Abdominal traumaAbdominal trauma

Complex lesions

In only 40% of cases trauma is isolated in the abdominal wall

Combination of organ affected is extreme– Intraperitoneal (solid or hollow organs)– Retroperitoneal

Mechanism of trauma

Direct effect – weapon directly affects the abdominal viscera

Kinetic effect: acceleration or deceleration of the abdominal viscera: weight of the intra-abdominal viscera is multiplied by acceleration

Counter hit on the bony structures in proximity.

Complex lesions

One organ – an exception Complexity means:

– Organs in the same or different anatomical regions

– Multiple trauma / Multiple contusion

Emergency evaluation

ANY traumatized patient should be ragrded as serious until proven different

ATTENTION associated unapparent lesion my be more important then those obvious to clinical investigation

Lesions have to be graded according to their potential risk .

Information from friends, relatives or witnesses – with much care and suspicion

FORENSIC MEDICINE legal aspect are crucial Alcohol consumption

RESUSCITATION

ABC Priority

– Respiratory resuscitaion

– Cardiovascular stability

History taking Moment of aggression Aggressor (relative position to the victim) Weapon Patient’s position on impact Physiologic status of the digestive tract

(stomach) and urinary tract (bladder) Essentials on intestinal transit and urinary

function before and after trauma

History History of present disease

– What happened from the moment of trauma until presentation (there could be hours or days)

– Past medical problems: all very important– Certain pathologies may have additional

significance• Enlarged spleen (diverse cause) may be accessible

to direct trauma and may be more friable• Hernia of any kind• Previous surgical incisions• etc

History taking Previous diseases

– May appear as unessential but can change the course of diseases and produce significant changes in therapy

• Respiratory problems

• Cardiovascular problems

• Allergies

• Liver dysfunction

• Renal failure

• Diabetes

Clinical evaluation Inspection

– Deformities of the general shape of the abdomen

– Aspect of the abdominal muscles: if contracted should suggest peritonitis

– Abdominal movements with respiration and cough

– Anemia– Posttraumatic changes on the skin (impact site

as a mark of trauma, seroma, hematoma, and so on )

Clinical examination Palpation:

– Hypersensiblity of the skin – Pain induced by superficial or deep palpatin– Tumor mass in the structure of the abdominal

wall or in the abdominal cavity – Abdominal guarding

Clinical examination Auscultation

– Absence of intestinal sounds – reflex mechanism (spine injuries) or irritation (abdominal sepsis or hemoperitoneum)

Percution– Free air in peritoneal

cavity– Free liquid in the

peritoneal cavity

Abdominal wall Abdominal wall contusioncontusion

Nonspecific – like all contusions of the soft tissues

Ecchymosis : – Traumatic signature of the

weapon– Immediate after trauma –

superficial injuries– Late – deep structure are

affected– May be at a significant

distance from the impact area – migration of a hematoma by dissection in the soft tissues

Hematoma

Pseudo-tumor mass – accumulation of blood Large lumen vessels Presentation

– Diffuse– Cyst– Pulsating – arterial wound – EMERGENCY

Essential sign – crepitation Possible central fluctuation – liquefaction of the

clot

Special forms of Special forms of abdominal traumaabdominal trauma

Hematoma – rectus abdomini

rupture

Anatomic particularities:– Fascial intersections that

segment the muscle– Rectus sheet– Abundant network of

vessels , large vessels inside the sheet

Hematoma is well circumscribed, in tension, developed between two intersections.

During contraction of the wall: painful and does not disappear inside the abdomen.

Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis.

Hematoma –psoas muscle

rupture

Anatomic particularities:– Situated deep in

retroperitneum– Adjacent to branches from the

lumber plexus (crural, femurocutaneous, ilio-hypogastric and ilio-inguinal)

Developed in the retroperitoneum and behaves like a deep situated tumoral mass, not well circumscribed, immobile over deep structures.

Disappears during abdominal wall contractions

Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis

May appear spontaneous

SeromaMorel-Lavallee

Small vessels injury with spontaneous hemostasis – tangential trauma with shearing mechanism

Develops in time, but does not feel the entire space available = fluctuence not always present

Usually normal skin Will be absorbed in time, sometimes requiring

aspiration

Rupture of the diaphragm

Indirect mechanism via an acute increase in abdominal pressure

Direct mechanism – crushing the base of the thorax

False herniation of abdominal viscus in the thorax. (false = no peritoneum)

Respiratory problems due to intrathoracic compression

Digestive problems – difficult to evaluate in a trauma patient with more serious lesions.

