Abdominal Trauma, Blunt and Penetrating
Express ER’s Main Campus Site has Emergency Care near you. We are trained and ready to treat abdominal trauma whether it is blunt or penetrating.
When you are brought into our Emergency Service near you, we will assess any abdominal trauma to identify if it is of an immediate life-threatening emergency on the initial assessment or a delayed threat on life on the secondary review.
Here is the order in which we work with abdominal trauma:
- Primary survey
- Secondary survey
- Diagnostic evaluation
- Definitive care
Any trauma to the abdomen can be classified as penetrating or blunt, and after the assessment is completed the management is altered accordingly.
THE BLUNT INJURY of the ABDOMEN
A blunt injury to the abdomen is usually managed conservatively, but the use of interventional radiology and maybe surgery will be indicated with the severe injuries.
- Some of the forms of the standard mechanisms for blunt injury are falls, assaults, sports injuries, and automobile crashes.
- The organs that are usually affected are the: liver, large and small intestine, and spleen.
THE PENETRATING INJURY of the ABDOMEN
Patients who suffer from significant injuries that are penetrating usually require at least a laparotomy; it is mostly defined by the projectiles encountered like stabbings or gunshot wounds.
- If the wound is located between the line of the nipple (T4) and the creases of the groin anteriorly, and then from T4 to the iliac crests curves posteriorly is an abdominal injury.
- If the wound was made by a projectile, then that injury in the abdomen could be caused by an entry wound in about any part of your body.
There are four areas of the abdomen to be checked thoroughly in a penetrating injury:
- Thoracoabdominal area
- The Anterior Abdomen which lies between the anterior axillary lines; bound by the groin crease distally and the costal margin superiorly.
- The area that is superiorly delimited by your fourth (anterior) intercostal space, (lateral) sixth intercostal space, (posterior) and eighth intercostal space, and (inferiorly) delimited by the costal margin (however, definitions vary – there is a pragmatic approach for using the nipple line as your upper boundary – in the non-obese man). Injuries in this region seem to increase the chances of the mediastinal, chest, and diaphragmatic injuries.
- Flank Area – is from the lower part of the costal margin superiorly to the iliac crests being bound anteriorly by the front axillary line and posteriorly by the back axillary line.
- Flanks – From the lower costal margin superiorly to the iliac crests; that is bound in the front by the front axillary line and posteriorly by the back-axillary line.
- Back – lies between the back-axillary lines and extends from the costal margin to the iliac crests.
ASSESSING BLUNT ABDOMINAL TRAUMA
When you are about to evaluate the patient for blunt abdominal trauma during the initial survey the following steps should be followed:
- Work as a team with a systematic approach where you are prioritizing, identifying, performing immediate treatments, and delaying life-threatening situations.
- Watch the pelvic and abdominal injuries as they can cause life-threatening hemorrhage.
- When the abdomen is examined initially, perform it during the initial evaluation, with the theory of “Find Bleeding, Stop Bleeding.”
- Activate massive transfusion procedure if indicated
Secondary survey (during this phase watch for indications of need for emergency laparotomy)
- seat belt
- lap belt: 30% chance for the patient to have suffered mesenteric or intestinal injury
- retroperitoneal hemorrhage: ecchymosis of the periumbilical area and the flanks
- genital and perineum
- fullness: hemorrhage
- crackles or rales of the lower rib cage: splenic or hepatic injury
- peritonism: leakage with ruptured viscus
- vaginal or rectal examination
- Order a trauma series (e.g., pelvis XR, c-spine XR, CXR)
- Order a trauma blood series (e.g., LFTs, UEC, FBC, coags, lipase, type and hold, BHCG)
- Imaging at the bedside for the FAST scan, if hemodynamically stable and the imaging is warranted do =/- Ct of the abdomen.
- Insert gastric tube and IDC (indwelling catheter)
RADIOLOGY FOR BLUNT ABDOMINAL TRAUMA
If physical signs are absent, that is an indication for a need to take to emergent laparotomy, use imaging to see if the laparotomy is indicated, prioritize, recognize, and guide the managing of other injuries.
Diagnostic peritoneal lavage (DPL)
- DPL is rarely performed now due to the introduction of the ‘FAST’ Focused Assessment with Sonography in Trauma scan. Its main role is when ‘FAST’ and CT are unavailable or during mass casualty situations.
CT of ABDOMEN and PELVIS
- Used for hemodynamically stable patients
- definitive imaging with CT Abdomen/pelvis is performed in the hemodynamically stable when an emergency laparotomy is not indicated, and one of the following is present:
- Trauma patients who have abdominal tenderness
- Trauma patients with altered sensation
- Distracting injuries or injuries that are adjacent to structures
- Identifies specific anatomical structures that are injured, allows the grading of severity
- Concurrent imaging of other body areas is frequently indicated after the images of the initial reports have been received
- Images of the retroperitoneal structures
- Provides images of the spine and skeletal structures
- A blush of IV contrast is a strong predictor of failure of non-interventional management
- The patient usually must leave the ED
- Patient transfers are time-consuming
- Requires IV contrast and risk-averse reactions
- Radiation exposure
- Less sensitive with pancreatic, diaphragmatic and hollow viscus injuries
- Poor retrieval of the patient while the scanner is going should patient deteriorate
- Requires additional skilled staff (CT radiographers and radiologists)
PENETRATING ABDOMINAL TRAUMA ASSESSMENT
In patients with a penetrating injury of the abdomen, if immediate emergency laparotomy is not needed then when the patient is stabilized we must answer a couple of questions that serve as crucial decision intersections to guide our approach:
- Does the wound penetrate the peritoneum?
- Is there intraperitoneal organ injury?
Only two-thirds of stab wounds of the abdomen anteriorly violate the peritoneum, but only half require surgical intervention.
Assessment for peritoneal penetration:
- local wound exploration — involvement of abdominal fascia is considered a positive result.
- CXR — peritoneal penetration is confirmed by free air under the diaphragm, but the absence of free air does not rule it out
- Ultrasound —penetration of peritoneum is established by free fluid in the abdomen or some evidence of abdominal fascia damage, but lack of these findings does not rule it out
- DPL — is pretty invasive and not specific for any injuries requiring operative intervention. It may be used if an ultrasound is not available and some like it for thoracoabdominal wounds.
If the fascia is intact (i.e., all the above are negative, except peritoneal penetration):
- the wound can be cleaned and closed in the ED
- If there are no other concerns, the patient may be discharged
If local wound exploration is inadequate and abdominal fascia injury cannot be excluded, or there is proof of peritoneal penetration, then further probing should be done to assess for intraperitoneal injury.
IMAGING & EXPLORATION OF PENETRATING ABDOMINAL INJURIES
- While this is like the blunt abdominal trauma, there should also be a team approach to identify, prioritize, and immediately treat the life-threatening situations a patient is faced with that could be a delayed situation at times.
If an emergency lap is not indicated, two options are left for identifying intraperitoneal injury:
- CT abdomen
- direct laparoscopy
CT of the abdomen (which is 97% sensitive for peritoneal injury) is usually performed to look for evidence of any peritoneal penetration or intraperitoneal injury:
- free air
- free fluid
- bowel wall thickening
- wound tracts adjacent to a hollow viscous solid organ injury
An alternative in some emergency centers is a direct laparoscopy, which is most of the time performed for left thoracoabdominal wounds to avoid the risk of diaphragmatic injury (17%) and may allow the repair.