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ABDOMINAL AND

PELVIC TRAUMASalwa Malik

ST6 Emergency Medicine

Objectives

• Anatomy of the Abdomen

• Mechanisms of Abdominal injury

• Examination of the Abdomen and Pelvis

• Adjuncts used in assessment

• When to do a laparotomy

• Pelvic fractures and management

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Important points

• Unrecognised abdominal and pelvic injury continues to be

a cause of preventable death after truncal trauma.

• Significant blood loss can be present in the abdominal

cavity without any dramatic change in appearance or

dimensions and without any signs of peritoneal irritation

Anatomy of the Abdomen

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Retroperitoneal Anatomy:

Aorta, IVC, most of duodenum, pancreas, KUB, asc and

desc colons, rectum, female reproductive organs

Mechanisms of Injury

• Blunt

• Penetrating

• Explosion

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Types of Blunt trauma

• Direct blow

• E.g. intrusion of car door

• Compression and crushing

• Deform solid organs -> rupture

• Shearing

• Form of crushing

• Safety devices

• Deceleration injuries – movement of fixed and nonfixed parts of

body e.g. liver and spleen

• Airbag deployment = can still have abdominal injury!

Blunt trauma

• Spleen (40-55%)

• Liver (35-45%)

• Small bowel (5-10%)

• 15% incidence of retroperitoneal haematoma in patients who undergo laparotomy for blunt trauma

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Penetrating Trauma

• Stab wounds

• Low kinetic energy

• Liver, small bowel, diaphragm, colon

• Low-velocity v high-velocity gunshot wounds

• LV -> laceration and cutting; HV -> more damage

• Based on trajectory, cavitation effect, bullet fragmentation

• Small bowel, colon, liver, abdominal vasculature

• Explosions

• Combined blunt and penetrating

• Blast injuries – injuries obtained depends on distance/closed area

Assessment – history…be nosey!

• RTC

• Speed of vehicle

• Type of vehicles involved

• Type of collision

• Intrusion

• Safety devices – wearing seatbelts, airbags deployed

• Self-extricated?

• Patient’s position

• Status of passengers

• Penetrating trauma

• Time of injury

• Type of weapon

• Distance from patient (more distance, less damage)

• Number of wounds

• Amount of external bleeding at scene

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Assessment - Examination

• Full exposure

• Inspection

• Palpation

• Percussion

• Auscultation

• Don’t forget perineum!

• 50% incidence of significant transabdominal injuries

Assessment of Pelvis

• Findings suggestive of pelvic fractures

• Evidence of ruptured urethra:

• High riding prostate

• Scrotal haematoma

• Blood at urethral meatus

• Limb length discrepancy

• Rotational deformity of leg

PELVIS MANIPULATION CAN BE DETRIMENTAL – DO

NOT TOUCH!

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Adjuncts to Examination

• Gastric tube• Decompress stomach

• Remove gastric contents

• Reduce aspiration

• Blood indicates injury to GI tract

• DO NOT DO NASALLY IN BASILAR SKULL FRACTURES/FACIAL INJURIES – can be done ORALLY ONLY in these cases

• Urinary catheter• Relieve retention

• Decompression

• Assessing C

• Gross haematuria -> trauma to GU tract -> retrograde urethrogram to confirm intact urethra before catheterising. Otherwise SP catheter.

Adjuncts to Examination

• FAST Scan

• Hepatorenal

• Splenorenal

• Pericardial sac

• Pelvis

• XRAYs

• Chest and pelvis

• CT

• ONLY FOR HAEMODYNAMICALLY STABLE PATIENTS and NO

IMMEDIATE INDICATION FOR EMERGENCY LAPAROTOMY

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What does “Snow White and the 7 Dwarfs” really represent?

FAST v CT

FAST Scan

• Early diagnosis• Non invasive• Rapid• Repeatable• 86-97% sensitive• Portable• Operator dependent• Misses diaphragm, bowel,

pancreatic injuries• Negative scan does not

exclude pathology• For unstable blunt trauma

CT Scan

• Most specific for injury

• 92-98% specific

• Non-invasive

• Cost and time

• Contrast

• Misses diaphragm, bowel and some pancreas injuries

• Needs transportation

• Stable blunt trauma and penetrating back/flank trauma

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Who needs a laParotomy?

• Perforation

• Peritonism

• Protuding contents

• Penetrating wounds

• Positive FAST/CT

• …& haem unstable patients with blunt abdominal

injury

-> immediate exploratory laparotomy

Specific Injuries

• Diaphragm

• Left hemidiaphragm more commonly injured

• Look for elevation/blurring/NG tube in chest on CXR

• Confirm with laparotomy

• Duodenal

• Unrestrained drivers, bicycle handlebars

• Bloody gastric aspirate, retroperitoneal air

• Double contract CT

• Pancreatic

• Early normal amylase does not exclude

• Direct epigastric blow

• Double and triple contrast CT

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Specific Injuries

• Genitourinary

• Direct blows to back, flank -> ecchymoses, haematomas

• Gross haematuria

• Abdominal CT with contrast

• Anterior pelvic fractures cause urethral injuries

• Posterior - multisystem trauma

• Anterior - straddle impact

• 95% treated non-operatively

• Hollow viscus (intestines)

• Blunt injuries, deceleration

• Transverse linear ecchymoses (seatbelt sign) or lumbar “Chance”

fracture

• Solid organ

Pelvic trauma

• 1) AP compression (Open Book)

• E.g. Fall from height, ped v car, direct crush to pelvis

• Disruption of symphysis pubis -> haemorrhage

• 2) Lateral compression

• E.g. RTC

• Internal rotation of involved hemipelvis

• Not life-threatening haemorrhage

• 3) Vertical shear

• E.g. Fall

• High energy force

• Majorly unstable and haemorrhage

• 4) Complex (combination)

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Open Book (AP) Fracture

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Lateral Compression Fracture

Vertical Shear Fracture

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Complex pelvic fracture

Management of Pelvic fractures

• ABC…Haemorrhage control!

• Binders/splints

• Moving away from these

• Angiographic embolisation

• But if intraperitoneal blood -> laparotomy first

• Haemorrhage control fixation device

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Questions?

Conclusion

• Be nosey!

• Be thorough!

• Don’t touch pelvis!