Abdominal Trauma: A Comprehensive Guide and Considerations

1. Introduction

Abdominal trauma is a dangerous condition that can be life-threatening. Timely diagnosis and treatment are crucial to minimize complications and mortality. This article provides detailed information on abdominal trauma examination, including causes, mechanisms, injury characteristics, examination process, imaging diagnostics, and treatment.

2. Causes and Mechanisms

Abdominal trauma can result from various causes, including:

• Blunt trauma: Caused by motor vehicle accidents, falls from heights, being struck by a heavy object, etc.

• Penetrating trauma: Caused by gunshot wounds, stabbings, impalement, etc.

• Iatrogenic trauma: Due to medical interventions like endoscopy, dialysis, biopsies, etc.

Classification:

• Closed Abdominal Trauma (CAT): No penetrating wound to the abdominal wall.

• Higher mortality rate: Injuries are often severe and difficult to detect early.

• More challenging diagnosis: Symptoms are often vague.

• Usually accompanied by multi-organ trauma: Especially head and spinal injuries.

• Commonly injured organs: Spleen > Liver > Intestines.

• Common causes: Motor vehicle accidents (50-75%) > Direct blows (15%) > Falls (6-9%).

• Mechanism: Sudden pressure increase (direct impact, sudden deceleration) > Deceleration (injury caused by inertial forces).

• Penetrating Abdominal Trauma (PAT): There is a penetrating wound to the abdominal wall.

• High mortality rate: Especially with gunshot wounds (90%).

• Commonly injured organs: Small intestine > Colon > Liver.

• Penetrating wound types:

• Perforating wound: An object penetrates from outside to inside.

• Grazing wound: An object grazes the abdominal wall.

• Tangential wound: An object impacts the abdominal wall tangentially.

3. Injury Characteristics

Closed Abdominal Trauma (CAT):

• Solid organs: Injuries caused by impact with the ribs, spine.

• Hollow organs: Injuries due to sudden pressure changes within the organ (like the small intestines, bladder).

• Tears and avulsions: Tears or avulsions from mesentery, ligaments.

Penetrating Abdominal Trauma (PAT):

• Hollow organs: Direct injury caused by the penetrating object.

• Solid organs: Injuries due to transmitted force or from fragments of the penetrating object.

• Notes:

• Perineal or low chest wounds: Consider the possibility of injury to organs within the abdominal cavity.

• Combined with other injuries: Diagnosis can be challenging due to shock, respiratory distress, coma.

• Multi-organ injury: Multiple organs within the abdomen may be injured simultaneously.

4. General Trauma Examination

Primary Survey – ATLS Approach (ABCDE):

• A – Airway (Airway):

• Secure the airway.

• Immobilize the cervical spine (C-spine).

• B – Breathing (Breathing):

• Assess breathing.

• Diagnose pneumothorax (chest and abdominal X-ray).

• C – Circulation (Circulation):

• Control bleeding sources.

• Fluid resuscitation.

• D – Disability (Neurological Status):

• Assess neurological status.

• Diagnose accompanying spinal and head CT scans.

• E – Exposure (Exposure):

• Expose the entire body to look for accompanying injuries.

5. Taking a History

Secondary Survey:

• History:

• Ask the patient or family about the mechanism of injury, posture during the accident, direction of impact force, time from the accident to hospital admission, symptoms (abdominal pain, vomiting blood, hematuria, hematochezia), pre-hospital management.

• Past Medical History:

• Allergies, medications used, last meal.

6. Abdominal Examination

• Inspection:

• Examine the abdomen, back, perineum.

• Look for ecchymosis, abrasions, wounds, characteristic signs:

• Grey Turner: Flank ecchymosis.

• Kehr: Left shoulder pain.

• Balance: Perineal ecchymosis.

• Cullen: Periumbilical ecchymosis.

• Satbelt: Ecchymosis in the lumbar region.

• Palpation:

• Fixed pain, changing with each examination.

