The Initial Assessment

and Evaluation of
Abdominal Trauma
Tanya L. Zakrison
Trauma & Acute Care Surgery
St. Michaels Hospital
Sept. 20th, 2011

Objectives
How to recognize the trauma patient
with an abdominal injury
Anatomy

How to manage the patient with an

abdominal injury in the initial stage
Damage control resuscitation

How to evaluate the abdomen

Different modalities & whole body pan scan

Guidelines
European & EAST

Case 1 - Blunt Abdominal

Trauma
45F, high-speed MVC
Seat-belt sign, HD normal
How would you approach this patient?
How would that change if the pt. is HD
abnormal?
What if the patient also had a pelvic fracture?

Case 2 - Penetrating Abdominal

Trauma
23M, stab wound to anterior abdomen, HD
normal
How would you approach this patient? GSW?
How would that change if the patient is HD
abnormal?
What if the patient was stabbed in the flank?
The back? The thoracoabdominal area?
Cardiac box?

ATLS Approach
A intubation may be required if
hypotensive
B watch H/PTX in both blunt and
penetrating TAA injuries
C start with 2 L crystalloid, may need
to activate MTP MUST FIND & STOP
THE BLEEDING
D may see associated thoracolumbar
#s with BAT
E watch for SBS, other injuries

What is Hemodynamic
Normality?

Base deficit
lactate

Shock?
Rapid responder (20%)
Transient responder
(30%)
Non-responder (>30%)
Hypotension in the field
ATLS - 2L warmed
crystalloid (3:1)
Blood products as needed
Tranexamic acid (antifibrinolytic)
Follow urine output

The Lethal Triad of Death

More Complicated Than

Anticipated Acute
Coagulopathy of Trauma Shock

25% of trauma patients present coagulopathic

Damage Control
Resuscitation

Permissive hypotension
1:1:1 resuscitation (pRBCs, platelets,
FFP)
Damage control surgery
Stop the bleeding (pack)
Control the contamination
Definitive surgical anatomical
restoration later

Initial Resuscitation The Bottom

Line?
Identify what is
bleeding:
4 & on the floor
1. Chest
1. CXR

2. Intraperitoneal
abdomen
1. FAST

3. Retroperitoneal
abdomen
1. PXR, CT scan

4. Extremities (femur #s)

1. XRs

Then stop it:

OR
Angioembolization
Tourniquet
Reduction & stabilization

Very little to do in the

trauma bay prior to
OR if HD abnormal:
Intubate
CXR
Group & screen

If crashing:
Bilateral chest tubes

If dying:
ED thoracotomy

Get to OR ASAP

Initial Management of the Bleeding

Patient European Guidelines; CC
Recommendation 1:

2007

That time elapsed between injury and operation be

minimized for pts. In need of urgent surgical control
(grade1A)

Recommendation 2:
That a grading system be used to assess the clinical extent
of hemorrhage (ACS COT)

Recommendation 3:
pts. presenting in hemorrhagic shock AND an identified
source of bleeding undergo an immediate bleeding control
procedure UNLESS initial resuscitation measures are
successful

Recommendation 4:
pts. with an unidentified source of bleeding in hemorrhagic
shock should undergo immediate further assessment

Recommendation 5:
Trauma pts. should be resuscitated initially with crystalloid
to a BP of 80-100 mmHg in the absence of TBI

Tanyas guidelines:
Find what is bleeding
then stop it

Patient in Extremis = ED
Thoracotomy

The Abdomen
Thoracoabdominal area
Transverse nipple line to
costal margin

Anterior abdomen

Costal margin to groin

crease to anterior axillary
lines bilaterally

Flank area

Anterior axillary line to

posterior axillary line,
costal margin to iliac
crests

Back

Medial to posterior
axillary lines, tip of
scapula to iliac crests

Torso

All the above

Cardiac Box

Mediastinum

Thoracoabdominal area

The Abdomen is More Than Just

the Abdomen
Abdomen:
Intraperitoneal cavity

Clinical exam
FAST
DPL
CT scan
Exploratory
laparoscopy
Exploratory
laparotomy

Retroperitoneal cavity
& pelvis
Pelvic xray
CT scan
Exploratory
laparotomy

Thorax
(thoracoabdominal
injuries)
CXR

Heart & Great Vessels

(cardiac box injuries)
Cardiac FAST
CXR

Diaphragm & Bladder

(innocent bystanders)
Diagnostic laparoscopy
CT cystogram

Blunt Abdominal Trauma

Why investigate?
Unlike penetrating trauma, diagnosis of BAT by
clinical exam is unreliable, esp. decreased LOC
Late diagnosis of missed injuries leads to
increased mortality rates
Large prospective study- 10% of patients with
no clinical signs of injury had injuries found on
CT
Consensus guidelines suggest that the
threshold for investigation of BAT should be
very low EAST, 2002

