ABDOMINAL INJURIES And the management of

Abdomen

1. ABDOMINAL INJURIES

2. Why is it important All patients with MULTIPLE INJURIES / UNCONSCIOUS PATIENTS are potential patients for ABDOMINAL injuries Initial assessment is often difficult and inaccurate. Initial assessment is often compromised by alcohol intoxication, illicit drugs, brain and spinal cord injury and adjacent rib and spine injuries

3. WHEN TO SUSPECT?? High speed motor vehicle accidents Fall from height Penetrating wounds between nipple and perineum Explosions All UNCONSCIOUS trauma victims

4. TYPES

5. PENETRATING INJURIES CAUSES

6. BLUNT INJURIES MECHANISM Abdominal pressure rupture /burst injury of hollow organ Crushing effect Acceleration/Deceleration forces shear injury Seat belt injuries

7. ORGANS INJURED

8. ASSESMENT ABC

9. ASSESSMENT Airway with cervical spine stabilisation Maintain proper breathing and ventilation Assessment of hemodynamic stability is the most important initial concern Check pulse, BP, Pulse pressure CRT,diaphoresis,cold clammy skin, SpO2 etc

10. HISTORY Mechanism of injury Time of injury Response to initial treatment Extent of vehicular impact Fate of co-passengers Use of seat belts and air bag deployment

11. INITIAL ASSESSMENT Inspection : distension/bruises/contusion/laceration/ evisceration, entry and exit wound in bullet injuries. Palpation: tenderness, rebound tenderness, gaurding rigidity, crepitus Percussion : obliteration of liver dullness Auscultation: bowel sounds + / -

12. INSPECTION DISTENSION Pneumoperitoneum Flank Ecchymosis /Gray Turner’s sign Retroperitoneal Hemorrhage Umbilical Ecchymosis / Cullen’s sign Retroperitoneal Hemorrhage Evisceration of contents Other organ injury Abdominal wall contusions Internal organ injury Lacerations Internal organ injury Entry and exit wounds /Bullet injury Internal organ injury

13. ASSESMENT- contd Assessment of pelvic stability -should be done only once Urethral, perineal , rectal examination including per rectal examination. Vaginal examination in females. Gluteal examination.

14. ASSESSMENT- contd LOG ROLL to be done to rule out posterior/ Spinal injuries

15. ACTION Two large bore IV cannula to be inserted and 1-2 litres of warm crystalloid fluids given. Send investigations including blood grouping and cross matching. NG tube insertion-look for blood in the aspirate Pelvic binder-in pelvic injuries. Appropriate antibiotics to prevent intra abdominal sepsis Catheterisation to monitor urine output

16. RELEVANT INVESTIGATIONS Upright chest x ray including domes of diaphragm. FAST Supine abdominal x ray. X ray pelvis-AP view. CT scan- in haemodynamically stable. Contrast studies as and when indicated . Rule out pregnancy in female patients.

17. 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 Extended FAST (E-FAST): Add thoracic windows to look for pneumothorax and hemothorax .

18. Pitfalls of FAST A Negative fast does not rule out intra-peritoneal injury Pelvic view should be obtained prior to insertion of foley’s catheter FAST is difficult in patients with extensive subcutaneous emphysema and obesity Pelvic fracture may decrease the efficacy of FAST

19. Imaging Plain films: fractures – nearby visceral damage free intraperitoneal air Foreign bodies and missiles

20. Imaging Computed tomography Accurate for solid visceral lesions and intraperitoneal hemorrhage and retroperitoneal injuries. guide nonoperative management of solid organ damage IV not oral contrast

21. Diagnostic Peritoneal Lavage Largely replaced by FAST and CT In blunt trauma , used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examination In stab wounds , for immediate dx of hemoperitoneum , determination of intraperitoneal organ injury in stable pt with fascial penetration.

