ABDOMINAL TRAUMA

MAJ. GEN. (RETD). DR.NARESH KUMAR GIRI.

PROFESSOR OF SURGERY
NAIHS
Introduction
 Injury does not respect anatomical boundaries.
 Division of the body into abdomen and thorax is
artificial.
 Injury to the torso , with its associated
physiological consequences, is more appropriate.
 Torso - main part of the human body, primarily
made up of the chest, abdomen and pelvis, not
including the head, neck, arms and legs.
Injury mechanisms associated with torso trauma.

 Injury often traverses different anatomical

zones of the body, affecting structures on
both sides of traditional anatomical zones.
 These zones are known as junctional zones.

 These zones represent surgical challenges in

terms of:
- the diagnosis of the area of injury
- the surgical approach, which have to be
balanced against the physiological stability of
the patient.
Junctional zones
The key junctional zones are:
1. Between the neck and the thorax.
2. Between the thorax and the abdomen.
3. Between the abdomen, the pelvic
structures and the groin.
Abdominal Injury
Classified into the following categories based
on their physiological condition after initial
resuscitation.
1. Haemodynamically ‘normal’ – investigation
can be completed before treatment is planned.
2. Haemodynamically ‘stable’ – investigation is
more limited. Aimed at establishing whether
patient can be managed non-operatively,
whether angioembolism or surgery is required.
Abdominal Injury.
3. Haemodynamically unstable’ – investigation need to
be suspended as immediate surgical correction of the
bleeding is required.

A trauma laparotomy is the final step in the pathway to

delineate intra-abdominal injury:
- Difficult to determine the source of bleeding in the
shocked, multiple injured patient
- If doubt exists, especially in the presence of other
injuries, a laparotomy may still be the safest option.
Abdominal Injury
 Patient’s physiology must be assessed at
regular intervals.
 If there is indication of still active bleeding,

then the source must be identified, requiring

immediate surgery.
Abdominal Injury
 Blood loss into the abdomen can be subtle
and there may be no clinical signs.
 Blood is not and irritant and initially does not

cause any abdominal distension.

 Drop in blood pressure may be late sign in

young fit patients.

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

Rosen’s Emergency Medicine, 7 th ed. 2009

 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 viscous.
◦ Most common causes: motor vehicle accidents-
(50 - 75% of cases) > blows to abdomen (15%)
> falls (6 - 9%)
 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, 7 th ed. 2009

Pathophysiology of injury

Blunt Abdominal Trauma

 Rupture or burst injury of a hollow organ by
sudden rises in intra-abdominal pressure
 Crushing effect

 Acceleration and deceleration forces → shear

injury
 Seat belt injuries

 “Seat belt sign” - highly correlated with

intraperitoneal injury

Rosen’s Emergency Medicine, 7 th ed. 2009

 Closed Injuries.
 Closed injuries are the consequence of shock
waves that radiate from the point of impact or
direct compression of a viscus against a bony
prominence.
 Compression of a large segment of the

abdominal or abdomino-thoracic wall may burst

or split a structure such as the liver.
 Similar force, particularly if the breath is held and

the diaphragm tensed, may split that muscle.

Closed Injuries.
 Structures that are attached to bone by fascial
bands, such as the bladder and urethra, may
be torn when fracture occurs.
Penetrating injuries.
 In penetrating wounds the distinction
between high-and low-velocity agents is of
some importance.
 The common low velocity injury is by

stabbing:- Two forms –

1. Kinetic energy is low; victim can often see
it coming and is on the retreat at the moment
of impact.
Penetrating Injuries.
- When a heavy weapon ( a kitchen knife or a bayonet)
is used with frank homicidal intent or by the mentally
deranged.
- Such injuries are deeply penetrating and often
complex.
 Low -velocity missile wounds, eg. from handgun can be

difficult to manage.
- Bullet tends to follow fascial planes and the path is
difficult to predict.
- Close-quarters injury from shotgun blast may
produce very severe damage to both the abdominal wall
and underlying structures.
Penetrating Injuries.
2) High-velocity missiles produced by gunshot or
fragments from exploding mines and shells –
- Penetrate deeply and pursue bizarre courses,
extensively damaging anything in or around their
path.
 With projectiles of high kinetic energy :-

- Entry into the abdomen may occur from

practically anywhere in the body.
- At first site to be an innocent wound in buttock,
back or thigh can prove to have had disastrous intra-
abdominal consequences.
Penetrating Injuries.
 On the abdominal wall a tiny superficial
puncture can lead into the peritoneal cavity.
 The matter is often made more difficult to

assess by:
- the sliding of the fascial layers after injury,
- as patient’s position changes,
- obscures the deeper parts of the tract.
Two other matters are worthy of mention.

