable
o Blast injury. or unstable.
o Crush injuryearthquake, industrial accidents, and train o Arrange fluids, blood, catheters, ventilator, etc.
accidentscauses crush syndrome; compartment syndrome. o Further definitive therapy depending on severity and site
o Burn injury. of injury.
o Injury in alcohol patients.
Damage Control Surgery
o Resuscitation and early therapy in operation theatre itself.
o Minimum but essential surgery to control bleeding and
prevent contamination.
o Secondary definitive surgery at a later period to have final
control.

SPINAL INJURY
o Assess the type, extent and severity of the injury.
o Careful first aid and transfer to prevent further damage to
the spinal cord.

Trauma
Fig. 1.264: Class III dog bite on face in a boy.

Fig. 1.266: Hand injury involving all fingers.

Fig. 1.265: Degloving of scalp with bone periosteum exposing the skull
bone. Outer table was actually dead and required bone removal and
graft after healthy granulation tissue was formed.

Concepts in Trauma Management

o Concept of golden hour to treat the trauma patient is A
Fig. 1.267A
important.

Remember what you do not know. It differs you from others.

146

B
Fig. 1.267B Fig. 1.268: Degloving scalp trauma and exposed bone is
granulating well.
Figs 1.267A and B: A person has bitten this patient during a fight
and removed the central part of lower lip. It is repaired primarily by
Y repair. Remember human bites are most dangerous.
o Assess the sensory loss or motor loss properly.
o Assess fractures clinically, by X-ray and MRI.
o Central cord syndrome is common and is due to hyperflexion
or hyperextension of the neck in an injured patient causing
SRB's Manual of Surgery

ischaemia of spinal column due to interfering of spinal

artery blood flow.
o Brown-sequard syndrome: It is due to partial transection
of the cord causing ipsilateral motor function loss and
contralateral sensory function loss.
o High dose of steroid is very useful to prevent further damage.
o Rest, traction to neck.
o Decompression of spinal canal surgically by removing bone,
disc, haematoma is useful. Fig. 1.269: Neck trauma zones.
o Spinal stabilisation.
o Blood transfusion is given as required.
o Ryles tube for 5-7 days.
NECK INJURIES Other injuries like head, thorax, abdomen, maxillofacial
Neck is divided into zones for managing neck injuries area are discussed in respective chapters.
 Zone I: From clavicle to cricoid cartilage
 Zone II: From cricoid cartilage to angle of the mandible BULLET INJURIES
 Zone III: Above the angle of the mandible Bullet injury has wound of entry and wound of exit. Extent of
damage is not related to the external wounds. It is related to
the travel of bullet inside and extent of blast or cavitation effect
Indications for Neck Exploration in Injuries inside caused by the bullet. It causes burn damage.
o Expanding haematoma. It can damage vessels, organs like liver, spleen, kidneys,
o Uncontrolled external haemorrhage. bowel, lungs, heart, cranial structures, soft tissues, bones and
o Decreased carotid pulse. joints.
o Stridor, hoarseness, dysphonia, haemoptysis.
o Severe dysphagia, odynophagia. Management
o Blood in oropharynx.
o The wounds are explored properly under general anaes-
Treatment thesia.
o All dead tissues and dead muscles are excised.
o The neck is explored with adequate incision under general o Skin is generously and adequately incised.
anaesthesia. o Injured nerves are cleaned and silk marker stitches are
o The injured structure like vessels, oesophagus, trachea, placed to identify for later secondary suturing (Nerve should
muscles are sutured. not be sutured primarily in bullet injury).
o Antibiotics. o All foreign bodies are removed.
 Factors causing the damage 147
 High pressure wave
 Mechanical injury
 Chemical injury
 Thermal injury
 Inhalation of toxic gases and smoke

Organs Affected
o Ear drums, lungs.
o GIT, brain.
o Skeletal system.
Individual becomes deaf after blast and so rescue work
may be delayed.

Management
o Critical trauma care.
o Management of shock and triage primary manage-ment.
o Urgent surgeries like laparotomy, thoracotomy, craniotomy.
o Massive blood transfusion.

