Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Abdominal Trauma
 


> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER


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.
Figure 6.11
Figure 6.11

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.
Figure 6.12
Figure 6.12

Figure 6.13

Figure 6.13


Figure 6.14
Figure 6.14

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.
Figure 6.15

Figure 6.15

 

Figure 6.16
Figure 6.16


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.



Top of Page

> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  Kep Points  
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

 
Suspect intra-abdominal bleeding in cases of multiple trauma, especially if hypotension is unexplained

 
In the presence of hypovolaemia, the chest, pelvis and femur are alternative sites of major blood loss.

 
  Paediatric cases
 
Many blunt abdominal injuries can be managed without operation

 
Non-operative management is indicated if the child is haemodynamically stable and can be monitored closely

 
Place a nasogastric tube if the abdomen is distended, as children swallow large amount of air.
 
 














 

 

 

 

 

 

 

Kep Points

 
  Diagnostic peritoneal lavage:

 
Is indicated when abdominal finding are equivocal in the trauma patient

 
Should not be performed if there are indications for immediate laparotomy

 
Should be performed only after the insertion of a nasogastric tube and Foley catheter

 
Is rapid, sensitive and inexpensive

 
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

 
Gross evaluation of the returned fluid must be performed and decisions made on that evaluation if laboratory evaluation is not available

 
Ignore a negative result on diagnostic peritoneal lavage if the patient subsequently develops an acute abdomen: trauma laparotomy is then indicated.