Tools Available For Abdominal

Trauma

Physical exam
X-Rays
Ultrasound (FAST)
Computerized Tomography (CT)
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory laparotomy

Tools Available For Abdominal

Trauma
Physical exam bad for blunt, good for
penetrating (serial physical exams)
X-Rays
Ultrasound (FAST) helpful if positive
Computerized Tomography (CT) not for
HVI
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy for the diaphragm
Exploratory Laparotomy if needed

What Are We Worried

About?

Bleeding:

Liver
Spleen
Kidneys
Mesentery

Bowel:
Contamination

Bladder:
Intraperitoneal rupture

Diaphragm:
Mainly on the left side

How to Investigate Blunt

Abdominal Trauma? BMJ 2008
Concealed or occult hemorrhage is the
2nd most common cause of death after
trauma
Missed abdominal injuries are a frequent
cause of morbidity and mortality
Appropriate and expeditious
investigations are important
Non-operative management of solid
organ injury now more common

Physical Exam
Neither sensitive nor specific to rule out
intra-peritoneal hemorrhage (bleeding)
Excellent to watch for the development
of peritonitis (contamination)
Less than 24 hours, usually by 13 hours
A modality usually employed in
penetrating trauma

Very poor to detect bladder or

diaphragmatic injury

Seat Belt Sign Not Just the

Abdomen

Physical Exam Caveat

The Seat Belt Sign
Historically indicative of significant intraabdominal injury
Especially when accompanied by a Chance fracture
(L2 flexion distraction fracture) (up to 30-50% pts.)
Can occur together or in isolation on the neck, chest
or abdomen
Indicative of carotid, thoracic or intraabdominal
injuries
Hollow viscus injuries
Retroperitoneal injuries (duodenum and pancreas)
Solid organ (tearing of the falciform ligament)

Odds of intraabdominal injury increased 2.6x if SBS

present on passenger seated in the front seat
Coimbra, 2009

Focused Assessment With

Sonography in Trauma (FAST)
Looks for free intra-abdominal fluid (assumed to be
blood or gastrointestinal content, may be other)
Also pericardial fluid

Non-invasive, no radiation, repeatable

Highly Sn (79-100%) and Sp (96-100%)
Moreso in hemodynamic pts. after BAT
Repeating FAST also increases Sn

May still need other imaging modalities with a

negative FAST
Can be performed with equal accuracy by surgeons
Use controversial in penetrating trauma of the
abdomen
Only helpful if positive
VERY helpful for detecting intrapericardial blood
UABCDE

FAST

Diagnostic Peritoneal
Lavage (DPL)
Described in 1965, standard of care
Open or closed (Seldinger) approach
Highly accurate for hemoperitoneum (Sn = 95%, Sp =
99%)
Lead to a non-therapeutic laparotomy rate of 36%

Laparotomy when:
10 cc gross blood
Enteric contents
1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC /
mm3

High false positives with pelvic fractures

Do a supraumbilical approach

High Sn for hollow viscus injuries

Moreso than CT

Risk of visceral injury = 0.6%

Retroperitoneum cant be assessed

Diagnostic Peritoneal
Lavage

In real life:

Good tool if FAST

equivocal in the HD
abnormal pt. in the
setting of a pelvic
fracture
FAST unavailable, pt.
is HD abnormal

Computerized Tomography
Imaging modality of choice only in HD normal patients
Pts crumping in CT a performance indicator in trauma
centres

Sn = 92-97%, Sp = 99% for bleeding

Active arterial contrast extravasation, blush or
pseudoaneyurysm
Even with AKI, or in the elderly

Only modality to directly detect retroperitoneal injury

Less accurate for HVI
Still need serial physical exams
If pelvic fluid is present in absence of solid organ injury
exploratory laparotomy is mandated, especially if
moderate or large amounts of free fluid Chen, 2009
3% males may have pelvic fluid 2dary to resuscitation

Poor test to diagnose diaphragmatic injury

Computerized Tomography
Effect of whole-body CT during
trauma resuscitation on survival:
a retrospective, multicentre study
Huber-Wagner et al., Lancet 2009
Relative risk of mortality in blunt trauma
reduced by 25% according to TRISS
NNT = 17
Whole-body CT an independent predictor
of survival

Hypovolemic Shock
Complex

Indications for Laparotomy

Blunt Abdominal Trauma
Absolute Indications:
1.
2.
3.
4.
5.