 Firstly:- delay in the presentation of signs to

guide the surgeon to laparotomy may be the
consequence of a subserous haematoma,
which finally bursts.
 Although this is most common in spleen, it

can occur In relation to liver and gut.

 The need for repeated clinical examination of

the abdomen and sometimes special

investigations on suspicion is obvious.
 Secondly:- High- speed decelerations in head-
on collisons are not now necessarily
associated with death if the body is well
supported by a belt.
 The abdominal contents may continue to

move forward, avulsing coils of bowel from

their mesentery, tearing at points of relative
fixation such as the duodeno-jejunal flexure
and terminal ileum.
 Contusing by impact either against the
abdominal part of the safety harness or
between the anterior and posterior
abdominal wall.
Physical Exam

 Generally unreliable due to distracting injury,

spinal cord injury
 Look for signs of intraperitoneal injury

 abdominal tenderness, peritoneal irritation,

gastrointestinal hemorrhage, hypovolemia,
hypotension
 entry and exit wounds to determine path of
injury.

Rosen’s Emergency Medicine, 7 th ed. 2009

 Distention - pneumoperitoneum, gastric
dilation, or ileus
 Ecchymosis of flanks (Gray-Turner sign) or
umbilicus (Cullen's sign) - retroperitoneal
hemorrhage
 Abdominal contusions – e.g. lap belts
 ↓bowel sounds suggests intraperitoneal
injuries
 DRE: blood or subcutaneous emphysema
Diagnostic studies

 Lab tests: not very helpful

 May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase.

Rosen’s Emergency Medicine, 7 th ed. 2009

Investigation.
 Investigations are driven by the cardiovascular
status.
 In torso trauma, the best and most sensitive

modality is a CT scan with intravenous

contrast.
 In the unstable patient, this is generally not

possible.
Investigation.
 In penetrating injury, metal markers placed
on all external wounds before plain films are
taken.
 Helps in assessment of the trajectory

 Helps to correlate the number of holes and

the number of missiles that can be seen.

 Helps to determine whether two holes are

indicative of one missile passing through, or

two missiles, both retained internally.
 A single hole implies that the projectile has

been retained.
 Plain films of the abdomen.
 Plain films – erect and supine may show gas
shadows but are difficult to interpret.
 More useful film of the chest with the patient
upright – gas under the diaphragm confirms visceral
perforation. Small visceral punctures may go
undetected.
 Erect film may demonstrate diaphragmatic rupture.
 Lateral decubitus film may be useful in detecting
small amounts of free gas in unconscious patients.
Plain films of the abdomen.
 Observing signs of injury to the bony
structures on the periphery of abdomen, i.e.
chest, pelvis and lumbar spine.
 Loss of the psoas shadow may be helpful in

the diagnosis of retroperitoneal effusion.

Imaging

 Plain films:
 fractures – nearby visceral damage
 free intraperitoneal air
 Foreign bodies and missiles

Rosen’s Emergency Medicine, 7 th ed. 2009

 Imaging
 CT
 Accurate for solid visceral lesions and intraperitoneal hemorrhage
 Guide non-operative 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, 7 th ed. 2009

Imaging

 Angiography
 To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma, in an unstable patient
 Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma

Rosen’s Emergency Medicine, 7 th ed. 2009

Focused abdominal sonar for trauma (FAST) and
extended FAST (e-FAST)

 Focused abdominal sonar for trauma (FAST) is a

technique whereby ultrasound (sonar) imaging is
used to assess the torso for the presence of free
fluid, either in the abdominal cavity, and is
extended into the thoracic cavities and
pericardium (eFAST).
 It is a rapid, reproducible, portable and non-
invasive bedside test and can be performed at the
same time as resuscitation.
 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

Rosen’s Emergency Medicine, 7 th ed. 2009 Trauma.org

 Extended FAST (E-FAST):
◦ Add thoracic windows to look for pneumothorax.
FAST
 Morrison’s pouch (hepato-renal space)

trauma.org

Rosen’s Emergency Medicine, 7 th ed. 2009

FAST
 Perisplenic view

trauma.org Rosen’s Emergency Medicine, 7 th ed. 2009

FAST
 Retrovesicle (Pouch of Douglas)

