Trauma! Abdominal Injuries

aka Trauma Tribulation 020

Post coauthor: Peter Allely

The cannonball man from Trauma Tribulation 019 is getting prepared for transfer to the CT scan. You still suspect a significant abdominal injury. Do you know how to recognise and manage the most common and important intrabdominal organ injuries in the ED?

Questions

Q1. How would you recognize and manage injuries to the spleen?

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:

Q2. How would you recognize and manage injuries to the liver?

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:

Q3. How would you recognize and manage injuries to the duodeneum?

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:

Q4. How would you recognize and manage injuries to the small intestines?

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:

Q5. How would you recognize and manage injuries to the pancreas?

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:

Q6. How would you recognize and manage injuries to the diaphragm?

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:

References

  • 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.
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Comments

  1. F says

    Excellent post Chris and Peter. Avid reader/lurker here.

    As an aside, I was recently told that patients with spleen injury can present with reflex bradycardia due to haemoperitoneum and vagal stimulation (as classically, or allegedly, occurs in ectopic pregnancy). I’d never heard of it before, and a quick PubMed search didn’t yield any supporting evidence… any thoughts?

    • says

      Bradycardia is common in many types of hemorrhagic shock. What we learn in medical school is often incorrect!

      One theory is that there are 2 phases:
      1) inital catacholamine surge with tachycardia, followed by
      2) subsequent bradycardia of uncertain mechanism (?parasympathatic mediated)
      But there also seems to be a group of patients who have relative bradycardia -- they fail mount the initial tachycardia. Some have also noted that bradycardia is more common in acute rapid blood loss.
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC344269/

      Some have explained the bradycardia as being due to vagal stimulation from peritoneal stimulation in intra-abdominal hemorrhage, but bradycardia has been seen in penetrating extremity trauma too.
      http://www.ncbi.nlm.nih.gov/pubmed/2310066

      IT has also been noted that bradycardia has a better prognosis in traumatic hemorrhage, rather than being preterminal as is classically taught.
      http://www.ncbi.nlm.nih.gov/pubmed/9751546

      Hope that helps,
      Chris

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