Shock
Peritonitis
Blood out of NG tube or on rectal exam
Intraperitoneal bladder rupture
Diaphragmatic rupture

Initial Management of the Bleeding

Patient European Guidelines; CC
2007
Recommendation 6:
Early FAST for the detection of FF in patients with
suspected torso trauma

Recommendation 7:
Pts. with significant FF on FAST with hemodynamic
instability should undergo urgent surgery

Recommendation 8:
HD normal pts. with suspected head, chest and/or
abdominal bleeding following high-energy injuries
should undergo further assessment using CT

Recommendation 9:
Single Hct is not helpful; lactate or base deficit is
helpful to estimate and monitor the extent of
bleeding and shock

BAT & Pelvic #

May have ongoing bleeding from the
abdomen, pelvis (retroperitoneum) or both
FAST used for intraabdominal bleeding
PXR for pelvic fractures (APC, VS, LC)
Abdomen trumps pelvis (80-90% venous
bleeding)
Pelvic bleeding should subside with
stabilization in the majority of cases
Laparotomy done first if FAST positive

Open Book Pelvic

Fracture

Pelvic Fracture has large

potential space for
hemorrhage

Col (ret) Mark W.

Bowyer MD

Close Pelvis Many

Devices Available to

Surgical consult
Pelvic wrap
Intraperitoneal gross blood?
Yes
No
Laparotomy

Angiograph
y

Control
hemorrhage
Fixation device

Initial Management of the Bleeding

Patient European Guidelines; CC
2007
Recommendation 10:
Pts. in shock with pelvic ring fractures should undergo
immediate closure and stabilization

Recommendation 11:
If ongoing instability, proceed to early
angioembolization or surgical bleeding control such
as packing

Recommendation 12:
Early bleeding control must be achieved by packing,
direct surgical bleeding control, the use of local
hemostatic procedures. If pt. is exsanguinating, aortic
cross-clamping may be employed as an adjunct

Recommendation 13:
Damage control surgery should be employed in the
severely injured pt. with signs of shock, ongoing
bleeding and coagulopathy

EAST Guidelines Evaluation of

Blunt Abdominal Trauma, 2001
Level I:
Exploratory laparotomy is indicative for patients
with a positive DPL
CT is recommended for the evaluation of
hemodynamically stable patients with equivocal
findings on physical examination, associated
neurologic injury, or multiple extra-abdominal
injuries. Under these circumstances, patients with a
negative CT should be admitted for observation (i.e.
contamination)
CT is the diagnostic modality of choice for nonoperative management of solid visceral injuries (i.e.
bleeding)
In HD stable patients, DPL and CT are
complementary diagnostic modalities

EAST Guidelines Evaluation of

Blunt Abdominal Trauma, 2001
Level II:
FAST may be considered as the initial diagnostic
modality to exclude hemoperitoneum
Exploratory laparotomy is indicated in HD
unstable patients with a positive FAST
If HD stable with a positive FAST, follow up CT
permits nonoperative management of select
injuries
Surveillance studies (DPL, CT, repeat FAST) are
required in HD stable pts. With indeterminate
FAST results

Tanyas Summary - BAT

In stable go to the OR for a laparotomy
If you are worried about contamination (HVI)
Fluid in the pelvis in absence of SOI

If you are worried about an intraperitoneal

bladder injury or large diaphragmatic injury

In unstable go to the OR for a

laparotomy
If the bleeding is in the abdominal cavity
If the bleeding is in the pelvis for packing as
still ongoing after stabilizing

Penetrating Abdominal
Trauma

ATLS Approach
A intubation may be required if
hypotensive
B watch H/PTX in both blunt and
penetrating TAA injuries
C start with 2 L crystalloid, may need
to activate MTP MUST FIND & STOP
THE BLEEDING
D may see associated thoracolumbar
#s with BAT
E watch for SBS, other injuries

