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Injuries to the Abdominal Wall and Organs

  • Major surgical emergency
  • Commonly associated with head, chest, pelvic and bone injuries
  • Difficult to diagnose as patient is often unconscious
  • AAST (American Association for the Surgery of Trauma) Injury Scale
    • Most commonly used injury scoring grades are for liver, kidney, spleen, pancreas

Types

  • Blunt – spleen most commonly affected
  • Penetrating – liver most commonly affected
    • Low velocity – stab wounds
    • High velocity – gunshot

Etiology

  • Road traffic accidents – seatbelts decrease risk of head injury, but present a risk for abdominal organs
  • Gunshot wounds – penetrate peritoneum, causing significant damage to major structures

Pathophysiology

  • Can be life threatening as abdominal organs can bleed profusely
  • Solid organs e.g. liver and kidneys bleed a lot
  • Hollow organs e.g. stomach are not as likely to bleed, but more prone to infection

Liver injuries

  • Liver is the most vulnerable abdominal organ to injury
  • Serious risk for shock – tissue is delicate and has large blood supply
  • Can be lacerated, contused with haematoma
  • Severe injury – exsanguination requiring emergency blood

Spleen injuries

  • Most common cause of massive bleeding in blunt traumas
  • Ruptured spleen can lead to life threatening shock

Pancreatic injuries

  • Relatively rare organ to be injured
  • However, when injury does occur it has a high mortality rate due delayed diagnosis and treatment
  • Delayed diagnosis is common as pancreatic injuries are subtle to identify
  • Most evident findings of pancreatic injuries -post-traumatic pancreatitis with blood, edema, and soft tissue infiltration

Kidney injuries

  • Causes bloody urine
  • A kidney with multiple lacerations can cause fragmentation of kidney tissue

Bowel injuries

  • Small intestine most likely to be damaged in penetrating injury
  • Causes perforation and gas in cavity
  • Associated complications – infection, abscess, bowel obstruction and fistula

Abdominal compartment syndrome

  • Occurs when intra-abdominal pressure exceeds 20mmHg
  • Can occur as a result of severe abdominal trauma, sepsis or peritonitis
  • Can lead to oliguria, respiratory failure and cardiac arrest if abdomen is not decompressed

General clinical features

  • Features of shock – pallor, tachycardia, hypotension, cold peripheries, sweating, oliguria
  • Abdominal distension
  • Pain, tenderness, rebound tenderness, guarding, rigidity, dullness in flank
  • Respiratory distress, cyanosis
  • London’s sign – abrasion over the abdominal skin suggests possible visceral injury
  • Features of specific organ injuries

Investigations

  • US Abdomen – FAST (Focused Assessment with Sonography for Trauma)
    • Rapid, noninvasive, bedside investigation of pericardium, splenic, hepatic, pelvic areas
  • Diagnostic peritoneal lavage (DPL) – for blunt injury of abdomen
    • Through catheter saline/Ringer’s solution infused into peritoneal cavity
    • Patient is changed to different positions
    • Fluid content aspirated from the abdomen to assess for presence of free blood, leukocytes
  • CT, laparoscopy

Treatment

Follow protocol for assessment of major trauma (e.g. road collisions, falls from height)

  • Airway control – suction, chin lift
  • High flow oxygen
  • Cervical spine control
  • IV fluids
  • Analgesia
  • Antibiotics – prophylactic IV antibiotics for compound fractures/penetrating wounds
  • Advanced trauma life support (ATLS)
    • Primary survey – Airway, Breathing, Circulation, Disability (neurological status), Exposure
    • Secondary survey – head to toe examination to identify other injuries

Surgery

  • Emergency laparotomy
    • Indications – frank haemoperitoneum, significant DPL, haemodynamically unstable patient, significant intra-abdominal injuries on CT/US
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