• Peritoneal irritation < Resistance < Rigidity.

• Percussion:

• Decreased dullness: Loss of liver dullness, dullness in the lower regions with free fluid.

• Auscultation:

• Paralytic ileus (detected in the late stage).

• Vaginal-rectal examination:

• Blood on the glove: Bowel perforation.

• Tender Douglas pouch: Blood, gastrointestinal fluid.

• Bone fragments.

• Examination of scrotum-perineum:

• Ecchymosis, blood in the meatus.

7. Blood Tests

• Complete Blood Count (CBC):

• Hb, Hct: Does not decrease in the early stages.

• WBC: Increased due to catecholamine release from stress (10-20k) => Suspect solid or hollow organ injury.

• Amylase, Lipase:

• Increased in pancreatic trauma.

• Normal does not rule out necrosis.

• AST, ALT:

• Increased in liver trauma.

• Ethanol, drugs of abuse: Assess intoxication, drug use.

• Urine:

• Re-test if necessary.

8. Imaging Diagnostics

• Abdominal X-ray: Limited value in diagnosing closed abdominal trauma.

• Other tests:

• FAST ultrasound (Focused Assessment with Sonography for Trauma):

• Abdominal paracentesis: Puncturing the abdomen to collect fluid.

• Abdominal lavage: Washing the abdominal cavity with saline solution to look for signs of infection.

• CT scan: Computed tomography of the abdomen.

• Wound exploration: Investigating the depth of a stab wound, checking the peritoneum.

• Angiography: Assessing vascular injury.

• Retrograde cystography: Checking for urethral injuries.

#### 8.1. FAST Ultrasound (Focused Assessment with Sonography for Trauma)

• Advantages:

• Bedside, can be repeated multiple times, non-invasive, detects small fluid volumes, low cost.

• Disadvantages:

• Limitations in diagnosing solid organ injuries, retroperitoneal injuries, diaphragmatic injuries.

• Uncooperative patients, obesity, gas distention.

• Less sensitive to hollow organ injuries.

• Procedure:

• Dividing the abdomen into 4 zones: Pericardium, around the liver and hepatorenal recess, around the spleen, pelvis (Douglas).

• Detects fluid volumes of 100-500ml.

• Free fluid-pneumothorax.

#### 8.2. CT Scan of the Abdomen

• Indications:

• Hemodynamically stable patients.

• Clinically suspected or unable to examine (paralyzed, comatose).

• Investigating multiple organs at once.

• Guiding treatment.

• Advantages:

• Allows comprehensive investigation of the abdomen, detecting hollow and solid organ injuries, providing accurate diagnosis.

• Disadvantages:

• Not suitable for hemodynamically unstable patients with a high risk of significant bleeding.

#### 8.3. Abdominal Paracentesis & Lavage

• Rarely used due to potential complications and low effectiveness.

#### 8.4. Wound Exploration

• Investigate the depth of the stab wound.

• Check the peritoneum.

• Local anesthesia, wide incision for exploration.

#### 8.5. Diagnostic Endoscopy

• Used for hemodynamically stable patients.

• Can detect diaphragmatic injuries with a sensitivity of 87.5% and a specificity of 100%.

• Can treat injuries.

• Complications: Anesthesia, surgery.

9. Laparotomy

• Indications:

• Shock accompanied by an intra-abdominal bleeding source.

• Clear peritonitis.

• Evisceration.

• Failure of conservative treatment.

10. Considerations

• Diagnosis of abdominal trauma should rely on clinical examination findings, laboratory tests, and imaging diagnostics.

• Early diagnosis and timely treatment are crucial factors determining patient prognosis.

• Patients require close follow-up after treatment to detect early complications.

11. Conclusion

Abdominal trauma examination is a complex process requiring specialized knowledge and experience from physicians. Timely diagnosis and treatment will help minimize complications and mortality. Patients should be closely monitored after treatment to detect potential complications.