Blunt Injury to abdomen

Etiology
  • Vehicular trauma: Auto-to-auto and auto-to-pedestrian collisions 50-75% of cases. 
  • Falls and industrial or recreational accidents.
  • Iatrogenic trauma during cardiopulmonary resuscitation, manual thrusts to clear an airway, and the Heimlich maneuver.
Signs and symptoms
  • Pain
  • Tenderness
  • Gastrointestinal hemorrhage
  • Hypovolemia
  • Evidence of peritoneal irritation
  • Large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings.
  • Bradycardia may indicate the presence of free intraperitoneal blood.
  • Lap belt marks: Correlate with small intestine rupture
  • Steering wheel–shaped contusions
  • Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign): Indicates retroperitoneal hemorrhage, but is usually delayed for several hours to days
  • Abdominal distention
  • Auscultation of bowel sounds in the thorax: May indicate a diaphragmatic injury
  • Abdominal bruit: May indicate underlying vascular disease or traumatic arteriovenous fistula
  • Local or generalized tenderness, guarding, rigidity, or rebound tenderness: Suggests peritoneal injury
  • Fullness and doughy consistency on palpation: May indicate intra-abdominal hemorrhage
  • Crepitation or instability of the lower thoracic cage: Indicates the potential for splenic or hepatic injuries
DIAGNOSIS:
  • Assessment of hemodynamic stability
  1. In the hemodynamically unstable patient, a rapid evaluation for hemoperitoneum can be accomplished by means of diagnostic peritoneal lavage (DPL) 
  • In hemodynamically stable patient the focused assessment with sonography for trauma (FAST) should be done 
  • Radiographic studies of the abdomen are indicated in stable patients when the physical examination findings are inconclusive.
  • Patients with a spinal cord injury
  • Those with multiple injuries and unexplained shock
  • Obtunded patients with a possible abdominal injury
  • Intoxicated patients in whom abdominal injury is suggested
  • Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure
  • Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum.
  • An examination is interpreted as positive if free fluid is found in any of the 4 acoustic windows, negative if no fluid is seen, and indeterminate if any of the windows cannot be adequately
  • assessed.
  • CT scanning often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention Unlike DPL or FAST, CT can determine the source of hemorrhage.
 MANAGEMENT:
  1. Treatment of blunt abdominal trauma begins at the scene of the injury and is continued upon the patient’s arrival at the ED or trauma center.
  • Indications for laparotomy in a patient with blunt abdominal injury include the following:
  1. Signs of peritonitis
  2. Uncontrolled shock or hemorrhage
  3. Clinical deterioration during observation
  4. Hemoperitoneum findings on FAST or DPL
  5. Preferred incision for abdominal exploration in Blunt injury abdomen is Always Midline incision
  • Nonoperative management
  • Based on CT scan diagnosis and the hemodynamic stability of the patient, as follows:

  1. For the most part, pediatric patients can be resuscitated and treated nonoperatively; some pediatric surgeons often transfuse up to 40 mL/kg of blood products in an effort to stabilize a pediatric patient Hemodynamically stable adults with solid organ injuries, primarily those to the liver and spleen, may be candidates for nonoperative management
  2. Splenic artery embolotherapy, although not standard of care, may be used for adult blunt splenic injury
  3. Nonoperative management involves closely monitoring vital signs and frequently repeating the physical examination & IV fluid administration
Exam Question of:
  • Blunt injury abdomen, patient was hemodynamically stable, next investigation is X-ray abdomen
  • Blunt injury of abdomen by RTA with established Airway & stable respiration , Blood collection for cross matching & IV fluid adminisration is the next line of management
  • In Renal injury following blunt injury to abdomen management will include Diagnostic peritoneal lavage,IVP,Exploratory laparotomy
  • Preferred incision for abdominal exploration in Blunt injury abdomen is Always Midline incision
  • Blunt injury abdomen, patient was hemodynamically stable, next investigation is FAST

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