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Trauma to the abdomen occurs as an isolated injury or associated
with high energy polytrauma. The principles of primary
trauma care include the abdominal evaluation as a part
of the acute resuscitation protocol, see Unit 16: Acute
Trauma Management and the Annex: Primary Trauma Care Manual.
When a patient presents with abdominal injuries, give priority
to the primary survey:
| 1 |
Establish
a clear airway. |
| 2 |
Assure
ventilation. |
| 3 |
Arrest
external bleeding. |
| 4 |
Set
up an intravenous infusion of normal saline or Ringer’s
lactate. |
| 5 |
Insert
a nasogastric tube and begin suction and monitor output. |
| 6 |
Send
a blood sample for haemoglobin measurement and type and
crossmatch. |
| 7 |
Insert
a urinary catheter, examine the urine for blood and monitor
the urine output. |
| 8 |
Perform
the secondary survey: a complete physical examination
to evaluate the abdomen and to establish the extent of
other injury. |
| 9 |
Examine
the abdomen for bowel sounds, tenderness, rigidity and
contusions or open wounds. |
| 10 |
Administer
small doses of intravenous analgesics, prophylactic antibiotics
and tetanus prophylaxis. |
If the diagnosis of intra-abdominal bleeding is uncertain,
proceed with diagnostic peritoneal lavage. Laparotomy is indicated
when abdominal trauma is associated with obvious rebound, frank
blood on peritoneal lavage or hypotension and a positive peritoneal
lavage. Serial physical examination, ultrasound and X-rays
are helpful in the equivocal case. Repeated examination is
an important means of assessing the indeterminate case. Even
experienced practitioners should seek the opinion of colleagues
to aid in evaluating equivocal abdominal findings and the inexperienced
practitioner should not hesitate to do so. X-ray the chest,
abdomen, pelvis and any other injured parts of the body if
the patient is stable. If you suspect a ruptured viscus, a
lateral decubitus abdominal X-ray may show free intraperitoneal
air.
Diagnostic peritoneal lavage
After the primary survey, resuscitation and secondary survey
have been completed, the findings indicating intra-abdominal
bleeding or lacerated viscera may not be adequate to confirm
diagnosis. Serial physical examination can be supplemented
with diagnostic peritoneal lavage (DPL) to make a decision
on whether trauma laparotomy should be performed. The availability
of computerized axial tomography in referral centres has reduced
the use of DPL, but it is not obsolete and should be available
at the district hospital.
Technique
| 1 |
Infiltrate
a local anaesthetic with epinephrine (adrenaline) into
the abdominal wall and peritoneum at an infra-umbilical
site (Figure 6.11). The epinephrine reduces abdominal
wall bleeding.
|
|
| 2 |
Make
a 2.5 cm midline incision which is carried down through
subcutaneous tissue to the linea alba (Figure
6.12).
Apply counter traction to the fascia of the linea alba
with two stay sutures and make a 3–5 mm incision
through the fascia (Figure 6.13). Gently introduce a
catheter on a stylet into the peritoneum and advance
the catheter over the stylet into the pelvis (Figure
6.14).
|
Spontaneous
return of blood or gross aspiration of blood is an indication
for laparotomy.
|
|
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|
| 3 |
If
no blood is returned, infuse 20 ml/kg (1 litre in adults)
of intravenous solution (saline or Ringer’s lactate)
through the catheter (Figure 6.15). Attach the catheter
to a closed container and place on the floor. About 100
ml of fluid should flow back into the container (Figure
6.16). If the returning fluid has greater than 100000
red cells per ml or 500 white cells per ml, consider
performing a laparotomy. |
|
|
The red and white blood cell count can be determined in
the laboratory along with an examination for bacteria and
amylase. When laboratory evaluation is not available, the
approximate laparotomy threshold can be determined by looking
at the clarity of the fluid. If you cannot read “newsprint” through
the siphoned back solution due to the red colour, there
is sufficient blood to indicate the need for a laparotomy.
If the fluid is cloudy due to particulate material, it
is likely that there is a bowel injury and laparotomy is
also indicated.
Penetrating injuries
| :: |
Penetrating
injuries follow gunshot wounds and wounds induced by
sharp objects such as knives or spears |
| :: |
Laparotomy
with intra-abdominal exploration is indicated when the
abdomen has been penetrated, regardless of the physical
findings
|
| :: |
Signs
of hypovolaemia or of peritoneal irritation may be minimal
immediately following a penetrating injury involving
the abdominal viscera. |
Blunt injuries
| :: |
Blunt
injuries result from a direct force to the abdomen without
an associated open wound; they most commonly follow road
traffic accidents or assaults |
| :: |
Following
blunt injury, exploratory laparotomy is indicated in
the presence of:
– Abdominal pain and rigidity
– Free abdominal air, seen on a plain X-ray (lateral decubitus or upright
chest)
|
| :: |
Following
blunt abdominal trauma, signs that may indicate intra-abdominal
bleeding include:
– Referred shoulder pain
– Hypotension |
| :: |
Oliguria
associated with suprapubic pain suggests bladder rupture. |
Injuries to the diaphragm
| :: |
Penetrating
trauma to the upper abdomen and lower chest can result
in small perforations to the diaphragm which can be closed
with simple or mattress 2/0 sutures |
| :: |
Blunt
trauma can result in a large rent in the left diaphragm
(the liver protects the diaphragm); the presence of viscera
in the chest, identified by auscultation or chest X-ray,
is diagnostic. |
|
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| |
 |
|
 |
Abdominal trauma is classified as
blunt or penetrating
|
 |
|
Intra-abdominal bleeding or gastrointestinal perforation
may be present without any evidence of abdominal wall injury
|
|
|
Intra-abdominal bleeding may be confirmed by peritoneal
lavage with saline, but a negative result does not exclude
injury, particularly in retroperitoneal trauma
|
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Suspect intra-abdominal bleeding in cases of multiple
trauma, especially if hypotension is unexplained
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|
In the presence of hypovolaemia, the chest, pelvis and
femur are alternative sites of major blood loss.
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Paediatric cases
|
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Many blunt abdominal injuries can be managed without
operation
|
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Non-operative management is indicated if the child is
haemodynamically stable and can be monitored closely
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Place a nasogastric tube if the abdomen is distended,
as children swallow large amount of air.
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Diagnostic peritoneal lavage:
|
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|
Is indicated when abdominal finding are equivocal in
the trauma patient
|
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Should not be performed if there are indications for
immediate laparotomy
|
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Should be performed only after the insertion of a nasogastric
tube and Foley catheter
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Is rapid, sensitive and inexpensive
|
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Diagnostic peritoneal lavage may rule out significant
abdominal trauma in the district hospital where the patient
may otherwise be unobserved and unmonitored for extended
periods of time
|
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Gross evaluation of the returned fluid must be performed
and decisions made on that evaluation if laboratory evaluation
is not available
|
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Ignore a negative result on diagnostic peritoneal lavage
if the patient subsequently develops an acute abdomen:
trauma laparotomy is then indicated.
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