Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
ABCDE of trauma
Airway management
Airway management techniques
Ventilation (breathing) management
Circulatory management
Circulatory resuscitation measures
Secondary surgery
Chest trauma
Abdominal trauma
Head trauma
Spinal trauma
Neurological trauma
Limb trauma
Special trauma cases
Transport of critically ill patients
Trauma response
Activation plan for trauma team
Primary Trauma Care Manual | Abdominal trauma
 

 

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.
Gunshot
Stabbing


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.



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