Penetrating Abdominal
Trauma
Violation of peritoneum
Therefore risk of intraabdominal injury that
requires surgery

Caused by stab wounds

Caused by gun shot
wounds
Caused by shot gun
wounds
Caused by other
penetrating objects

How common are injuries that

require surgical repair?
Anterior abdominal stab wounds:
25-33% will need a laparotomy

Posterior or flank stab wounds:

15% will need a laparotomy

Anterior gun shot wounds:

58-75% will need a laparotomy

Posterior gun shot wounds:

33% will need a laparotomy

Indications for Laparotomy

Penetrating Abdominal Trauma
Absolute Indications:
1.
2.
3.
4.
5.
6.

Shock
Peritonitis
Evisceration
Weapon still in situ
Blood out of NG tube or on rectal exam
Gross hematuria

Penetrating Abdominal Trauma

When to Operate in Stab
Wounds?

1. Shock

PPV = 80% for

therapeutic laparotomy

2. Peritonitis

PPV = 85% for

therapeutic laparotomy

Local (50%)
Diffuse (81%)

3. Evisceration

PPV = 75% for

therapeutic laparotomy

Intestinal (100%)
Omental (76%)

Stab Wounds
Anterior Abdominal Wall
Not all stab wounds to the anterior
abdominal wall (AAW) will have:
Violated the peritoneum
Caused intraabdominal injury requiring
operative repair

Up to 50% of stab wounds to the AAW

will not violate the peritoneum
Up to 50% that violate the peritoneum do
not cause injury requiring operative repair

Stab Wounds
Anterior Abdominal Wall
1. Local Wound Exploration (LWE)
Sterile procedure with local anesthetic

2. Serial Physical Examinations (SPE)

Done by same clinician to assess for
the development of peritonitis

3. Focused Assessment with

Sonography for Trauma (FAST)
Not indicated in penetrating trauma

4. Diagnostic Peritoneal Lavage (DPL)

Not done in many centers

Stab Wounds
Anterior Abdominal Wall
5. Computerized Tomography (CT)
Historically not used for anterior abdominal
stab wounds

More useful in penetrating injury to the flank and

back

6. Diagnostic Laparoscopy
Used to rule out:

Peritoneal penetration
Diaphragmatic injury on left side

7. Exploratory Laparotomy

Still the gold standard in ruling out intraabdominal injury

Pitfalls
1. DPL:

Cumbersome
Sensitivity poor for hollow viscus injury
Different criteria for positive tests in different
centers
Positive test for RBCs does not equate to
needing a therapeutic laparotomy

Many solid organ injuries managed non-operatively now

2. FAST (Soffer, 2004):

Very limited role in penetrating abdominal

trauma
Rarely changes management, even if positive
(1.7%)

Pitfalls
3. Diagnostic laparoscopy:
Only identifies peritoneal violation
Not sensitive for hollow viscus or
retroperitoneal injury
Automatic conversion to laparotomy will
still result in a high non-therapeutic rate
Still largely reserved to rule out
diaphragmatic injury with left
thoracoabdominal SWs

30% will have an injury to the diaphragm

Caution: 10% develop a tension pneumothorax

intraoperatively if no chest tube in place

Non-Operative Management of Stab

Wounds EAST 2010
1.
2.
3.
4.

Hemodynamically stable
No peritonitis or diffuse abdominal pain
In a center with surgical expertise
Patient is evaluable*
*Evaluable: absence of brain or spinal
cord injury, intoxication or need for
sedation or anesthesia

20% of patients selected for NOM will

fail (Clarke et al., 2010)

Stab Wounds Flank and

Back
Laparotomy used to be standard of care
Phillips, 1986
CT first reported for SWs to flank & back

Fletcher, 1989

Non-operative management with 3CT in 76%

of patients with SWs to flank & back

Jurkovich et al, 2009

Triple contrast CT scan has replaced DPL

Evaluates retroperitoneum as DPL cannot

Now mandatory laparotomy replaced

with triple contrast CT scan for stab
wounds to flank and back

Some centers advocate IV contrast only is

necessary

Thoracoabdominal Stab
Wounds
Historically, 33% of patients with left
thoracoabdominal stab wounds with have a
diaphragmatic injury
Murray, 1998

