Scott Reed, M.D.Scott Reed, M.D.Scott Reed, M.D.Scott Reed, M.D.

Abdominal TraumaAbdominal Trauma

Abdominal TraumaAbdominal Trauma

““Abdomen”Abdomen”– Derived from Latin word “abdere” Derived from Latin word “abdere”

which means “to hide”which means “to hide”– Often referred to as “the black box.”Often referred to as “the black box.”

“Follow the clues”

Abdominal TraumaAbdominal Trauma

Catagorized according to Catagorized according to MechanismMechanism– PenetratingPenetrating

GunshotGunshot StabbingsStabbings

– BluntBlunt Motor vehicle / Motorcycle accidentsMotor vehicle / Motorcycle accidents AssaultAssault FallsFalls Pedestrians struckPedestrians struck

Abdominal TraumaAbdominal Trauma

Trauma. Fourth ed. Mattox

Abdominal TraumaAbdominal Trauma

Trauma, Fourth ed. Mattox

Abdominal TraumaAbdominal Trauma

Major source of Morbidity and MortalityMajor source of Morbidity and Mortality Rapid Diagnosis is KeyRapid Diagnosis is Key

– Autopsy study comparing two trauma Autopsy study comparing two trauma systemssystems

– 100 consecutive deaths100 consecutive deaths San Francisco County – Trauma system San Francisco County – Trauma system

where all major injuries went to a Level I where all major injuries went to a Level I trauma centertrauma center

Orange County – Transported to nearest Orange County – Transported to nearest hospitalhospitalWest, JG, Trunkey, DD, Lim, RC: Systems of Trauma

Care: A study of two counties. Arch Surg 114:455, 1979

Abdominal TraumaAbdominal Trauma

San Francisco Co.San Francisco Co.– 16 deaths – 1 16 deaths – 1

considered considered preventablepreventable

– Missed Thor. Aortic Missed Thor. Aortic injuryinjury

Orange CountyOrange County– 30 deaths- 22 30 deaths- 22

considered considered preventablepreventable

– 10 of 22 died due to 10 of 22 died due to shock from shock from unrecognized unrecognized abdominal injuryabdominal injury

– 8 of 10 died in the 8 of 10 died in the first 6 hoursfirst 6 hours

West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of two counties. Arch Surg 114:455, 1979

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis

Physical ExamPhysical Exam– Requires neurologically intact patientRequires neurologically intact patient

Pain / TendernessPain / Tenderness GuardingGuarding Rebound / Peritoneal signsRebound / Peritoneal signs

– All that’s needed in penetrating All that’s needed in penetrating traumatrauma

– All that’s needed in All that’s needed in hemodynamically unstable blunt hemodynamically unstable blunt trauma.trauma.

Abdominal Trauma – DiagnosisAbdominal Trauma – Diagnosis

Physical ExamPhysical Exam– Penetrating – Gunshot Penetrating – Gunshot

wounds (high energy wounds (high energy injury)injury) Determining the Determining the

trajectory can give an trajectory can give an idea of what is injuredidea of what is injured

Need even number of Need even number of holes and/or bullets on X-holes and/or bullets on X-rayray

Must be careful since Must be careful since bullets can “settle” to bullets can “settle” to dependent areasdependent areas

Abdominal Trauma – DiagnosisAbdominal Trauma – Diagnosis

Physical ExamPhysical Exam– Penetrating – Stabbing (Low energy)Penetrating – Stabbing (Low energy)

More difficult since there is only an More difficult since there is only an entrance and no “trajectory”entrance and no “trajectory”

Injury can be far from the injuryInjury can be far from the injury May be all that is needed in May be all that is needed in

hemodynamically stable patients hemodynamically stable patients (observation). No good study to pick up (observation). No good study to pick up hollow viscus injuries.hollow viscus injuries.

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis Ultrasound (F.A.S.T.)Ultrasound (F.A.S.T.)