22. Diagnostic peritoneal lavage Done by open and closed technique Considered positive if the aspirate contains more than or equal to 1,00,000 RBCs/mm3 More than 500 WBCs/mm3 Positive gram stain for food debris, bacteria

23. Management of blunt injury

24. Management of penetrating injury

25. INDICATIONS FOR EMERGENCY LAPAROTOMY 1.Bladder rupture 2.Clinical deterioration during observation 3.Free air on x-ray 4.Hemoperitoneum findings on FAST 5.Hypotension despite adequate resuscitation 6.Hypotension with evidence of abdominal injury 7.Diaphragmatic injury 8.Signs of peritonitis 9.Evisceration of abdominal contents

26. Non operative management Close monitoring of vital signs Repeated reassessment

27. SCENARIO 1 A young man was brought to emergency after he was hit accidently in left upper abdomen while practicing taekwondo. He was semi conscious and complained of pain abdomen.

28. ASSESSMENT Patient semi conscious,RR-22/min,pulse-140/min,bp-90/60mmhg. P/A –distended, tenderness in left hypochondrium . Bony crepitus over left lower rib,sluggish bowel sounds. Provisional diagnosis-blunt injury abdomen ? splenic injury.

29. ACTION FAST to determine presence of blood in abdominal cavity. X ray chest. IV fluids-2 wide bore cannula . Arrange adequate blood. Urgent surgical consult. Transfer if surgical facilities not available. NG tube aspiration. Urinary catheterisation. Injection TT and broad spectrum antibiotics.

30. HIGHLIGHTS Mechanism of injury with hemodynamic instability is suggestive of hemoperitoneum with splenic injury. Positive FAST with hemodynamic instability –urgent laparotomy .

31. Take home Early hemorrhage control is mandatory in hemodynamically unstable patients. Do not wait for unnecessary investigations. Arrange blood and proceed with laparotomy to control ongoing abdominal hemorrhage .

32. SCENARIO 2 A young lady was brought to ED after involved in a road traffic accident. she was not wearing seat belt properly. She is complaining of pain abdomen.

33. ASSESSMENT Conscious ,RR-18/min,PR-90/MIN,BP-110/76mmhg. P/A-bruises over anterior abdominal wall, guarding, rigidity present, rebound tenderness present, liver dullness obliterated, bowel sounds absent. Provisional diagnosis- bowel injury with peritonitis ? Bowel perforation.

34. ACTION X ray chest Nil oral, IV fluids Urinary catheterisation. Broad spectrum antibiotics. Arrange adequate blood. Urgent surgical consultation.

35. HIGHLIGHTS Mechanism of injury with feature of peritonitis suggest bowel injury. Urgent laparotomy is indicated.

36. TAKE HOME Inappropriately worn seat belt with bruises over abdominal wall is suggestive of “bucket handle injury” of bowel. Signs of peritonitis mandates laparotomy in this case

37. Scenario 3 A 35yrs old lady [20weeks pregnant]was stabbed in right lower chest by a chain snatcher. She was brought to ED by police and complaining of shortness of breath and pain over the chest and abdomen.

38. Assessment Conscious, RR 24/min, PR-100/min, BP-110/70 Stab wound in right 9 th ICS Chest –right side hyper-resonant note with absent breath sounds. left chest was normal. Trechea in midline and no neck vein engorgement Abdomen – rt hypochondrail tenderness, uterus 20 weeks size, FH PRESENT, BS sluggish CXR –right simple pneumothorax FAST- positive

39. Action IVF through two large bore canual Resuscitate with 1 to 2 litres of warm RL Right ICD insertion Surgical consult for hemoperitoneum Obstetrician consult

40. Highlights Penetrating lower chest injury with typical clinical and radiographic findings clinch the diagnosis

41. Take home In penetrating injuries below nipple line (4 th ICS) –consider possibility of intra abdominal injury Positive FAST with hemodynamic stability -can be managed non operatively

42. Conclusion Assessment of abdominal trauma remains challenging High index of suspicion ,systematic examination and few simple diagnostic tests can clinch the diagnosis Early surgical consultation and transfer is mandatory for better outcome