Prospective study of left throacoabdominal SWs

Diaphragmatic injury in 26% of patients who
had no indication for laparotomy
Patients with left thoracoabdominal stab wounds
may be observed for 12 hours

If no need for laparotomy by that time, may

repair diaphragm using laparoscopic
techniques

CT Scan for Anterior Abdominal

Wall Stab Wounds
Not well defined, evolving modality
Does not add much to serial physical
exams
Poor test for:
Hollow viscus injuries
Diaphragm injuries

Use if:
1.High suspicion of solid organ injury (liver,
spleen, kidney) based on wound location (R or
LUQ)
2.Positive FAST exam
3.Hematuria

 While selective management of anterior

abdominal stab wounds is appropriate...
Selective management of anterior
abdominal GSWs is still controversial
But this can reduce the rate of
nontherapeutic laparotomy from 30-50%
to 5-10%

Non Operative Management of

Gun Shot Wounds Guidelines
(EAST) 2010
1.Hemodynamically stable
2.Tangential wound
3.No peritoneal signs
4.Consider only if patient is evaluable
5.Exception if GSW to RUQ

Non Operative Management of Gun Shot

Wounds to Right Upper Quadrant (NonTangential) - Guidelines
Absolute indications:
1. Hemodynamically
stable
2. Patient is evaluable*
3. Minimal to no
abdominal tenderness

* Evaluable: absence of
brain or spinal cord
injury, intoxication or
need for sedation or
anesthesia

EAST Guidelines 2010

Patients with GSWs who are selected
for initial non-operative management
should have other diagnostic tests

This should be an abdominal pelvic

CT scan to facilitate initial
management decisions

Is a Non-Therapeutic
Laparotomy Bad?
Ventral incisional hernia rate 5 - 20%
Lowe et al., 1972

245 pts. with negative or non-therapeutic laparotomies after

mainly penetrating trauma
20.4% complication rate (evisceration in 4 pts.)
1.6% mortality rate related to unnecessary laparotomy

Demetriades, 1993

11% of non-therapeutic laparotomies with major complications

LOS = 4.1 days if no complications vs. 21.2 days if complicated

Renz & Feliciano, 1995

Complications in 41.3% of 254 pts. with laparotomies for

trauma

Velmahos et al, 2001

$ 9.5 million saving with NOM over 8 years, 1856 pts. with GSW

How long to observe?

Patients with penetrating abdominal injuries
selected for NOM should be observed for 24
hours
They may be discharged after 24 hours in
the presence of a reliable physical exam
and minimal to no tenderness
The majority of asymptomatic patients who
failed NOM after SWs did so within 12 hours
Alzamel et al, 2005

24 hours still recommended by most

centers

Inaba &
Demetriades,2007

Summary Stab Wounds to

Abdomen
Non-operative management if no:
Shock, peritonitis, evisceration &
patient evaluable

LWE as per clinician preference

May discharge patient home if no
fascial violation

Serial physical exams by same

clinician X 24 hours
Watch for peritonitis, discharge home if
minimal or no pain

Summary Stab Wounds to

Abdomen
CT scan if
SW to R or LUQ to rule out solid organ injury
SW to flank or back as CT may rule out peritoneal
violation
May send home after or..

May observe patient after CT for 24 hours

nonetheless

Delayed laparoscopy after 12 hours of

observation if
TAA SW to left upper quadrant to identify and repair
any diaphragmatic injury

Summary GSW to Abdomen

Non-operative management if no:
Shock, peritonitis, evisceration & evaluable

All patients undergo CT scanning

Anterior abdomen, flank or back
If GSW tangential (no peritoneal breach) & no
peritoneal signs, patient may be discharged
home
If solid organ injury, may manage nonoperatively
Consider repeat imaging in 7 days to manage
asymptomatic complications in 50%

If hollow viscus injury, proceed with laparotomy

If no apparent injury, observe for 24 hours

Summary Penetrating
Abdominal Trauma
Low threshold to operate
Dont forget trauma to thoracic
structures if TAA
FAST only helpful with bleeding if positive
Always do a pericardial FAST if close to the
box

CT only helpful with bleeding

Less so with HVI

Serial physical exams helpful in all

Thank you!
zakrisont@smh.ca