Fig. 1.270: Multiple pellets over elbow region after gunshot.

Trauma
o Tendon repair should not be done primarily.
o Wound should not be closed. It should be left open.
o Adequate blood transfusion and antibiotics coverage should
be given.
o Major artery or vein are sutured. Vein graft can be used. But
synthetic graft should never be used.
o Thorough inspection, irrigation and debridement of injured
joints is done.
o Immobilisation is done.
o Tetanus toxoid, antitetanus globulin (3000 units IM), antigas
gangrene serum is given.
o Second look surgeries at a later period is done once patient
has been stabilised. Fig. 1.271: Degloving injury buttock. It needs colostomy to protect
o Delayed primary closure in 4-7 days or secondary closure the wound from sepsis. Later once skin coverage is done colostomy
in 14 days is done. is closed.
o Depending on extent of defect, skin grafting or flaps are
used.
o Laparotomy, thoracotomy, craniotomy are done depending
on the site of the injury.

BLAST INJURIES
Here extent of damage is much more than bullet injuries.
It creates complex blast wave which contains blast pres-
sure wave and mass movement of air. A B
This explosion pressure wave is more than 1000 pounds per Figs 1.272A and B: Crush injury foot with retained skin from plantar
square inch. This pressure wave has got incident pressure and aspect was rotated forward (Courtesy: Dr Mayur Rai, Orthopaedician,
reflected pressure. Both will cause severe damage. KMC, Mangalore).

Well done is better than well said.

148 presume internal injury. Tachycardia, hypotension, shock may
be evident when there is significant haemoperitoneum. Injuries
may be organ injury like of liver, spleen, kidney, pancreas, etc.
or bowel injury or retroperitoneal injury which is often under
diagnosed or missed. Major vessel injury like of inferior vena
cava, mesenteric vessels can cause real threat to life unless it
is identified and managed early. 25% of entire trauma patients
need surgical exploration of the abdomen.

Fig. 1.273: Penetrating injury. Pole missed all the major vessels.
Miraculously the patient survived, after a Marathon surgery to tell
her tale to her children.

o Antibiotics.
o Ventilator support.
o Management of specific organs like eye, ear.

PENETRATING INJURIES
o It can occur in abdomen, thorax, cranial cavity.
o It causes haemorrhage, damage to internal organs like liver,
bowel vessels, lung, pericardium and heart, brain.
SRB's Manual of Surgery

Fig. 1.275: Traumatic haemoperitoneum.

Abdominal trauma can be blunt or stab/penetrating or

abdominal wall injuries. Spleen is the most common organ
involved in blunt trauma. Often in blunt trauma first part of
the jejunum or ileocaecal junction gives way (blow out effect)
Fig. 1.274: Stab wound on the back communicating into the thoracic due to traction often causing complete transection of bowel
cavity. Wound was explored and sutured, with an ICT inserted into horizontally close to the junction. It is due to force of the mobile
the thoracic cavity.
part of the bowel over the fixed part. Liver is the most common
o It is life-threatening and immediate surgical intervention organ involved in penetrating injuries.
is the only treatment. Patient requires adequate amount of Injuries of the abdomen may be closed injuries, compres-
blood transfusion, antibiotics, shock management. sion injuries and penetrating injuries. Penetrating injuries may
be low velocity injury like stab injuries or high velocity injury
ABDOMINAL TRAUMA like gunshot injuries. Penetration of blunt weapon causes less
deep trauma than sharp weapon (sickle, knife). In sickle injury
It can be: tip and sharp edge moves in curved pattern and so it is often
 Blunt trauma difficult to predict the depth, track and organs injured.
 Stab injury Routinely followed indications for exploration in abdominal
 Abdominal wall injury trauma arehypotension without any other cause; bleeding
through wound; continuous bleeding in nasogastric tube; evis-
Abdominal trauma is a major surgical emergency which ceration of abdominal content through the open wound except
most surgeons face. It is often associated with head injuries, in case of protruded omentum without any hypotension and
chest, pelvic and bone injuries. Often patient is unconscious features of peritoneal irritation; air under diaphragm in blunt
causing difficulty in diagnosing the condition. Often more abdominal injury (not in penetrating injury as external air gets
importance is given to other system injuries like of head, sucked into the peritoneal cavity through the wound).
thorax and bones whereas abdominal injury is not addressed
properly causing life-threatening consequences. When patient
Types
is conscious, history related abdominal trauma is useful. Abra-
sion over the abdominal skin suggests the possibility of internal o Liver injury.
injury (Londons sign). Distension, tenderness, rebound tender- o Spleen injury.
ness, fullness and dullness in the flank when present one should o Gastric/small bowel/colonic injuries.
o Duodenal injuries. General Clinical Features 149
o Pancreatic injuries.
o Injuries to kidney/bladder/urethra. o Features of shockpallor, tachycardia, hypotension, cold
o Mesenteric injury. periphery, sweating, oliguria.
o Vascular injuries. o Abdominal distension.
o Associated injuries like of diaphragm, lungs. o Pain, tenderness, rebound tenderness, guarding and rigidity,
o Abdominal compartment syndrome. dullness in the flank on percussion.
o Gunshot or blast injuries. o Respiratory distress, cyanosis depending on the amount of
blood loss.
o Bruising over the skin of the abdominal wall.
o Features specific of individual organ injuries.

