Abdominal Trauma Management

Abdominal Trauma Management - Belly Blow Basics

• Types: Blunt (e.g., MVA, falls) vs. Penetrating (e.g., GSW, stab).
• ATLS Approach: Primary survey (ABCDE - Airway, Breathing, Circulation, Disability, Exposure) is paramount.
• Hemodynamic Instability Signs: SBP < 90 mmHg, HR > 120 bpm, altered mental status, cool peripheries, ↓ urine output.

⭐ Kehr's sign (referred left shoulder pain due to diaphragmatic irritation) often indicates splenic injury or hemoperitoneum.

Abdominal Trauma Management - Scan & Scope

• Laparoscopy: Diagnostic/therapeutic in stable patients (penetrating trauma: peritoneal violation).
• DPL Contraindications: Prior surgeries, coagulopathy, pregnancy (relative).

⭐ The FAST exam primarily detects free intraperitoneal fluid, not specific organ injuries.

Abdominal Trauma Management - Trauma Theatre Tactics

• Rapid Sequence Intubation (RSI):
  • Induction: Ketamine (1-2 mg/kg) or Etomidate (0.3 mg/kg) for unstable patients.
  • Paralytic: Succinylcholine (1-1.5 mg/kg) or Rocuronium (1.2 mg/kg).
• Anesthesia Maintenance: Ketamine, low MAC volatiles; prioritize hemodynamics.
• Fluid Resuscitation:
  • Crystalloids initially.
  • Permissive Hypotension: Target SBP 80-90 mmHg (avoid in TBI).
• Massive Transfusion Protocol (MTP):
  • Activate for uncontrolled hemorrhage.
  • Ratio: PRBC:FFP:Platelets 1:1:1 (📌 Mnemonic: "One Big Family Plate").
• Tranexamic Acid (TXA):
  • Loading: 1g IV over 10 min, then 1g over 8 hrs.
  • Administer within 3 hours of injury.
• Temperature Management: Maintain normothermia (>35°C); use fluid warmers, forced air.

⭐ Early administration of Tranexamic Acid (TXA) within 3 hours of injury reduces mortality in bleeding trauma patients.

Abdominal Trauma Management - Patch & Pray

Damage Control Surgery (DCS) for exsanguinating patients with the "lethal triad":

• 📌 AHC:
  • Acidosis: pH < 7.2
  • Hypothermia: Temp < 35°C
  • Coagulopathy: INR > 1.5 / PTT > 60s
• DCS Phases:
  • 1. Abbreviated laparotomy (control hemorrhage/contamination).
  • 2. ICU resuscitation (correct physiology).
  • 3. Planned re-laparotomy for definitive repair.
• Temporary Abdominal Closure (TAC): e.g., Bogota bag, vacuum-assisted closure.
• Anesthetic Goals: Aggressive resuscitation, permissive hypotension (initially), prevent further heat loss, manage coagulopathy.

⭐ The 'lethal triad' of acidosis, hypothermia, and coagulopathy is a key indication for initiating damage control surgery.

Abdominal Trauma Management - Gut Reactions

• Splenic Injury: Management based on AAST spleen injury scale (Grade I-V); non-operative common. Anesthetic: Prepare for massive transfusion, large-bore IV access.
• Liver Injury: AAST liver injury scale (Grade I-VI); Pringle maneuver (hepatic inflow occlusion) for hemorrhage. Anesthetic: Coagulopathy, massive transfusion protocol.
• Bowel/Mesenteric Injury: Signs of peritonitis (rigidity, guarding), ↑sepsis risk. Anesthetic: RSI, early antibiotics.
• Pancreatic/Duodenal Injury: Often retroperitoneal, diagnosis challenging. Anesthetic: Vigilance for associated injuries, fluid resuscitation.

⭐ Blunt duodenal injuries are often missed on initial FAST and CT, requiring high index of suspicion for delayed presentation or unexplained sepsis.

High‑Yield Points - ⚡ Biggest Takeaways

• Damage Control Resuscitation (DCR): permissive hypotension, hemostatic resuscitation (1:1:1), damage control surgery.
• Early activation of Massive Transfusion Protocol (MTP) is critical for ongoing hemorrhage.
• Prevent and treat the lethal triad: hypothermia, acidosis, and coagulopathy.
• FAST scan is the initial imaging modality for detecting hemoperitoneum.
• Anticipate difficult airway; Rapid Sequence Intubation (RSI) often needed, secure C-spine.
• Exploratory laparotomy is the gold standard for uncontrolled intra-abdominal bleeding.
• Vigilance for Abdominal Compartment Syndrome (ACS), especially post-resuscitation_._