– Focused Abdominal Focused Abdominal Sonogram for TraumaSonogram for Trauma Really is fast (done in the Really is fast (done in the

trauma bay)trauma bay) Non-invasive and can be Non-invasive and can be

repeatedrepeated Only determines the presence Only determines the presence

of fluid in the abdomen of fluid in the abdomen (between 80 – 95% sensitive)(between 80 – 95% sensitive)

Not very specific (which Not very specific (which organ) or what type of fluid organ) or what type of fluid (blood, succus, ascites)(blood, succus, ascites)

Abdominal Trauma – X-RaysAbdominal Trauma – X-Rays

Can show Can show evidence of evidence of free air (hollow free air (hollow viscus injury)viscus injury)

Can help Can help determine the determine the trajectory of trajectory of the missilethe missile

41 y/o female

S/P MVA

Level of the Aortic Arch

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis

Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL)– Has all but been replaced by FAST Has all but been replaced by FAST

examexam– Inserted catheter into abdomenInserted catheter into abdomen

Gross blood (10cc or more) - positiveGross blood (10cc or more) - positive

– Instilled 1 liter normal salineInstilled 1 liter normal saline Over 100,000 RBC’s, 500 WBC, bile or Over 100,000 RBC’s, 500 WBC, bile or

fibers of food on micro - positivefibers of food on micro - positive

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis

Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage– Invasive – 1% injury rateInvasive – 1% injury rate– Oversensitive (small amount of blood Oversensitive (small amount of blood

can make a positive by micro) – 50cccan make a positive by micro) – 50cc– Non-specificNon-specific– Problem in the era of non-operative Problem in the era of non-operative

management of solid organ injurymanagement of solid organ injury– ? Role in CT with fluid but no solid ? Role in CT with fluid but no solid

organ injury (? Hollow viscus injury)organ injury (? Hollow viscus injury)

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis

Computed Tomography (CT Scan)Computed Tomography (CT Scan)– Started in mid-1980’s and has Started in mid-1980’s and has

revolutionize trauma care.revolutionize trauma care. Sees more than just the abdomen Sees more than just the abdomen

(spinal and pelvic fractures) Done in (spinal and pelvic fractures) Done in conjunction with the head and C-spine.conjunction with the head and C-spine.

More specific (solid organ injury) and More specific (solid organ injury) and examines the retroperitoneal areas examines the retroperitoneal areas (pancreas, kidney, duodenum)(pancreas, kidney, duodenum)

Arterial injuries can be studiedArterial injuries can be studied

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis

CT Scan – DrawbacksCT Scan – Drawbacks– Misses hollow viscus injuriesMisses hollow viscus injuries– Can’t evaluate the diaphragmCan’t evaluate the diaphragm– Involves IV contrast (allergic Involves IV contrast (allergic

reactions 1:1000) and radiationreactions 1:1000) and radiation– Tough to run a code in a donut Tough to run a code in a donut

(need a stable patient)(need a stable patient)

Abdominal Trauma - Abdominal Trauma - AngiographyAngiography

Using catheters via a femoral / Using catheters via a femoral / brachial approach to occlude arteriesbrachial approach to occlude arteries

Used increasingly for solid organ Used increasingly for solid organ injuryinjury– Liver – Embolize either Right/Left Liver – Embolize either Right/Left

hepatic arteries (Liver has both arterial hepatic arteries (Liver has both arterial and portal blood supplies)and portal blood supplies)

– Spleen – Can be selective or embolize Spleen – Can be selective or embolize the entire organthe entire organ

Abdominal Trauma - Abdominal Trauma - AngiographyAngiography

Can convert what would be a large and Can convert what would be a large and bloody case into a easily managed bloody case into a easily managed situationsituation

Doesn’t always workDoesn’t always work– Now operating later on a sicker patientNow operating later on a sicker patient– Can embolize too much and infarct other Can embolize too much and infarct other

vascular bedsvascular beds All fluid isn’t blood – Can miss small All fluid isn’t blood – Can miss small

bowel injuriesbowel injuries

Abdominal Trauma - Abdominal Trauma - ObservationObservation

Liver and Spleen injuries can be Liver and Spleen injuries can be observedobserved– Acceptable in minor injuries with Acceptable in minor injuries with

minimal bleeding seen on CT scanminimal bleeding seen on CT scan– Have to observe VERY closelyHave to observe VERY closely

Repeated abdominal examsRepeated abdominal exams Vital signs, dropping hematocritsVital signs, dropping hematocrits

– Have to be ready to operate if Have to be ready to operate if needed quicklyneeded quickly

Abdominal Trauma - DiagnosisAbdominal Trauma - Diagnosis LaparoscopyLaparoscopy

– Excellent for stable stab Excellent for stable stab wounds (peritoneal wounds (peritoneal penetration/diaphragm penetration/diaphragm injury)injury)