Investigations
1. Ultrasound abdomen. FAST is Focused Abdominal Sonar
Trauma: It is rapid, noninvasive, portable bedside method
of investigation focusing on pericardium, splenic, hepatic
and pelvic areas. Blood more than 100 ml in cavities can be
identified. It is not reliable for bowel or penetrating injuries.
It often needs to be repeated.
2. Diagnostic peritoneal lavage (DPL): It is done in case
of blunt injury abdomen. Through a subumbilical lavage
catheter one litre of normal saline/Ringers lactate is infused
into the peritoneal cavity. Patient is changed to different
positions and side-to-side. Fluid content is aspirated from
the abdomen for assessment.
It has got 98% accuracy rate.
A

Trauma
One of the criterias signifies positive lavage

 10 ml or more of gross blood

 RBC count more than 1,00,000/cumm
 WBC count more than 500/cumm
 Amylase level in the fluid more than 175 IU/dl
 Presence of bile, bacteria, food particles or foreign body
B

It is the procedure of choice in physiologically unstable

patient with blunt abdominal injury (like with spinal injury,
unconscious patient).

Contraindications for DPL

 When laparotomy is definitely indicated
 Previous laparotomy
 Pregnancy
 Obesity

3. CT scan is indicated in assessing retroperitoneum, solid

organ injuries. It is noninvasive and highly specific.
4. Diagnostic laparoscopy (DL) is valuable method in stable
C abdominal trauma patient.
Figs 1.276A to C: Stab injury to LIF by an angry husband to his wife
causing left common iliac artery transection injury with aortic partial Treatment
injury. In spite saphenous vein graft reconstruction patient could not
survive (Courtesy: Professor Yogishkumar, MS, KMC, Mangalore). Emergency laparotomy.

Only bed of thorns can give crown of roses.

150

A B
Figs 1.277A and B: Diagnostic peritoneal lavageincision and technique. 10 French polyvinyl catheter is used. Urinary bladder is emptied by
passing a catheter. After injecting xylocaine local anaesthesia into subumbilical region, 2-3 cm vertical subumbilical midline incision is made.
Skin, linea alba is incised. Local anaesthesia is infiltrated into the peritoneum again. Peritoneum is held with two haemostats and a purse
string suture is placed using polyglactic acid absorbable suture material. Peritoneum is incised for 3 mm length. Catheter (standard peritoneal
dialysis catheter) is introduced into the peritoneal cavity. If blood enters the catheter immediately, it means early laparotomy is needed
and carried out without continuing the peritoneal lavage. Otherwise, one litre of normal saline is infused into the peritoneal cavity rapidly
in few minutes through the catheter using a drip set with elevation of the fluid bottle/bag. Patient is moved well to mix the fluid in all four
quadrants. Now bag is lowered below so that fluid from the peritoneal cavity reenters/siphoned into the bag. Collected fluid is analysed for
red cells, leukocytes, etc. DPL may not be useful in bowel injury, retroperitoneal injury, diaphragmatic injury, organ haematoma (subcapsular
splenic haematoma). If patient is decided for observation catheter can be left in situ for repeat DPL after 6 hours. One has to remember
that DPL is not a substitute for clinical assessment and monitoring. In Lazarus-Nelson approach Teflon catheter with a guide wire is used.
SRB's Manual of Surgery

