Abdominal Trauma

Initial Approach - Belly Bruises & Bleeds

• ABCDE (ATLS): Prioritize airway, breathing, circulation. Control external hemorrhage.
• Abdominal Exam:
  • Inspect: Bruises (seatbelt, Cullen's, Grey Turner's), distension, wounds.
  • Auscultate: Bowel sounds (absent/↓ in peritonitis/ileus).
  • Palpate: Tenderness, guarding, rigidity, rebound.
  • Percuss: Dullness (hemoperitoneum), tympany.
• Key Indicators of Intra-abdominal Bleed:
  • Shock: Tachycardia, SBP < 90 mmHg, cool peripheries.
  • Positive abdominal findings.
  • Falling Hb/Hct.
• Diagnostic Adjuncts:
  • FAST: For unstable patients, detects free fluid.
  • CT Scan: Gold standard in stable. Details organ/retroperitoneal injury.
  • DPL: If FAST unclear/unavail in unstable. Positive: >10mL blood, specific counts.

⭐ Seatbelt Sign: Indicates major force; high risk: bowel, mesenteric, lumbar spine (Chance #) injury.

Investigations - Scan, Scope, or Slice?

Guided by stability & mechanism.

• Unstable Patient:
  • eFAST: Initial.
    • Positive (hemoperitoneum) → Immediate Laparotomy ("Slice").
    • Negative/Equivocal → DPL, or resuscitate & repeat eFAST. CECT if transiently stable.

  • ⭐ Unstable blunt trauma + positive eFAST mandates direct laparotomy, avoiding imaging delays.

• Stable Patient:
  • eFAST: Initial screen.
  • CECT Abdomen/Pelvis (Scan): Gold standard. Details injury, grade, active bleed (extravasation), retroperitoneum.
  • Laparoscopy (Scope):
    • Select penetrating trauma (anterior stab, tangential GSWs) for peritoneal/diaphragmatic assessment.
    • Diagnostic & therapeutic.
• Diagnostic Peritoneal Lavage (DPL):
  • Rare; if CECT/eFAST unavailable.
  • Positive: >10mL gross blood aspirated; lavage: RBC >100,000/mm³, WBC >500/mm³.

Organ-Specific Injuries - Gut Reactions & Repairs

• General Principles: Control hemorrhage, prevent contamination. Repair vs. Resection & Anastomosis vs. Diversion. Damage Control Surgery (DCS) for unstable patients.
• Small Bowel Injury (Most common):
  • Blunt (e.g., seatbelt sign, associated Chance fracture) or penetrating.
  • Hematoma (non-expanding, intact serosa): Observation.
  • Perforation: Primary repair (transverse closure).
  • Multiple injuries close together / devitalized segment: Resection & anastomosis.
• Large Bowel Injury:
  • Higher septic risk due to bacterial load.
  • Management based on stability, contamination, time, location:
    • Stable, minimal contamination: Primary repair or resection & anastomosis.
    • Unstable, gross contamination, left colon: Hartmann's procedure (resection, end colostomy, rectal stump closure).
    • Right colon: Right hemicolectomy & ileocolic anastomosis often feasible even with contamination.
• Stomach Injury:
  • Rich blood supply, good healing.
  • Management: Debridement & 2-layer primary repair.
• Duodenal Injury (Retroperitoneal, high risk):
  • Often occult; Kocher maneuver for exposure.
  • Hematoma: NG decompression, TPN; surgery if obstruction persists >1-2 weeks.
  • Perforation (simple): Primary repair.
  • Complex (D1/D2, >75% circumference, tissue loss): Pyloric exclusion + gastrojejunostomy (PE GJ).

  ⭐ Unexplained retroperitoneal air/fluid on CT, or persistent ↑serum amylase post-trauma, warrants high suspicion for duodenal injury.

• Rectal Injury:
  • Intraperitoneal: Primary repair (like colon).
  • Extraperitoneal: Proximal diversion (colostomy), presacral drainage, direct repair if accessible. 📌 3 D's: Diversion, Debridement, Drainage (distal washout controversial).

Special Considerations - Crisis Control & Aftermath

• Damage Control Surgery (DCS): For "triad of death" (acidosis, hypothermia, coagulopathy).
  • Phase 1: Control hemorrhage/contamination, temporary abdominal closure.
  • Phase 2: ICU resuscitation (correct physiology).
  • Phase 3: Definitive surgical repair.
• Abdominal Compartment Syndrome (ACS):
  • Intra-abdominal pressure (IAP) > 20 mmHg + new organ dysfunction.
  • Tx: Urgent decompressive laparotomy.
• REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta): For non-compressible torso hemorrhage. Zone 1 (supraceliac) / Zone 3 (infrarenal).
• Key Complications: Sepsis, ARDS, MODS. Crucial: VTE prophylaxis.

⭐ ACS mortality can be > 50% if decompressive laparotomy is delayed.

High-Yield Points - ⚡ Biggest Takeaways

• Spleen is most injured in blunt trauma (BAT); small bowel/liver in penetrating (PAT).
• FAST scan for hemoperitoneum in unstable patients; CT scan for stable patients.
• DPL for unstable patients if FAST unclear; >10 mL gross blood is positive.
• Exploratory laparotomy for unstable patients with positive FAST/DPL or evisceration.
• Seatbelt sign indicates high risk of hollow viscus injury & Chance fracture.
• Kehr's sign (left shoulder pain) suggests splenic injury.