– Hard to see everythingHard to see everything Can “run the bowel”Can “run the bowel” hard to see retroperitoneum, hard to see retroperitoneum,

lesser sac, and assess liver / lesser sac, and assess liver / spleen injuriesspleen injuries

– Invasive, expensive Invasive, expensive – may need to to openmay need to to open

Abdominal Trauma - SurgeryAbdominal Trauma - Surgery

Once thought that all repairs Once thought that all repairs needed to be done at the initial needed to be done at the initial surgerysurgery– Long surgery / multiple repairs on Long surgery / multiple repairs on

hemodynamically unstable patientshemodynamically unstable patients– Cold, Acidotic, CoagulopathicCold, Acidotic, Coagulopathic– Patients diedPatients died

Abdominal Surgery - SurgeryAbdominal Surgery - Surgery

Damage Control surgeryDamage Control surgery– Stop the bleeding and contamination Stop the bleeding and contamination

and then get out.and then get out. Pack the liverPack the liver Staple out injured small bowel/colon (no Staple out injured small bowel/colon (no

anastamosis needed)anastamosis needed) Vascular shunts Vascular shunts

– Leave abd open or just close skinLeave abd open or just close skin– Get to ICU for resuscitation/warmingGet to ICU for resuscitation/warming

Abdominal Trauma - SurgeryAbdominal Trauma - Surgery

Damage Control SurgeryDamage Control Surgery– After 24 to 48 hours go back to the After 24 to 48 hours go back to the

OROR Patient is resuscitated, warm, stablePatient is resuscitated, warm, stable

– Establish GI continuityEstablish GI continuity– Wash out areas of contaminationWash out areas of contamination– Vascular repairsVascular repairs– Patients livePatients live

Abdominal Trauma - NursingAbdominal Trauma - Nursing

The Open Abdomen The Open Abdomen – A clear, fenestrated plastic layer over A clear, fenestrated plastic layer over

the bowel and viscera (Vi-drape)the bowel and viscera (Vi-drape)– OR towel, Kerlex, or sponge in the OR towel, Kerlex, or sponge in the

dead spacedead space– Large drains in the guttersLarge drains in the gutters– Cover entire opening with occlusive Cover entire opening with occlusive

dressing (Ioban)dressing (Ioban)– Place drains to suctionPlace drains to suction

Abdominal Trauma - NursingAbdominal Trauma - Nursing

Open Abdomen (VacPack, Blue Open Abdomen (VacPack, Blue Towel)Towel)– Can be done fast in the ORCan be done fast in the OR– Controls abdominal fluids (can Controls abdominal fluids (can

measure)measure)– Prevents abdominal compartment Prevents abdominal compartment

syndrome (more to follow)syndrome (more to follow)– Can be taken down in ICU to allow Can be taken down in ICU to allow

inspection of the abdomeninspection of the abdomen

Abdominal Trauma - NursingAbdominal Trauma - Nursing

DrainsDrains– Placed in areas where fluid may collect.Placed in areas where fluid may collect.

Near an anastomosisNear an anastomosis Pancreatic injuryPancreatic injury

– Must look for changes in output Must look for changes in output Increase could signal a leak, or sudden stop Increase could signal a leak, or sudden stop

could indicate the drain is cloggedcould indicate the drain is clogged Type and quality of the fluid (suddenly Type and quality of the fluid (suddenly

becomes bloody or bilious)becomes bloody or bilious)

Abdominal Trauma – NursingAbdominal Trauma – Nursing

FistulasFistulas– Abnormal connection between two Abnormal connection between two

epithelialized compartments.epithelialized compartments.– Named for the two organs Named for the two organs

connectedconnected

Abdominal Trauma - NursingAbdominal Trauma - Nursing

FistulasFistulas– Enterocutaneous (Small bowel to skin)Enterocutaneous (Small bowel to skin)

Most commonMost common Usually involves the wound or Usually involves the wound or

incisionincision Will see bowel contents in the Will see bowel contents in the

woundwound Often due to surgical mishapsOften due to surgical mishaps

Abdominal Trauma - NursingAbdominal Trauma - Nursing

Colocutaneous (colon to skin)Colocutaneous (colon to skin) Colovesicular (colon to bladder)Colovesicular (colon to bladder) The stomach, pancreas, The stomach, pancreas,

gallbladder, arteries, and veins gallbladder, arteries, and veins can all be involved in fistulascan all be involved in fistulas

Mechanism: Direct external pressure

on vascular structures,

diaphragm and abdominal wall

Abdominal Compartment Syndrome

Abdominal Compartment Abdominal Compartment SyndromeSyndromeWhat is normal?What is normal?