 Pericardium (subxiphoid)

Rosen’s Emergency Medicine, 7 th ed. 2009

trauma.org
 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
subcutaneous air.
◦ Can’t distinguish blood from ascites.
◦ High- (31%) false-negative rate in detecting
haemoperitoneum in the presenceRosen’s
of Emergency
pelvicMedicine,
fracture
7 ed. 2009
th
Utilisation of eFAST
 Detects free fluid in the abdomen or pericardium.
 Will not reliably detect less than 100ml. of free blood.
 Does not directly identify injury to hollow viscus.
 Cannot reliably exclude injury in penetrating trauma.
 May need repeating or supplementing with other
investigations.
 Is unreliable for assessment of the retroperitoneum.
Diagnostic Peritoneal Lavage

 Largely replaced by FAST and CT

 In blunt trauma, used to triage patients who is
haemodynamically unstable and has multiple
injuries with an equivocal FAST examination
 In stab wounds, for immediate diagnosis of
hemoperitoneum, determination of intraperitoneal
organ injury, and detection of isolated diaphragm
injury
 In GSW, not used much

Rosen’s Emergency Medicine, 7 th ed. 2009

Diagnostic Peritoneal Lavage

 1. Attempt to aspirate free peritoneal blood

 >10 mL positive for intraperitoneal injury
 2. Insert lavage catheter by Seldinger, semi- open, or
open method
 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, 7 th ed. 2009
Local Wound Exploration

 To determine the depth of penetration in stab

wounds
 If peritoneum is violated, must do more
diagnostics

 Prepare, extend wound, carefully examine (No blind

probing)
 Indicated for anterior abdominal stab wounds, less
clear for other areas

Rosen’s Emergency Medicine, 7 th ed. 2009

Laparoscopy

 Most useful to evaluate penetrating wounds to

thoraco-abdominal region in stable patients.
 especially for diaphragm injury

 Can repair organs via the laparoscope

 diaphragm, solid viscera, stomach, small bowe l.

Rosen’s Emergency Medicine, 7 th ed. 2009

Laparoscopy or thoracoscopy
 Valuable screening investigation in stable patients with
penetrating trauma, to detect or exclude peritoneal
penetration and/or diaphragmatic injury.
 Laparoscopy may be divided into:
● Screening: used to exclude a penetrating injury with
breach of the peritoneum.
● Diagnostic: finding evidence of injury to viscera.
● Therapeutic: used to repair the injury. (diaphragm,
solid viscera, stomach, small bowel).
Laparotomy
 In most institutions, evidence of penetration
requires a laparotomy to evaluate organ injury, as
it is difficult to exclude all intra-abdominal injuries
laparoscopically.
 When used in this role laparoscopy reduces the
non-therapeutic laparotomy rate.
 There is no place for laparoscopy in the unstable
patient.
Laparoscopy
 Disadvantages:
◦ Poor sensitivity for hollow visceral injury,
retroperitoneum.
◦ If diaphragm injury, pneumothorax during
insufflation.
Thank You
 ABDOMINAL TRAUMA
MANAGEMENT

Maj.Gen.(Retd). Dr.Naresh Kumar Giri.

Professor of Surgery.
NAIHS.
Abdominal Trauma 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 perforation/

spillage
 In general, leave foreign bodies in and remove

in the Operation Theatre.

Rosen’s Emergency Medicine, 7 th ed. 2009
Abdominal Injury
 Blood loss into the abdomen can be subtle
and there may be no clinical signs.
 Blood is not and irritant and initially does not

cause any abdominal distension.

 Drop in blood pressure may be late sign in

young fit patients.

 Preoperative management
 The following procedures are mandatory:
1. Adequate channel for volume replacement.

Sufficient replacement administered to stabilize

circulation.
2. If possible red cells for transfusion should be

available in large quantities.

3. One exception to the rule of restoring the circulation

before exploration:- situation where blood loss is

too rapid that it is necessary to control the bleeding
before resuscitation can proceed.
 Diagnosed by the failure of 2 or more litres of
replacement fluid in 10 min or less to bring about
significant improvement in patient’s vital signs,
particularly profound arterial hypotension.
 Bold surgeon and a cool anaesthetist willing to put

the patient to sleep while laparotomy is done.