exploratory laparotomy is done. Plain X-ray abdomen may

show gas under diaphragm.
Difficulty arises in deciding about the need for laparotomy
in abdominal trauma in unconscious patients. If severity of
external injury is out of proportion to the existing severe shock
then exploratory laparotomy is indicated in an unconscious
patient. It is also often difficult to diagnose bowel injury in such
patients. If it is suspected laparotomy should be undertaken in
such patients. Associated spinal injury masks the abdominal
findings.
Injuries may be of liver, spleen, GIT, pancreas, mesentery,
vascular or diaphragm. Associated chest, pelvis, skeletal and
head injuries should be remembered.

Features of Blunt Trauma

o Features of profound shock, progressive distension of
abdomen, pain, tenderness, guarding, rigidity, rebound
tenderness, dull flank.
Fig. 1.278: Blunt injury abdomen. Note the bruising over o Features specific of individual organ injury like obliteration
abdominal skinLondons sign. liver dullness in bowel injury.
o Bruising of skin over the abdomenLondons sign.
Indications for laparotomy o Respiratory distress, cyanosis.
o Repeated clinical examination is a must in blunt trauma.
 Frank haemoperitoneum
 Significant diagnostic peritoneal lavage Evaluation
 Haemodynamically unstable patient
 U/S or CT scan shows significant intra-abdominal injuries
Ultrasound Abdomen
o It is very useful, simpler, noninvasive method of evaluating
the abdomen. Negative ultrasound means no immediate
BLUNT TRAUMA OF ABDOMEN further intervention is needed and also conservative treat-
It is common in accidents. It is often missed or lately diag- ment can be undertaken.
nosed. Ultrasound/CT abdomen or diagnostic peritoneal lav- o Advantages of ultrasound: There is no danger of radiation;
age (DPL) is useful. In many cases on clinical grounds direct it can be done bedside; it can be repeated many times; it
 is cost-effective. Its sensitivity is 90%; specificity is 98%. arteriography and also the bleeding vessel can be identified. 151
Focused abdominal sonar (ultrasound) for trauma (FAST) But venous bleed cannot be assessed by this.
is very useful method. d. Doppler assessment of major vessels may be beneficial
o Disadvantages: It is less useful in obesity, with interposi- especially for IVC, aorta, iliac vessels, and portal system;
tion of gas, when fluid is less than 500 ml; retroperitoneal but with haemoperitoneum visualisation window may be
injuries and bowel injuries. poor and vessels can be better identified by contrast CT
o Focused abdominal sonar trauma (FAST): It is rapid, scan.
noninvasive, portable bedside method of investigation
focusing on pericardium, splenic, hepatic and pelvic areas. Management Concepts in Abdominal Trauma
Blood more than 100 ml in cavities can be identified. It is o Evaluation of extent of the injury; number of organs injured
not reliable for bowel or penetrating injuries. It often needs and severity of injury; haematocrit assessment (haemoglobin
to be repeated. drop up to 6 gm% is tolerated well with adequate tissue
oxygenation. Rapid drop of hemoglobin needs adequate
Diagnostic Peritoneal Lavage (DPL) (by Perry) number of blood to be kept ready for transfusion, like
It is useful in blunt injury abdomen. It is not very useful in 5/10/bottles or more); central line for volume replace-
penetrating injury, bowel injury, retroperitoneal and pelvic ment; urinary catheterisation; administration of systemic
injuries. antibiotics.
o Autotransfusion of blood is very useful as a life-saving
CT Scan of Abdomen procedure in such situation. Blood from the cavity is sucked
out into a sterile bottle which contains 150 ml of 3.8%
It is most commonly used and better investigation for abdomi- sodium citrate dextrose solution. This blood is strained/
nal trauma. It is useful in blunt/penetrating trauma, suspected filtered through gauze and re-transfused. If there is colonic
pancreas, spleen, liver, duodenal, retroperitoneal injuries. and small bowel injuries auto transfusion is not possible for
Smaller injuries, early haemoperitoneum are better detected. fear of sepsis due to contamination.
It is noninvasive, highly specific, highly accurate (96%), with o Upper midline incision extending down across the left of
low false-positive/low false-negative, noninvasive. the umbilicus is the preferred incision. But surgeon should
not be hesitant to extend the incision into the thorax or do
Other Investigations