Traumatic diaphragmatic hernia

Posttraumatic hernia

Early or late complication of trauma BREAK IN THE MUSCULAR-FASCIAL

LAYER – may be obscured by gravity of initial trauma

In time it develops like a true hernia through a new week point

Symptoms are very similar to all postoperative hernia BUT no scar

Abdominal woundsAbdominal wounds

Classification

Superficial Penetrate

– Perforated

20% of all peace time abdominal trauma

90% of all war time abdominal trauma

Wounds and contusions can be present inthe same time

Non-penetrated abdominal wounds

Diagnostic is essential = lack of penetration

Intact serosal layer – difficult to appreciate especially in a blunt trauma with a wound

DIAGNOSTIC CRITERIA

Anamnesis – Weapon and trajectory – Relative position of aggressor and victim – Direction of the weapon as it hits– Physiologic status– Number of wounds

Local examination

Gentle, after a careful antiseptic preparation of the skin and wound

Use a blunt gentle instrument to probe the wound If not a simple stab wound (that is complex

wounds with non-linear trajectory) the information will always be incomplete. ATTENTION to strata movements between impact and examination

An examination with a negative result is not necessary conclusive

General examination of the abdomen

Look for signs and symptoms suggestive for penetrating and perforated wound

Monitor the clinical status of the patient – that is safe in the case of a negative evaluation (regarding a probable superficial wound) – Admit patient for hospital care for at least 24

hours

Lab exams

Their purpose is to identify signs of major syndromes related to the peritoneal cavity– Peritonitis– Hemorrhage– Intestinal obstruction– Acute pancreatitis

• According to type of wound and trajectory

Surgical evaluation of the abdominal cavity

In this case IT IS a method of EXPLORATION– Laparotomy– Laparoscopy MAJOR LIMITS

• Check the integrity of the peritoneal surface• Check the integrity of viscus• Check for fluid in periteneum TYPE

Andominal exploration should be as complete as possible – HOW MUCH IS COMPLETE

TAKE GOOD CARE

Any abdominal wound (even very small or apparently without significance) can be penetrated. MINIMAL ACCESS SURGERY

A small wound can be accompanied by a big disaster in the abdomen.

Initial evaluation can be misleading

Penetrated wounds

All the abdominal wall has been penetrated (including the parietal peritoneum) but no viscus in injured :– PROTOTYPE: first trocar in laparoscopic

approach It is not common – more frequent with stab

wounds Exploration – same methods

Clinical evaluation

Wound exploration: – How much the instuments can be inserted in

comparison with the width of the abdominal wall = RELATIV

– Is the probe free to move? = RELATIVA

If the wound is large enough abdomina viscus can herniate outside = DIAGNOSTIC

Significance

Major risk for a viscus injury, even if not apparent

Major risk to err due to absence of clinical manifestation at presentation

Risk of infection of the peritoneal cavity In traumatic evisceration – risk of

strangulation

Indications for operation Perforations not conclusive excluded Traumatic evisceration Non-perforant character questionable

(patient unconscious)– Laparotomy– Laparoscopy

Perforated wounds

Symptoms depend on viscus involved and time interval from lesion (25-35% multiple organs affected)

Dg obvious when in the wound– Digestive content OR colonic content OR

blood in quantity larger then we expect ?????– Symptoms develop in time – check for

patients condition

Major clinical presentation

Peritonitis Intraperitoneal

hemorrhage Intestinal

obstruction Upper GI

bleeding Pancreatitis

PERITONITISPERITONITIS

Acute peritonitis

Essentials for diagnostic

Abdominal pain, vomiting, fever, altered general status

Abdominal guarding, localized or generalized abdominal pain. Rebound pain.

LATE – abdominal distension – paralitic ileus

Increased WBC Free fluid in the abdominal cavity

Etiology – extremely diverse

Infections = by far the most frequent – GI tract perforations– GI tract necrosis- ORIGIN: perforation of any cavity with septic content

(urinary, genital, abscesses secondary opened in the free cavity iatrogenic, etc)

Chemical irritation– Perforated ulcer

Primary peritonitis – no cause (diabetes, liver cirrhosis, etc)

Clinical evaluation General signs are dominant

Nausea Vomiting Altered status High fever – septic

fever

WBC Changes in electrolyte

balance

Abdominal signs

Spontaneous abdominal or pain induced by palpation– Localized or generalized– Signs of peritoneal irritation (vibrations transmitted to

parietal peritoneal layer elicit pain)• Pain during coughing• Pain on sudden decompression• Pain on percussion

– Pelvic peritonitis: pain on pelvic or vaginal examination. Rectal examination is essential

Abdominal signsAbdominal guarding

– Muscles adjacent to inflamation becomes spastic

– In generalized peritonitis ABDOMINAL RIGIDITY

– Rigidity disappears in :• Late aspects of peritonitis• Major toxic states• Unusual cases with abdominal wall with no

tonicity

ABDOMINAL SIGNS Paralitic ileus

– Peritoneal inflamation inhibits intestinal motility

– Cardinal signs:• Low amplitude or no

intestinal sounds

• Meteorism

• Passage of flatus or feces stopped

• Vomiting

ABDOMINAL SIGNSAir in the

abdominal cavity– NO pre-hepatic

dullness– Atention:

• Situs inversus

• Chiliaiditi syndrome

ABDOMINAL SIGNS

Imagistic– Plain X-Ray of the abdomen

• Pneumoperitoneum • Air-fluid levels• Thick bowel wall

– CT – may develop the cause in certain cases

Paracentesis – liquid in the abdomen – type of fluid can give a clue + bacteriological examination

Differential diagnosis

Intestinal obstruction Localized infections

(acute cholecystitis) Pancreatitis Renal colic Pneumonia (inferior lobe)

Porphyry Fever of other origin ISTERIA Insect byte Retroperitoneal

hematomas Neurological disorders:

– Spinal injuries– Syphilis of the spinal cord

CONCLUSIONS

Essentials of diagnostic are based on CLINICAL DATA

Signs suggestive for peritoneal irritation JUSTIFY an aggressive surgical exploration