 Rapid infusion (of the order of 1-2 litres in 10 min)

under close observation, to have the patient at the

earliest on the OT table.
 Autotransfustion
 Using blood from within the abdomen as a means
of providing oxygen-carrying capacity when, stored
blood is in short supply.
 Blood sucked out into a sterile suction bottle

containing 150ml of 3.8% of sodium citrate

dextrose solution, strained through gauze and re-
transfused.
 To a level of 6 g/dl of haemoglobin, tissue

oxygenation will be satisfactory provided blood

volume and thus tissue perfusion is maintained.
 Nasogastric tube.
 Induction of anaesthesia should always be

preceded by oxygenation of the patient.

 All patients should have the bladder emptied by

urethral catheterization.
 A large dose of antibiotics can be administered

 ? On table lavage.

 Operating table where intraoperative X-rays can be

taken. Suspected renal injury – IVU.

 Tactics of Exploration.
 Incisions: In open injury the site of entry and the
known or inferred direction of the track are the
chief determinants of the position of the abdominal
incision.
 In majority of instances a long midline laparotomy

is the incision of choice:-

a. It provides ease and rapidity of access.
b. Flexibility of exposure and simplicity of closure..
 Vertical incision can be extended laterally either in

the abdomen or across the costal margin into chest

to deal with unexpected problem
 Incision that permits free retraction of the
edges nearly out of the paracolic gutters and
through which the small bowel can be
completely displaced on to the abdominal
wall, so permitting easy, detailed inspection of
other structures.
Excision of entry and exit wounds in penetrating
injury.

 These wounds do not threaten life and while

they are being dealt with more blood is
frequently being lost within.
 For this reason when a midline incision is

used, local excision is deferred until the end of

the procedure.
 When an oblique approach is made, exit and

entry wounds can usually be included in the

incision and excised as it is made.
Procedure at Laparotomy
 Massive life- threatening bleeding nearly
always has an obvious source and should be
arrested at once by finger pressure.
 In the case of liver by a pack.

 Blood is then scooped and sucked out from all

four quadrants as completely as possible.

 Re-accumulation of blood indicates an

uncontrolled lesion. Scoop and suction.

 From this point on there are only two
contraindications to preliminary complete
formal laparotomy:-
1. A low-velocity stab wound in which it is
clear that injury has occurred just deep to
the penetration and that this injury has
been identified.
2. Bleeding that must be decisively controlled
at once to ensure survival.
Formal Laparotomy.
 Carried out by eviscerating all small bowel
upwards and to the right over the right edge
of a vertical laparotomy.
 Removal of the bowel from the abdominal

cavity now permits the pelvic contents to be

seen and the floor of the pelvis to be cleanly
sucked out.
 Inspection continues….
Formal Laparotomy.
 Finally, if injury from behind has occurred or a
missile track from in front suggests the need to:-
1. the lesser sac below the stomach is opened
and the pancreas is examined.
2. the right colon and duodenum are mobilized .
Serves to expose the right kidney,
3. only by the most minute inspection of every
centimeter of gut will the operator avoid
occasionally missing the small perforations.
Principles of abdominal surgery for trauma.

 Decision making.
 Aortic clamping: There are two occasions when it

may be necessary to clamp the aorta to save the

patient from death by rapid exsanguination-
1. When abdomen has been opened and
catastrophic bleeding cannot be assessed or controlled
by conventional measures.
2. If the abdomen is opened, bleeding, until then at
least partially controlled by tamponade, becomes more
severe and rapidly produces profound hypotension.
Principles of abdominal surgery for trauma.

 In the former aorta controlled below the

diaphragm.
 In the latter – whether to go straight to

laparotomy or to perform a prelaparotomy

thoracotomy and clamp the lower thoracic
aorta.
 Speed in both decision making and operation

is of the essence.
 Principles of abdominal surgery for trauma –
Resection or Repair
Resection is sometimes a necessity for definitive
treatment eg.
1. In extensive trauma to liver- segmental
resection or lobectomy , then to stitch together
bruised and battered tissues.
2. In wounds of the right colon, hemicolectomy is
preferred to exteriorization.
3. In multiple perforations of the small bowel,
provided they are closely grouped, resection may be
more expeditious than repair.
 Principles of abdominal surgery for trauma.

