Management of Blunt Abdominal Trauma

Epidemiology

• Estimated number of trauma victims in the United States about 57 million annually, resulting in approximately 2 million hospitalizations and 150,000 deaths.
• The incidence of blunt abdominal trauma is approximately 80% of all abdominal trauma.
• In Indonesia, it was found that the national prevalence of injuries was 8.2%, with the highest prevalence found in South Sulawesi (12.8%) and the lowest in Jambi (4.5%).

Penetrating Abdominal Trauma

• Stab trauma occurs 3 times more than gunshot trauma, but the mortality is lower

• A stab wound passes through adjacent abdominal structures and most commonly involves the liver (40%), small intestine (30%), diaphragm (20%), and colon (5%).

Blunt Abdominal Trauma

• Blunt trauma to the abdomen can result from a number of mechanisms including motor vehicle accidents, falls from a height, assault, and sports injuries

• In patients with blunt trauma, the organs most commonly injured are the spleen (40% to 55%), liver (35% to 45%), and small intestine (5% to 10%).

Anatomy

Definition

• Trauma --> Damage or injury caused by physical actions by breaking the continuity of a structure.

• Abdominal trauma is damage to the structures located between the diaphragm and the pelvis caused by blunt or sharp objects.

Pathomecanism

• Deceleration -> tears at fixation points, including vascular pedicles and mesenteric attachments
• external compression -> presence of substantial can cause an increase in intra-abdominal pressure
• crushing -> organ damage due to compression of the abdominal contents between the abdominal wall and the spine or the bones of the chest wall.

Evaluation

• ample

a : allergies

m : medications

p : past medical history

l : last meal

e : events leading to presentation

Anamnesis (riw. kecelakaan)

pem fisik

• inspeksi
• auskultasi
• perkusi
• palpasi

• primary survey

a : Airway

B : Breathing

c : Circulation

d : Disability (status neurologis)

e : Exposure. `

Hemodynamic instability

• Systolic blood pressure < 90 mmHg with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill)

• Altered level of consciousness/ shortness of breath

• Systolic blood pressure > 90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs

• Shock index > 1 (Heart rate/systolic blood pressure)

• Transfusion requirement of at least 4-6 unite of packed red blood cells within the first 24 h

PEMERIKSAAN PENUNJANG

Laboratory

Metabolic and haematological testing are of limited use in the initial management of acute trauma patients. Targeted laboratory evaluations can provide trauma patients with an assessment of the severity of the injury

Laboratory tests as an initial evaluation of trauma include:

• Hematocrit -> can determine the rate of bleeding, time of injury, and the amount of exogenous fluid administration
• Leukocyte count (WBC) -> the process of tissue injury, acute bleeding or peritoneal irritation
• Serum amylase concentration -> can determine the presence of pancreatic injury
• Liver function tests -> elevated transaminase concentrations -> with AST threshold >=109 U/L and ALT 97 U/L -> suspected hepatic injury

Plain Radiographs

• Hemodynamically abnormal with penetrating abdominal wounds do not require screening x-rays.

• Hemodynamically normal and has penetrating trauma above the umbilicus or a suspected thoracoabdominal injury, an upright chest x-ray is useful to exclude an associated hemothorax or pneumothorax, or to determine the presence of intraperitoneal air.

• Penetrating trauma
• Pneumoperitoneum
• Other injuries

FAST (Focused Assessment with Sonography for Trauma)

• FAST is used to identify free intraperitoneal fluid in Morrison's pouch, left upper quadrant, and pelvis.

• This method is very sensitive for detecting intraperitoneal fluid >250 mL, this method is not reliable for determining the source of bleeding or solid organ injury.

• Intraperitoneal fluid
• Hemodynamically instable
• Quick bedside

"Positive" FAST Imaging

FAST imaging detects intra-abdominal bleeding.

(A) Bleeding is suspected when fluid is seen between the line of the right kidney and liver,

(B) between the left kidney and the spleen,

(C) or in the pelvis.

DPL (Diagnostic Peritoneal Lavage)

• Patients with free intra-abdominal fluid without organ injury are monitored closely for signs of developing peritonitis;

• Hemoperitoneum
• Quick bedside
• Mass casualty situations

CT SCAN (Computed Tomography)

• CT scans provide information relative to specific injuries and organs, and they can diagnose retroperitoneal and pelvic organ injuries that are difficult to assess by physical examination, FAST, and DPL.

• Goldstandard
• Spesific anatomical injuries
• Source of bleeding

CT SCAN IMAGING

CT scan that detects solid organ injury,

(A) Contrast extravasation associated with grade IV splenic laceration,

(B) and the number of subscapular hematomas in grade III liver lacerations.

Laparaskopi diagnostik atau torakoskopi

Diagnostic laparoscopy or thoracoscopy may be an important examination in stable patients with penetrating trauma, to detect or detect peritoneal penetration and/or diaphragmatic injury.

Conservative Therapy

• Conservative therapy -> if there is no indication of immediate laparotomy or the results of investigations do not reveal any intra-abdominal organ injury.

• Evaluate the patient by assessing vital signs, urine output, hemoglobin level, and hematocrit.

• Repeat ultrasound or CT scan if there is a decrease in hemoglobin.

• Three bags of blood transfusion products should be given if abdominal distension, signs of infection, vomiting, hematuria, or tachypnea are present.

Indication for emergency laparatomy

• Blunt abdominal trauma + hypotension with positive FAST or CT scan, positive diagnostic peritoneal lavage (DPL) or peritonitis

• Penetrating abdominal trauma (+ hypotension)

• Free air

• Evisceration

• Gun shot wound travrsing peritoneum or retroperitoneum

• GI bleeding following penetrating trauma

• Penetrating object is still in situ

Complications

• Contusions in the abdomen, buttocks, pelvis, waist, inguinal, perineal, and genital areas

• Rupture of solid or hollow organs

Prognosis

• The overall prognosis for patients with blunt abdominal trauma is good if treated and followed up quickly.