At rest At rest 0 – 5mmHg0 – 5mmHg Valsalva Valsalva 60 – 80mmHg60 – 80mmHg CoughCough 80cmH2O80cmH2O VomitingVomiting 60cmH2O60cmH2O Active liftingActive lifting Over 150mmHgOver 150mmHg

– During lifting the pressure is related to During lifting the pressure is related to the velocity of muscle contraction and the velocity of muscle contraction and comes back to baseline once the comes back to baseline once the movement has endedmovement has ended

Abdominal Compartment Abdominal Compartment SyndromeSyndromeGrading SystemGrading System

Grade IGrade I 10 – 15mmHg10 – 15mmHg Grade IIGrade II 16 - 25mmHg16 - 25mmHg Grade IIIGrade III 26 – 35mmHg26 – 35mmHg Grade IVGrade IV >35mmHg>35mmHg

Abdominal Compartment Abdominal Compartment SyndromeSyndromeCauses (Acute)Causes (Acute)

– Intra-abdominalIntra-abdominal Bowel obstruction / Bowel obstruction /

IleusIleus Ruptured AAARuptured AAA Mesenteric venous Mesenteric venous

obstructionobstruction AbscessAbscess PneumoperitoneumPneumoperitoneum Intraperitoneal Intraperitoneal

bleed / traumableed / trauma Viseral edemaViseral edema

RetroperitonealRetroperitoneal– PancreatitisPancreatitis– Pelvic Frx/bleedsPelvic Frx/bleeds– Ruptured AAARuptured AAA

Abdominal WallAbdominal Wall– Burn EscharBurn Eschar– Massive hernia repairMassive hernia repair– Closing the tight Closing the tight

abdomenabdomen

Abdominal Compartment Abdominal Compartment SyndromeSyndromeConstellation of SymptomsConstellation of Symptoms Renal failureRenal failure

– Decreased urine outputDecreased urine output Respiratory failureRespiratory failure

– Dec compliance, inc pulmonary edema / airway Dec compliance, inc pulmonary edema / airway pressurepressure

Cardiac failureCardiac failure– Decreased cardiac output (dec preload / inc afterload)Decreased cardiac output (dec preload / inc afterload)

Visceral failureVisceral failure– Dec blood flow to liver, bowel (bacterial translocation)Dec blood flow to liver, bowel (bacterial translocation)

Neurologic complicationsNeurologic complications– Increased intracranial pressureIncreased intracranial pressure

Abdominal wall “failure” Abdominal wall “failure” – Dehissence, hernia formationDehissence, hernia formation

Abdominal Compartment Abdominal Compartment SyndromeSyndromeTypesTypes PrimaryPrimary

– hypertension (IAH) Secondary A process hypertension (IAH) Secondary A process within or involving the abdomen itself within or involving the abdomen itself which leads to increased intra-which leads to increased intra-abdominalabdominal

SecondarySecondary– IAH which results even though no direct IAH which results even though no direct

abdominal injury has occurredabdominal injury has occurred– Often overlookedOften overlooked– Strongly related to resuscitation fluids Strongly related to resuscitation fluids

(iatrogenic)(iatrogenic)

Saggi et. al Journal of Trauma 1998

Abdominal Compartment Abdominal Compartment SyndromeSyndromeMeasuring pressuresMeasuring pressures

Bladder Pressure (gold standard)Bladder Pressure (gold standard)– Clamp foley catheterClamp foley catheter– Instill 50-100cc saline into bladderInstill 50-100cc saline into bladder– Use pressure transducer via sampling Use pressure transducer via sampling

portport Accurate – Corresponds well with Accurate – Corresponds well with

direct intra-abdominal catheters and direct intra-abdominal catheters and insufflation during laparoscopyinsufflation during laparoscopy

Reliable and reproducibleReliable and reproducible

Abdominal Compartment Abdominal Compartment SyndromeSyndromeNew Perspectives on Old New Perspectives on Old ConceptsConcepts

Abdominal Compartment Abdominal Compartment SyndromeSyndromeEVMS ExperienceEVMS Experience

Resuscitation greater than 12 Resuscitation greater than 12 liters in the first 24 hours was a liters in the first 24 hours was a risk factor for the development of risk factor for the development of secondary abdominal secondary abdominal compartment syndromecompartment syndrome

R.C. Britt, et. al.