 Drainage.
 Gastrostomy and feeding jejunostomy.

 Injury does not necessarily respect anatomical

boundaries and that several areas of damage may

combine to produce a complex picture.
 Part of the challenge of abdominal surgery for

trauma is the stimulus that it produces to develop

quick, decisive thinking and action to deal with a
wide variety of injury patterns, some of which the
operator may not have encountered before.
Management of penetrating abdominal trauma

forsurenot.com
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
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
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
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
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

surgery.
1. Is immediate laparotomy 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
 Management of penetrating abdominal trauma

Back/Flank
 Risk of retroperitoneal

injury
 Intraperitoneal organ

injury 15-40%
 Difficulty evaluating

retroperitoneal organs
with exam and FAST
 Stable pts, CT scan is

reliable for excluding

significant injury:
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
Management of Blunt abdominal trauma

ashwinearl.blogspot.com
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 Haemodynamically stable patients, CT is

preferred.

Rosen’s Emergency Medicine, 7 th ed. 2009

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
 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
Damage Control

Resuscitation in the ICU

PRBC (/Platelet/FFP
 Recombinant activated factor VII

◦ Increased thromboembolic complications

 Re-warming 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
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
 Abdominal Compartment Syndrome

 Common problem with abdominal trauma

 Definition: -elevated intraabdominal pressure (IAP)

of ≥20 mm Hg, with single or multiple organ

system failure
 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
 Abdominal Compartment Syndrome

Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

 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
 Abdominal Compartment Syndrome
 Management
 Surgical abdominal decompression
 Nonsurgical: paracentesis, NGT, sedation
 Staged approach to abdominal repair
 Temporary abdominal closure

Bailey J. Crit Care 2000, 4:23–29 Sugrue M. Curr Opin Crit Care 2005; 11:333-338
Individual organ injury
Individual Organ Injury - Liver
 Blunt liver trauma occurs as a result of direct
injury.
 Solid organ , compressive forces can easily

burst the liver substance.

 It is usually compressed between the impacting

object and the rib cage or vertebral column.

 Most injuries are relatively minor and can be

managed non-operatively.
Individual Organ Injury- Liver
 Penetrating trauma is relatively common.
 Bullets have a shock wave and when they pass

through liver/solid organ cause significant

damage some distance from the actual track
of the bullet.
 Not all penetrating wounds require operative

management and may stop bleeding

spontaneously.
Liver
 CT investigation of choice in stable patients.
 It provides information on the liver itself.

 Injuries to the adjoining major vascular and

biliary structures.
Liver
Individual Organ Injury - Liver.
Injury with vascular component should be
reimaged.
Significant risk of development of:
- subsequent ischaemia.
- false aneurysm.
- arteriovenous fistulae or
- haemobiliary fistula.
All patients should be rescanned prior to discharge.
 Management –Liver Injury
The operative management of liver injuries can be
summarized as ‘the four P’s:
- Push;
- Pringle; the inflow from the portal triad is
controlled by Pringle’s manoeuver, with direct
compression of the portal triad, either digitally or
using a soft clamp.
- Plug; - silicon tubing or a Sengstaken- Blackmore
tube
- Pack.
Management – Liver Injury
 Bleeding points controlled locally when
possible.
 Angioembolisation if required.

 Not necessary to suture penetrating injuries

to liver, unless haemostasis cannot be

controlled by other means.
 If direct damage to hepatic artery – tied off.

 Damage to portal vein must be repaired. If

tied mortality > 50%. Refer to specialist

centre.
Biliary Injuries.
 Isolated traumatic biliary injuries rare.
 Mainly occur from penetrating trauma, often

in association with injuries to other structures

that lie in close proximity.
 Common bile duct can be repaired over a T-

tube.
 Or drained and referred to appropriate care as

part of damage control, or even ligated.

 Individual Organ Injury - Spleen
 Splenic injury occurs from direct trauma.
 Most injuries, especially in children, can be

managed conservatively.
 In adults, especially in presence of other injury or

physiological instability, laparotomy should be

considered.
 Spleen can be packed, repaired or placed in a mesh

bag.
 Splenectomy safer option, especially in unstable

patient with multiple potential sites of bleeding.

Spleen
 Individual Organ Injury - Spleen
 Selective angioembolisation of the spleen can
play a role.
 After splenectomy – significant though transient

changes to blood physiology.