Trauma
horizontal T or extend as needed depending on the internal
organ injury.
a. Abdominal diagnostic paracentesis (Drapanas and
McDonald): Here 18 G short bevel spinal needle is inserted o First priority after opening the abdomen is immediate
into the peritoneal cavity after injecting local anaesthetic control of profuse bleeding using finger compression or mop
agent into the abdominal wall. With continuous suctioning or pressure. Later once the field is clean; area is assessed for
through syringe, needle is passed at various sites. Positive the extent of injury without releasing the compressed finger
tap means return of minimum of 0.1 ml of nonclotted blood. on the bleeding site. A vascular clamp or bulldog clamp is
False-positive result occasionally can occur due to needle helpful in such situation. Once it is applied over the site
puncture of abdominal wall vessels. Needle should not be of bleeding, compressing finger can be removed. Vascular
inserted close to previous abdominal scar as bowel may be suturing using 4 zero or 6 zero polypropylene/resection of
adherent underneath the scar. Change of direction of needle the tissue; reconstruction of the area; persistent pressure mop
is done by withdrawing the needle tip outer to peritoneum in situ with closure of the abdominal wall with an option of
and again puncturing the peritoneum. Puncture by 18 G second look surgery in 48 hours are the different options.
needle of nondistended bowel will seal without any leakage. Individual organs are assessed and graded for injuries and
Peritoneal tap should be avoided if bowel is distended. Bilat- managed accordingly.
eral flank tap/four quadrant tap is also done with similar o During laparotomy entire abdomen should be inspected/
result. Rectus sheath haematoma and false-negative results palpated carefully for any additional missed injuries. Lesser
are the problems. sac, retroperitoneum, duodenum, pancreas and diaphragm
b. Diagnostic laparoscopy is very useful. It can be done should be checked. Often peritoneum on the margin of the
under local anaesthesia. Haemoperitoneum, solid organ duodenum and right side colon is incised, duodenum and
and diaphragmatic injuries are well assessed. But bowel colon is reflected medially to visualise the retroperitoneum.
and retroperitoneal injuries are more likely to be missed. Pelvic structures need special attention. Rectum, urinary
c. Arteriography through Seldinger technique is useful in bladder injuries are likely to be missed if proper attention
suspected cases of renal arterial injury (thrombosis/spasm); is not given. On catheterization, if urine is clear it means
intimal tears, traumatic aneurysm and aortic occlusion (after urinary system is normal. Portal venous system should be
seat belt injury) are well diagnosed with arteriography. assessed.
Often it can be therapeutic also. Pelvic bleed extending into o Resection or repair should be decided later once haemostasis
retroperitoneum is not uncommon which can be assessed by is maintained. Whether the injury is to the bowel or organs

What we need is cup of understanding, barrel of love and an ocean of patience.