Balough, The American J. of Surg. 2003

Abdominal Compartment Abdominal Compartment SyndromeSyndromePossible Prevention StratagiesPossible Prevention Stratagies

ACS carries high mortalityACS carries high mortality Abdominal decompression also Abdominal decompression also

has high morbidity and mortalityhas high morbidity and mortality– At risk groups can be identified At risk groups can be identified

High volume resuscitations (burns, High volume resuscitations (burns, traumas)traumas)

Pt’s post hemorrhage and shockPt’s post hemorrhage and shock

– ACP can be easily measuredACP can be easily measured

Abdominal Compartment Abdominal Compartment SyndromeSyndromePeritoneal Catheter PlacementPeritoneal Catheter Placement

– Abdominal pressures over 20 Abdominal pressures over 20 mmHgmmHg

– Abdominal perfusion pressures Abdominal perfusion pressures (APP) less than 50mmHg(APP) less than 50mmHg Abdominal perfusion pressure Abdominal perfusion pressure

equals the mean arterial pressure equals the mean arterial pressure minus the abdominal pressure. minus the abdominal pressure. (MAP – ACP = APP)(MAP – ACP = APP)

Results – Total GroupResults – Total Group

Thirty minutes after the DPL catheter was Thirty minutes after the DPL catheter was placed: (Avg starting ACP was 24.9mmHg)placed: (Avg starting ACP was 24.9mmHg)– Average ACP decreased 7.7mmHg Average ACP decreased 7.7mmHg

(p=0.003)(p=0.003)– Average MAP increased 9.7mmHg Average MAP increased 9.7mmHg

(p=0.02)(p=0.02)– Average APP increased 17.4mmHg Average APP increased 17.4mmHg

(p=0.007)(p=0.007)– Average Pulm Compliance increased Average Pulm Compliance increased

7.9 (p=0.0027.9 (p=0.002) )

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

19 y/o male – motorcycle crash19 y/o male – motorcycle crash– Multiple rib fracturesMultiple rib fractures– Facial fracturesFacial fractures– Bilateral Tibia/fibula fracturesBilateral Tibia/fibula fractures– Grade I spleen lacerationGrade I spleen laceration

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

Had both lower extremities repaired on Had both lower extremities repaired on HD#2HD#2

Rib fractures managed with pain Rib fractures managed with pain control and pulmonary toiletcontrol and pulmonary toilet

Facial fractures repair on HD#5Facial fractures repair on HD#5 Spleen observedSpleen observed Left ICU on HD#4 and went to floorLeft ICU on HD#4 and went to floor

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

Morning rounds HD#8Morning rounds HD#8– HR – 70 to 80 bpmHR – 70 to 80 bpm– BP 120/75BP 120/75– Using only Percocet for painUsing only Percocet for pain– H/H – 11/33H/H – 11/33

Planning D/C home soonPlanning D/C home soon

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

10pm Nurse called for increased pain in 10pm Nurse called for increased pain in Left ShoulderLeft Shoulder– Determined this was a new complaint Determined this was a new complaint

and no shoulder injury was and no shoulder injury was documenteddocumented

– Repeated vital signsRepeated vital signs HR – 110HR – 110 BP – 95/50BP – 95/50 Patient was diaphoretic and palePatient was diaphoretic and pale

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

Nurse immediately contacted house Nurse immediately contacted house staff with new complaints and vital staff with new complaints and vital signssigns– Patients seen and examinedPatients seen and examined– Abdomen now tender with guardingAbdomen now tender with guarding– Repeat H/H – 6.5/19Repeat H/H – 6.5/19

Abdominal Trauma – Case Abdominal Trauma – Case ReportReport

Emergent Abdominal CT Scan revealed Emergent Abdominal CT Scan revealed massive hemoperitoneum and delayed massive hemoperitoneum and delayed rupture of the spleenrupture of the spleen

Taken immediately to OR for emergent Taken immediately to OR for emergent splenectomysplenectomy

Did well and was discharged on Did well and was discharged on HD#13HD#13

Abdominal Trauma – Nursing Abdominal Trauma – Nursing QuoteQuote

““I don’t need to know exactly I don’t need to know exactly what is wrong…I just need to what is wrong…I just need to know that something is wrong”know that something is wrong”

My MomMy Mom