 Platelet and white cell count rise may mimic

sepsis.
 Inoculation against Pneumococcus is advisable

within 2-3 weeks, by which time patient;s

immune system has recovered.
Individual Organ Injury – Pancreas.

 Most pancreatic injury occurs as a result of

blunt trauma.
 Major problem is of diagnosis as it is a

retroperitoneal organ.
 CT remains the mainstay of accurate

diagnosis.
 Amylase or lipase estimation is insensitive.

 In penetrating trauma, injury may only be

detected during laparotomy.

 Individual Organ Injury – Pancreas.
 Classically the pancreas should be treated with
conservative surgery and closed suction drainage.
 Injuries to the pancreatic body to the left of the

superior mesenteric vessels and to the tail are

treated by closed suction drainage alone.
 Distal pancreatectomy if the duct is involved.

 Proximal injuries (to the right of the superior

mesenteric artery) are treated:-

- as conservative as possible.
- partial pancreatectomy may be necessary.
 Individual Organ Injury – Pancreas.

 The pylorus can be temporarily closed (pyloric

exclusion) in association with gastric drainage
procedures, to minimize pancreatic enzyme
stimulation by gastric juice or distenstion.
 A Whipple’s procedure (pancreaticoduodenectomy)

is rarely needed and should not be performed in

emergency situation because of high mortality.
 A damage control procedure with packing and

drainage should be performed and referred for

definitive surgery.
Individual Organ Injury - Stomach
 Most stomach injury are caused by penetrating
trauma.
 Blood presence is diagnostic if found in the

nasogastric tube, in the absence of bleeding

form other sources.
 Surgical repair required.

 Examine stomach fully as an injury to the front

of the stomach can be expected to have an

‘exit’ wound elsewhere on the organ.
Individual Organ Injury – Duodenum.

 Duodenal injury is frequently associated with

injuries to the adjoining pancreas.
 Duodenum lies retroperitoneally and so injuries

are hidden, discovered late or at laparotomy

performed for other reasons.
 CT is the diagnostic modality of choice.

- only sign may be gas or fluid collection in the

periduodenal tissue.
- leakage of oral contrast.
 Individual Organ Injury - Duodenum

 Smaller injuries can be repaired primarily.

 The first, third and fourth part of duodenum

behave like small bowel, and can be repaired in

the same fashion.
 The second part of the duodenum is fixed to the

pancreas with a common blood supply.

 Major trauma, especially if the head of the

pancreas is simultaneously injured, should be

treated as part of a damage control procedure
and be referred for definitive care.
Individual Organ Injury – Small Bowel.

 Frequently injured as a result of blunt trauma.

 Individual loops may be trapped, causing high-

pressure rupture of a loop or tearing of the

mesentery.
 Penetrating trauma is also a common cause of

injury.
 Small bowel injuries need urgent repair.

 Haemorrhage control takes priority and these

wounds can be temporarily controlled with simple

sutures.
 Individual Organ Injury – Small Bowel.
 In blunt trauma with mesenteric vessel damage,
bowel ischaemia that results will dictate the extent
of resection.
 Resections carefully planned to limit the loss of

viable bowel.
 Haematomas in the mesenteric border need to be

explored to rule out perforations.

 With low energy wounds, primary repair. More

destructive wounds associated with military type

weapons require resection and anastomosis.
 Individual Organ Injury - Colon
 Injuries from blunt injury are relatively infrequent.
 More frequently in penetrating injury.

 Repaired primarily if little contamination or

viability satisfactory.
 If extensive contamination, physiologically

unstable or the bowel is of doubtful viability, then

bowel can be closed off (‘clip and drop’}.
 Defunctioning colostomy and later bowel

reanastomosed once patient is stable.

Individual Organ Injury - Rectum
 Only 5% of colon injuries involve the rectum.
 Generally from penetrating injury.

 Occasionally following fracture of the pelvis.

 Digital rectal examination will reveal presence

of blood.
 These injuries are often associated with

bladder or proximal urethral injury.

Individual Organ Injury – Rectum.
 With intraperitoneal injuries, rectum is
managed as for colonic injuries.
 Full thickness extraperitoneal rectal injuries:-

- diverting end-colostomy and closure of the

distal end (Hartmann’s procedure)
- loop colostomy.
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

Conclusions
 FAST is non invasive, 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.

Thank You