152 (liver/spleen/kidney, etc.) resection or repair approach is the adjacent bowel, then it should be gently evacuated.
decided depending on the severity of individual organ injury Mesenteric leaf is opened using curved scissor; clot is
(based on scale or grade). evacuated using gentle finger dissection; bleeder is identi-
o Mesenteric tear may be the cause for haemoperitoneum. fied and ligated. If there is compromised bowel function,
Tear may be perpendicular or parallel to the bowel. If it it should be resected. Bleeding from the major vein like
is perpendicular, haemostasis and approximation of the superior mesenteric vein is disastrous as tear may not be
mesentery is sufficient; if it is parallel tear, then blood localised but may be extensive; and even gentle dissection
supply to corresponding bowel may be compromised and may cause more tear. It is carefully mobilised; vascular
resection of that part of the bowel is indicated. Mesen- clamps are applied and repaired using 5 zero polypro-
teric haematoma is left alone if small and nonprogres- pylene sutures.
sive. Whether there is any colour changes in the adjacent o Aortic clamping: Catastrophic bleeding found after opening
bowel should be observed. If haematoma is large; if it is the abdomen which cannot be controlled and bleeding
progressive; if it causes compromised blood supply to with profound hypotension are the indications for aortic
clamping. Profuse intraperitoneal bleed comes under control
temporarily by tamponade effect of tense abdominal wall
and it itself temporarily helps the patient. The moment
abdomen is opened; tamponade effect is released causing
further rapid bleed leading into critical catastrophe. If such
event is expected prior to opening the abdomen very quick
rapid thoracotomy (prelaparotomy thoracotomy) through
left 5th intercostal space is done; left lung is deflated and
displaced; pleura over the thoracic aorta is incised; aorta
is dissected using finger; vascular clamp or soft intestinal
occlusion clamp is applied to occlude the thoracic aorta.
SRB's Manual of Surgery

Later laparotomy is performed to go ahead with manage-

ment of the bleeding. If profound bleeding is observed after
laparotomy necessitating the aortic clamping, it is done
by applying the clamp in infradiaphragmatic part of the
A aorta. Peritoneum is incised on the right of the abdominal
oesophagus in infradiaphragmatic area; aorta is dissected
using finger high up close to diaphragm to avoid injury to
celiac plexus; clamp is applied across (infradiaphragmatic
aortic occlusion).
o Usually drainage using tube drains on either side of the
abdomen is used even though it is controversial. ICT should
be placed if thoracotomy is also undertaken.
o Jejunostomy for enteral nutrition is ideal in all major
abdominal injuries. Often gastrostomy is also done along
with jejunostomy in case of duodenal and pancreatic
injuries.
o Management of individual organs after grading its severity
of the injuryduodenum, pancreas, liver, spleen, bowel,
B kidney, etc. (Please refer individual chapters for detail
highlights of individual organ injury is given below).
o Management as critical care (ICU with intensivist); multiple
blood transfusions; management of sepsis, maintenance of
respiration, management of electrolyte changes, treatment
of renal failure, provision of nutrition, prevention of DVT,
management of DIC are very essential part of postoperative
treatment.

DUODENAL INJURY
o Its severity depends on the type and extent of the injury.
o It can be haematoma or lacerations.
o Lacerations can cause duodenal disruption, may be < 50%
C or > 50% or 75% or more.
Figs 1.279A to C: Traumatic blunt injury abdomen causing small bowel o Laceration may extend into the ampulla, distal CBD,
injury which is sutured using interrupted horizontal silk sutures. pancreas or with duodenal devascularisation.
 Grading of duodenal injury SMALL BOWEL INJURY 153
Grade I Haematoma Involving single portion of the o It can be blunt injury or stab injury.
Laceration duodenum. o Blunt injury causes disruption of either duodenojejunal
Partial thickness injury without
region or at ileocaecal region.
perforation.
o Presentation is like haemoperitoneum or features of peri-
Grade II Haematoma Involving more than one portion.
tonitis.
Laceration Disruption less than 50%
circumference.
o Monks localising zones in the abdomen signify the location
of the small bowel injury.
Grade III Laceration Disruption of 50-75% of the
circumference of 2nd part of the
o Presence of pattern bruising over the abdominal wall
duodenum; disruption 50-100%
signifies the small bowel injury and its site. It is called as
of the 1st, 3rd or 4th part of the Londons sign.
duodenum.
Grade IV Laceration Disruption more than 75% of 2nd part Management
of the duodenum and involving the
o Plain X-ray abdomen shows gas under abdomen with
ampulla or distal common bile duct.
ground-glass appearance.
Grade V Laceration Severe disruption of o U/S abdomen is useful.
Vascular duodenopancreatic complex. o Laparotomy and closure of the perforation if it is small.
Duodenal devascularisation.
o In presence of extensive bowel injury or multiple injuries,
resection and anastomosis is done.
Management o Any associated injuries should be dealt with accordingly.
o CT scan is more relevant investigation.
o Associated other injuries should be managed accordingly.
o Haematoma without extension is managed conservatively
with nasogastric aspiration, antibiotics and IV fluids.
o Lacerations are sutured surgically with a stenting or often
with bypass like gastrojejunostomy.

