The
abdomen is commonly injured in multiple trauma. The liver
is the commonest organ injured in penetrating trauma. In blunt
trauma, the spleen
is often torn and ruptured.
The initial evaluation of the abdominal trauma patient must
include:
| A |
Airway
and cervical spine |
| B |
Breathing |
| C |
Circulation |
| D |
Disability
and neurological assessment |
| E |
E
xposure. |
Any
patient involved in any serious accident should be considered
to have an abdominal injury until proved otherwise. Unrecognized
abdominal injury remains a frequent cause of preventable death
after trauma.
There are two basic categories of abdominal trauma.
| 1 |
Penetrating
trauma where surgical consultation is important: e.g.
|
| 2 |
Non-penetrating
trauma: e.g.
| • |
Compression |
| • |
Crush |
| • |
Seat
belt |
| • |
Acceleration/deceleration
injuries. |
|
About
20% of trauma patients with acute haemoperitoneum (blood
in abdomen) have no signs of peritoneal irritation at the
first examination and the value of a repeated primary
survey cannot be overstated.
Blunt trauma can be very difficult to evaluate, especially
in the unconscious patient. These patients may need a peritoneal
lavage. An exploratory laparotomy may be the best definitive
procedure if abdominal injury needs to be excluded.
Complete physical examination of the abdomen includes rectal
examination, assessing:
| • |
Sphincter
tone |
| • |
Integrity
of rectal wall |
| • |
Blood
in the rectum |
| • |
Prostate
position. |
Remember
to check for blood at the external urethral meatus.
Deep penetrating foreign bodies should remain in situ until
theatre exploration.
Women of childbearing age should be considered pregnant until
proven otherwise. A shocked pregnant mother at term can usually
be resuscitated properly only after delivery of the baby. The
fetus may be salvageable and the best treatment of the fetus
is resuscitation of the mother.
DIAGNOSTIC PERITONEAL LAVAGE (DPL)
Diagnostic peritoneal lavage (DPL) may help in determining
the presence of blood or enteric fluid due to intra-abdominal
injury. The results can be highly suggestive, but a negative
result does not rule out intra-abdominal injury. If there is
any doubt, a laparotomy is still necessary.
Indications for diagnostic peritoneal lavage include:
| • |
Unexplained
abdominal pain |
| • |
Trauma
of the lower part of the chest |
| • |
Hypotension,
systolic 90 mmHg, haematocrit fall with no obvious explanation |
| • |
Any
patient suffering abdominal trauma and who has an altered
mental state (drugs, alcohol, brain injury) |
| • |
Patient
with abdominal trauma and spinal cord injuries |
| • |
Pelvic
fractures. |
The
relative contraindications for lavage are:
| • |
Pregnancy |
| • |
Previous
abdominal surgery |
| • |
Operator
inexperience |
| • |
If
the result does not change your management. |
OTHER SPECIFIC ISSUES WITH ABDOMINAL TRAUMA
Pelvic fractures are often complicated by massive haemorrhage
and urology injury.
| • |
Examining
the rectum for the position of the prostate and for the presence
of blood or rectal or perineal laceration is essential |
| • |
X-ray
of the pelvis, if clinical diagnosis is difficult. |
The
management of pelvic fractures includes:
| • |
Resuscitation
(ABC) |
| • |
Transfusion |
| • |
Immobilization
and assessment for surgery |
| • |
Analgesia. |
Pelvic fractures often cause massive blood loss.
|
