63. Injuries to the abdominal wall and the abdominal organs.

Question 1

Location of abdominal injuries can be to the

Answer 1

1. Ab wall
2. Organs
3. Vasculation

Question 2

Abdominal Organs can be

Answer 2

a. Solid organs: liver, spleen, pancreas, kidney

b. Hollow organs: stomach, SI, colon, ureters, bladder

Question 3

Classification of Abdominal Trauma

Answer 3

1. Open (penetrating)
   a. Stab wounds. Gunshot to damage intra ab strictures

b. Can cross diaphragm

In Penetrating open trauma: both parietal layers are disrupted

In Non-penetrating open trauma: no damage to organs or parietal layers. Subcutaneous damage

2. Closed (blunt)
   a. Direct blow e.g. kick

b. Impact with object – e.g. fall on bicycle bas
c. Sudden deceleration – fall from height

Question 4

Abdominal Injury - Most injured organs

Answer 4

Spleen – liver – hollow organs such as small intestine

Question 5

Abdominal Injury - Least injured organs

Answer 5

The retroperitoneal wall, pancreas and kidney

Question 6

Abdominal Injury - Clinical Presentation

Answer 6

• Shock – hemodynamic due to bleeding, skin is pale, cold, increased peripheral resistance, decreased Hct
• Peritonitis – trauma of SI, LI, stomach, liver + spleen
• Eusceration (removal of viscera) – when injury of ab wall >3cm
• Bowel obstruction, biliary leak, abscess, intestinal ischaemia
• Kidney – renal insufficiency
• Lungs – increased intra pressure – decreased breathing – hypoxaemia
• CVS – increased intra pressure – decreased VR from lower extremities = hypotention
• Multi organ dysfunction

Question 7

Abdominal Injury - Diagnostic Investigations

Answer 7

CT (gold standard)

US

MRI

Diagnostic peritoneal lavage (DPL) – test if blood in peritoneum
o >100,000 RBC/μL = +ve. Equivalent to 20ml of free blood in peritoneum

• Focused Abdominal Sonar for Trauma (FAST)
  o Detects free fluid only detectable if >100ml
  o Diagnostic laparoscopy

Question 8

Abdominal Injury - Parenchymal aka Solid organs Trauma

Answer 8

spleen and liver injuries result in bile in peritoneum aka biliary peritonitis

x-ray not in lateral position – perforation of duodenal ulcer lie on left (pt position when doing x-ray) – air goes to right paracolic gutter)

a. Rapture of capsule of all organs
b. Laceration damage to parenchyma
c. Hematoma
d. 24-48hrs = develop haemusperitoneum
i. 24-48hrs after this = peritonitis

e. Labs = increased WBC, normal RBC (initially) then decrease
i. Blood loss = anaemic syndrome is loss >500ml

Question 9

Abdominal Injury - Hollow Organs Trauma

Answer 9

Trauma to stomach + intestine

a. Clinical pic = similar to peptic ulcer
b. Rupture of organ causes stercoral peritonitis aka perulant peritonitis . This results in faecal contamination of peritoneal cavity

Question 10

Abdominal Injury - Retroperitoneal organ trauma

Answer 10

Pancreas + kidney

a. Trauma to pancreas = pancreatitis
i. head + body pancreatitis occurs due to pressure/compression = sudden deceleration

b. Trauma to the Kidney – rapture = forms heavy retroperitoneum phlegmon
i. laceration of renal artery
ii. Tx = nephrectomy

Question 11

Abdominal Injury - Aorta trauma

Answer 11

Die on impact

a. Normal blood vol = 5L-6L
i. If you lose 2L instantly this means death

b. Algovers shock index (sensitive indicator of LV disfunction) = HR / (systolic arterial BP – (riva-rocci)
i. Normal = 0.5-0.7
ii. >0.9 = critical ill, poor outcome

Question 12

Management: Of Gunshot wounds

Answer 12

Exploratory laparotomy – EXCEPT in RUQ

Question 13

Management: of Stab wound

Answer 13

Assess haemodynamic stability

i. Stable: digital exploration with gloved finger – if inconclusive findings = CT
ii. Unstable: exploratory laparotomy

Question 14

Management of Blunt trauma

Answer 14

Assess hemodynamic stability

i. Stable: CT
ii. Unstable: FAST
1. +ve = laparotomy
2. Inconclusive = DPL - direct peritoneal lavage