Trauma
o ERCP stenting or CBD bypass is also often required.

Complications
 Infection, duodenal leak.
 Peritonitis, haemorrhage.

PANCREATIC INJURY
o It can be in the head or body and tail of the pancreas. A
o It may be associated with injury to duodenum or portal or
superior mesenteric veins.
o It can be contusion or severe lacerations.

Management
o High resolution CT scan is diagnostic.
o Distal pancreatectomy for injuries distally.
o Conservative treatment is useful with antibiotics, IV fluids.
o Whipples operation or total pancreatectomy is done as a
last resort.
o Drainage of the pancreatic bed is simple and often useful
method.

Complications
B
o Pancreatitis, septicaemia. Figs 1.280A and B: Assault causing stab injury abdomen. On opening
o Pancreatic fistula, pancreatic abscess formation. the abdomen, multiple perforations were found in the small bowel
Pancreatic injury has got high mortality (> 45%). and was sutured. Patient recovered well.

Happiness is not destination, it is a manner of travelling.

154 COLONIC INJURY SPLENIC INJURY
o Left sided injury is treated with proximal colostomy with It can be subcapsular haematoma, laceration or hilar injury.
closure of the wound if it is small, or resection and anas- It can be associated with other organ injuries like left kidney,
tomosis if it is wider area. Closure of colostomy is done at left lobe of the liver, splenic flexure of the colon or pancreas.
later stages after 3-6 months. It can cause torrential haemorrhage and shock.
o Small wound over right sided colon can be sutured primarily. It is the most common organ injured in blunt injury abdomen.
o Ileostomy alone or ileostomy with ileo-transverse anasto-
mosis or right hemicolectomy with ileostomy is indicated Management
in following situations:
 Extensive peritoneal contamination. o U/S abdomen, diagnostic peritoneal lavage are the inves-
 Colonic vascular injuries. tigations.
 Haemodynamically unstable patients. o Blood transfusions.
 Long-term hypotension after trauma. o Splenorrhaphy is done in selected patients so as to save
the spleen.
o Splenectomy.
LIVER INJURY o Management of associated injuries.
It can be subcapsular haematoma, lacerations, deeper injuries,
lacerations with disruption of hepatic lobes or segments or Complications of Splenectomy
liver injury with vascular injuries like of inferior vena cava or
o Left lung atelactasis.
hepatic veins.
o Overwhelming postsplenectomy infection (OPSI).
Present with features of haemorrhagic shock, distension
o Pancreatitis and pancreatic fistula.
of the abdomen, tenderness, rebound tenderness, guarding,
o Gastric bleeding.
rigidity.
o Subphrenic abscess.
SRB's Manual of Surgery

