Trauma! Abdominal Injuries

Recognition

• Most commonly injured organ in blunt abdominal trauma
• Abdominal pain, localized tenderness (LUQ)
• Possible hemorrhagic shock
• CT abdomen with IV contrast is the investigation of choice (spleen injuries are graded I to V according to severity)

Management

• Most hemodynamically stable injuries can be managed non-operatively (especially Grades I to III)
• Injuries involving the hilum or avulsion often require surgery (Grade IV or V)
  — hemodynamic instability is the only real contra-indication to conservative management
• Angiography with embolization should be considered if:
  — a contrast blush is seen on CT
  — AAST grade > III
  — moderate hemoperitoneum is present
  — evidence of ongoing bleeding

Learn more here:

• Trauma Professional’s Blog — Delayed Spleen Rupture: Part 1 and Part 2
• Trauma Professional’s Blog — Splenic Vascular Blush
• Trauma Professional’s Blog — Grading Spleen Injuries Simplified
• Trauma Professional’s Blog — EAST Guidelines Update: Spleen Injury

Recognition

• Most commonly injured organ in penetrating abdominal trauma
• Abdominal pain, localized tenderness (RUQ)
• Possible hemorrhagic shock
• CT abdomen with IV contrast is the investigation of choice (liver injuries are graded I to VI according to severity)

Management

• Most hemodynamically stable injuries can be managed non-operatively
• Angiography with embolization should be considered if:
  — a contrast blush is seen on CT
  — evidence of ongoing bleeding
• Operative management may initially adopt a damage control approach with simple packing only followed by definitive procedure when haemodynamically stable
• Interventional modalities may be used to treat complications such a biloma, hepatic abscess, etc (e.g. ERCP, percutaneous drainage, laparoscopy)

Learn more here:

• Trauma Professional’s Blog — EAST Guidelines Update: Liver Injury

Recognition

• Suspect in unrestrained drivers in frontal impact MVC and in patients who sustain direct blows to the abdomen, e.g. from bicycle handle bars.
• Abdominal pain and tenderness
• Bloody gastric aspirate
• Retroperitioneal air on abdominal x-ray or CT abdomen
• Can be confirmed by double contrast CT abdomen

Management

• Resuscitation
• Surgical repair via laparotomy

Learn more:

• Trauma Professional’s Blog — What’s the Diagnosis #1? The Answer

Recognition

• Clinical signs can be minimal initially
• Usually a deceleration injury (e.g. MVC with lap belt)
• May involve bowel wall and / or mesenteric avulsion with subsequent intraperitoneal bleeding and devascularisation of bowel
• Coexistent lumbar distraction fracture (Chance fracture) may be present
• An abdominal seatbelt sign mandates definitive imaging
• May be missed on early FAST scan and CT abdomen — DPL or repeat examination may be required

Management

• Surgical repair

Learn more:

• Trauma Professional’s Blog — Bucket Handle Injury Part 1 and Part 2
• Trauma Professional’s Blog —Seat Belt Sign

Recognition

• Classically from a direct blow, e.g. motorbike handlebars
• Abdominal pain +/- vomiting
• Double contrast CT abdomen and amylase / lipase may initially be normal

Management

• Usually conservative, rarely surgical exploration and repair are needed

Learn more:

• Trauma Professional’s Blog — Bicycle handlebar injury to the epigastrium

Recognition

• More common in penetrating trauma — suspect if wound tract may extend between T4 and T12 levels
• Suspect also in severe blunt trauma (e.g. abdominal crush injury, ejection)
  — respiratory distress if left-sided
  — deep visceral pain if right-sided
• Most commonly posterolateral left hemidiaphragm, as liver diffuses force and protects the right diaphragm
• Chest x-ray may be normal or show:
  — elevation or “blurring” of the hemidiaphragm
  — hemothorax
  — an abnormal gas shadow that obscures the hemidiaphragm
  — the gastric tube being positioned in the chest.

Management

• Decompress stomach with a gastric tube
• Laparotomy for repair, laparoscopy may be performed first.

Learn more:

• Trauma Professional’s Blog — What’s wrong in this photo? The Answer
• Trauma Professional’s Blog — Practical tips on Diaphragm Injury
• litfl.com — Trauma Tribulation 004: A Fiendish Finding

• Fildes J, et al. Advanced Trauma Life Support Student Course Manual (8th edition), American College of Surgeons 2008.
• Kozar RA, Feliciano DV, Moore EE, Moore FA, Cocanour CS, West MA, Davis JW, McIntyre RC Jr. Western Trauma Association/critical decisions in trauma: operative management of adult blunt hepatic trauma. J Trauma. 2011 Jul;71(1):1-5. Review. PubMed PMID: 21818009
• Legome E, Shockley LW. Trauma: A Comprehensive Emergency Medicine Approach, Cambridge University Press, 2011.
• Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice (7th edition), Mosby 2009. [mdconsult.com]
• Moore FA, Davis JW, Moore EE Jr, Cocanour CS, West MA, McIntyre RC Jr. Western Trauma Association (WTA) critical decisions in trauma: management of adult blunt splenic trauma. J Trauma. 2008 Nov;65(5):1007-11. PubMed PMID: 19001966.
• Raikhlin A, Baerlocher MO, Asch MR, Myers A. Imaging and transcatheter arterial embolization for traumatic splenic injuries: review of the literature. Can J Surg. 2008 Dec;51(6):464-72. Review. PubMed PMID: 19057735; PubMed Central PMCID: PMC2592580.