BLUNT TRAUMA ABDOMEN
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
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
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
Assessment of hemodynamic stability
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.
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:
Signs of peritonitis
Uncontrolled shock or hemorrhage
Clinical deterioration during observation
Hemoperitoneum findings on FAST or DPL
Preferred incision for abdominal exploration in Blunt injury abdomen is Always Midline incision
Based on CT scan diagnosis and the hemodynamic stability of the patient, as follows:
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
Splenic artery embolotherapy, although not standard of care, may be used for adult blunt splenic injury
Nonoperative management involves closely monitoring vital signs and frequently repeating the physical examination & IV fluid administration