 CT is diagnostic tool
 Liver injury is graded depending on involvement of hepatic RENAL INJURY
veins, portal system, biliary system and duodenum
o It is commonly managed conservatively.
 Often high grade liver injury also can be managed nonop- o IVU is the investigation of choice in renal injury.
eratively o Surgery is indicated when there is hilar injury, progressive
 Push (direct compression); Pringle (occluding portal triad at bleeding, failure of conservative treatment or perinephric
foramen Winslow with fingers temporarily); plug by emboli- abscess formation.
sation; pack the liver bed; repair of vena cava or portal vein;
stenting of biliary tree and hemihepatectomyare the URINARY BLADDER INJURY
treatment strategies Intraperitoneal bladder injury occurs in distended bladder.
It is treated always by surgical exploration through transab-
Management dominal approach. Bladder tear is sutured with keeping a
suprapubic cystostomy using Malecots catheter.
o Small tear is sutured. Extraperitoneal injury can be treated conservatively by
For larger tears: placing a Foleys catheter for 2-3 weeks.
 Deep sutures.
 Packing. ABDOMINAL COMPARTMENT SYNDROME
 Debridement.
 Haemocoagulants. o Normal intra-abdominal pressure is 2-12 mmHg. Abdominal
compartment syndrome is increased intra-abdominal pres-
o Liver resection is not done (not advisable) usually for
sure more than 12 mmHg. It is often sudden, rapidly progres-
injuries. sive decreasing the venous return to heart.
o Pringle manoeuvreby compressing the porta near o It is common in multiple traumas. Ileus, bowel oedema are
foramen Winslowto control bleeding (not more than 30 the factors causing it. It is also seen in retroperitoneal haem-
minutes). orrhage, pancreatitis, long-standing hernia after reduction
o Blood transfusions. into the peritoneal cavity.
o Treatment of associated injuries like of diaphragm, lung, o Upward displacement of the diaphragm, increased peak
duodenum, colon. inspiratory pressure, peripheral resistance, intrapleural
o Antibiotics. pressure, CVP and PCWP; hypoxia, hypercapnia, acidosis;
compression of IVC, decreased venous return to heart,
Complications of Liver Injury cardiac output and right atrial pressure, decreased visceral
and renal blood flow and glomerular filtration; mesenteric
o Haemorrhage, septicaemia, bile leak. venous hypertension; bowel wall oedema and ischaemia
o Liver failure, haemobilia. are the effects. Oliguria, respiratory failure, cardiac arrest
o Subphrenic abscess, CBD stricture. ensures if abdomen is not decompressed.
 Abdominal compartment syndrome (ACS) 155
Causes Features Management
Multiple trauma and ICU patients Hypoxia, hypercarbia Bladder pressure assessment
common
Postoperative ileus Decreased urine output Ryles tube aspiration
Acute abdomen Hypotension Resuscitation
Acute gastric dilatation Tense abdomendistended ICU care
Laparoscopic procedures Decreased venous return Surgical decompression
Intestinal obstruction Bowel ischaemia
Cardiac arrest

o Intra-abdominal pressure is measured using a urinary cath- on its point of contact with trunk and viscera continue to
eter in the urinary bladder. Pressure is graded (Busch) as move forward. It leads into severe contusion of abdominal
I10-15 cm of H2O; II16-25 cm of H2O; III26-35 cm contents; detachment of bowel from its mesentery due to
H2O; IVmore than 36 cm H2O. free forward rapid mobility of the bowel over a relatively
o Beyond grade III immediate decompression is needed. Initial fixed mesentery. Solid organ injury occurs only occasion-
volume preload is essential otherwise sudden decompression ally.
may cause cardiac arrest in asystole due to reduced preload, o Two point anchorages causes solid organ injuries like of
sudden influx of high potassium, acid and other metabolic liver/spleen. Lap-belt causes contusion and bowel injury
by products into the heart. commonly.
o Condition is a surgical emergency. o It is often difficult to identify the injuries due to presence of
more obvious other injuries. CT chest and abdomen diag-
Intra-abdominal pressure grading (Busch) in cm of water nostic peritoneal lavage (DPL) are very useful.

Trauma
I10-15 cm of H2O o Petechiae around iliac crest or costal margin are signs
II15-25 cm of H2O wherein one can suspect seatbelt injuries.
III25-35 cm of H2O o Distraction fracture of lumbar spine (chance fracture) with
IVmore than 35 hyperaesthesia of T12 and L1 level is often associated.
10% of such fractures are associated with intra-abdominal
injuries.
SEATBELT INJURIES o Treatment is immediate laparotomy and proceedbowel
o In an individual with seatbelt, during impact violent decel- suturing/resection/suturing of the organ injuries/splenor-
eration of human body occurs. Seatbelt impinges heavily rhaphy/splenectomy.

Success is the ability to go from one failure to another with no loss of enthusiasm.