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Closed Abdominal Injuries
Classification of Abdominal trauma Penetrating trauma
solid viscera injury Blunt trauma hollow viscera injury
Injuries from blunt trauma are more common and more difficult to assess
Mechanism of closed abdominal injury Deceleration forces from motor vehicle accidents
or falls may tear organs from their points of fixation
e.g. liver, bladder, gutA steering wheel or other solid object striking the
abdomen may disrupt any of the organs that cross the vertebral column
e.g. pancreas, duodenum, vena cava
Characteristic features of different organ injuries Parenchymal organ injury hollow organ injury liver, spleen, kidney stomach, intestine, gallbladder
internal hemorrhage acute peritonitis
pulses BP abdominal tenderness
abdomen soft rigidity
tenderness not clearly rebound tenderness
rebound tenderness obvious diminishing of liver dullness
presence of shifting dullness
Diagnosis—whether there is viscus damage
Repeated frequent examination is essential
Get the history of injuries
symptoms:abdominal pain, vomiting, nausea,
blood stained stool, hematuria,
management after injury
Physical examination
BP, pulses, temperature, abdominal tenderness,
rigidity, rebound tenderness, diminishing of liver
dullness, presence of shifting dullness and alter-
nation of bowel sound, P.R examination
Laboratory findings
intraabdominal bleeding: RBC Hb
WBC pancreatic injury: amylase in urine and blood
The early symptoms of abdominal injuryShock, especially hemorrhagic shock.
Severe constant abdominal pain, nausea, vomiting
and signs of acute peritonitis.
Shifting dullness present and diminished liver dullness
Vomiting of blood, passing bloody stool or urine
PR examination: tenderness, pulsating swelling may be detected and there maybe blood on gloves
X-ray examination of the chest and abdomen
Abdominal puncture
valuable in difficult cases
Diagnostic Peritoneal lavage(DPL)
more reliable technique , accurately reflects the
presence of significant visceral damage in about
95% of cases
Additional diagnostic modalities
Ultrasonography noninvasive, can detect hemoperitoneum and solid organ injury
CT scan --- highly accurate diagnostic modality Hemodynamically stable patient with an equivocal abdominal examination Patient with closed head injury Patient with spinal cord injury Hematuria in the stable patient Patient with pelvic fractures and significant bleeding
• Observation
If the patient still can not be diagnosed with
the above methods, the patient must be kept in
hospital under strict observation until the
diagnosis can be made clearly.
The rules of management during observation Absolute rest Restricting of diet and intravenous infusion Don’t use morphe or any sedatives Measuring BP, pulse rate, respiratory rate and temperature at definite intervals repeat abdominal examination and blood count If there is any doubt of gastric perforation, gastric
suction and antibiotics should be used
• Performing exploratory laparotomy if necessary Indication:
Increased tenderness or rigidity or distension
Evidence of continuing blood loss that can not
be clearly explained by extraabdominal source
Evidence of developing peritonitis
The presence of free air on X-ray
Enlarging of intraabdominal mass
Demonstration of blood, bile, intestinal
contents in abdominal puncture
High amylase level in abdominal fluid
In the presence of shock with increasing
abdominal rigidity and an inadequate
response to fluid replacement
Treatment principleKeep the airway free
Circulatory resuscitation
laparotomy
Control of hemorrhage, in extreme cases thoracotomy required
Contamination from lacerations of the gut should be stopped as quickly as possible
spleen injury Spleen is the most commonly injured intra-
abdominal organ
Splenic injury must be suspected in any patient
with blunt abdominal trauma, especially with left
lower rib fracture
Diagnosis is suspected on physical examination,
and confirmed by abdominal CT scan or explora-
tory laparotomy for hemoperitoneum
TreatmentSplenorrhaphy or partial resection
Total splenectomy hilar vascular injury
massive subcapsular hematoma
extensive fragmentation
total avulsion
severe associated injuries
continuing bleeding after attempted splenic repair
Nonoperative management
delayed spleen rupture must be considered
due to enlarging subcapsular hematoma
rupture of a traumatic
pseudoaneurysm
recurrent or ongoing hemorrhage
Liver and Biliary Tree The second most commonly injured organ following blunt traumaInjury is ofen minor and can be easily managed by direct suture ligation or by using hemostatic agents
Seven basic techniques in operationSutureInflow occlusionPacking Hepatic artery ligation ResectionMesh hepatorrhaphyAtrial-caval shunting
Common bile duct injuryCompletely transection or >50% injured
biliary-enteric anastomosisPerforated or <50% injured
primary repair and place a T-tube
Cholecystostomycholecystectomy
Gallbladder injury
Stomach injury Gastric rupture secondary to blunt
trauma is rare Iatrogenic gastric rupture vigorous ventilation with an endotracheal
tube misplaced in the esophagus
If vomitus or gastric aspirate is bloody, stomach injury should be suspected
At laparotomy, gastrocolic omentum must be widely opened for complete inspection
Treatment
Debridement and closureGastric diversion or resection is
rarely necessary
Small intestion injury Incidence 5% -- 15% MechanismCrush injury between the vertebrae
and anterior abdominal wallSudden increase of intraluminal
pressureTear at the junction of a mobile and a
fixed segment of bower
TreatmentSimple laceration --- suture, avoid excessive
narrowing of the bowelExtensive damage or multiple tears situated
fairly close --- resection of the involved segment
Colon injuryMost colon injuries can only be definitively
recognized at laparotomy.
Early diagnosis and treatment dramatically reduce infection complications.
Four tecniques in the managementPrimary repairResection and primary anastomosisExteriorization of repair colostomy
Guidelines of repair instead of colostomyOperation within 4 to 6 hoursLess than 6 units of blood transfusionNo evidence of prolonged shock or
hemodynamic instabilityMinimal soilage of peritoneal cavityInjury limited to one aspect of the colonNo associated colonic vascular injuryNo loss of abdominal wall
Rectum injuryAbdominal x-ray films are obtained for
the determination of retroperitoneal airProctosigmoidoscopy performed for
either direct visualization of the injury or for the evidence of hemorrhage
Transpelvic gunshot wounds should undergo celiotomy
TreatmentFull thickness rectal wounds above the
dentate line --- primary closure combined with a diverting colostomy
Wounds below the dentate line --- debridement accompanied by drainage
Wounds above the levators with penetration of the pelvirectal space Closure, if possibleProximal diverting colostomyPresacral (retrorectal) drainageIrrigation of the rectal stump