Investigation and Management of Blunt Abdominal Trauma Essay Submitted for partial fulfillment of master degree in general Surgery By Mohammed Elsayed Hendam M.B. B.Ch. Supervised by Prof. Dr/ Ahmed Mahmoud Saadeldin Professor of general & vascular surgery Ain Shams University Dr. Ahamed Farouk Mohamed Assisstant Professor of general & Vascular Surgery Ain Shams University Dr.Ahamed Kamal Gabr Lecturer of general & Vascular Surgery Ain Shams University Faculty of Medicine Ain Shams University 2009 INTRODUCTION Trauma is the leading cause of death in people under the age of 45 years, and 10% of these deaths result from abdominal injury which may be blunt (84%) or penetrating (16%). Early detection of these life-threatening injuries is the most important factor in decreasing the incidence of death due to intra-abdominal trauma. (Soyuncu et al., 2007) Blunt trauma secondary to motor vehicle accidents, motorcycle accidents, falls, assaults, and striking of pedestrians remains the most frequent mechanism of abdominal injury. (David et al., 2007) .Missed intra-abdominal injuries and concealed hemorrhage are frequent causes of increased morbidity and mortality, especially in patients who survive the initial phase after an injury. ( Udeani et al., 2008) The abdomen is frequently injured after both blunt and penetrating trauma. Approximately 25% of all trauma victims will require abdominal exploration . (David et al.,2007) The most commonly injured organs are the spleen, liver, retroperitoneum, small bowel, kidneys, bladder, colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often than women. ( Udeani et al., 2008) In 1990, approximately 5 million people died worldwide as a result of injury. The risk of death from injury varied strongly by region, age, and sex. Approximately 2 male deaths due to violence were reported for every female death. Injuries accounted for approximately 12.5% of all male deaths, compared with 7.4% of female deaths . ( Udeani et al., 2008) The abdomen is a diagnostic black box. Physical examination of the abdomen is unreliable, however, the presence of abdominal rigidity or gross abdominal distention in a patient with truncal trauma is an indication for prompt surgical exploration. Drugs, alcohol, head, and spinal cord injuries frequently complicate physical examination. It may also be impractical in patients who require general anesthesia for the treatment of other injuries. (Burch et al., 2007 ) Traumatic abdominal wall injuries (AWIs) may be missed on posttrauma computed axial tomography (CAT) scans that are ordered primarily to evaluate potential intra-abdominal or pelvic injuries. ( Dennis et al., 2009) Despite major improvements in the management strategies for multiply injured patients in recent decades, trauma remains the primary cause of death for young individuals in industrialized countries. (Stahel et al., 2009) Diagnostic radiology remains an essential part of the work-up of trauma patients. Computed axial tomography (CT) imaging of the abdomen has emerged as a minimum standard in the evaluation of all moderately and severely injured patients. Abdominal CT scans (AbdCTS) replaced diagnostic peritoneal lavage as the primary diagnostic modality for blunt trauma several years ago and is currently liberally used in most Emergency Departments (EDs) and trauma centers. ( Ekeh et al., 2009) Computerised tomography (CT) continues to be the gold standardfor imaging in blunt abdominal trauma. Focused abdominal sonographin trauma (FAST) has been used in adult patients to identify free fluid in the abdomen and assist in the triage of patients to further imaging or surgical intervention depending on haemodynamic stability . FAST has essentially replaced diagnostic peritoneal lavage (DPL) in the algorithm of investigation of abdominal trauma for free fluid, as it is non- invasive, easily repeatable and does not interfere with further imaging.( Soundappan et al., 2005) The shift from routine operative to selective nonoperative management (NOM) of blunt injuries to abdominal solid organs is one of the most notable trends in the care of trauma patients during the past 2 decades. Physicians are becoming increasingly comfortable in managing such injuries nonoperatively. ( Velmahos et al., 2003) Despite these developments, a small number of patients with catastrophic intra-abdominal injuries will continue to require immediate and skilled surgical intervention combined with expert resuscitation.(Jansen et al., 2009) AIM OF THE WORK This work aims to highlight the pathophysiology , diagnosis , investigations and updated and reasonable modalities of management of blunt abdominal trauma. Contents 1. Introduction. 2. Aim of the work. 3. Mechanisms and patterns of injury. 4. Pathophysiology of blunt abdominal trauma. 5. Diagnosis of blunt abdominal trauma: a. Clinical assessment. b. Investigations: - haemodynamically unstable patients. - haemodynamically stable patients. 6. Strategies for management: a. Initial management b. Management of specific abdominal injuries. -hepatic injury . - splenic injury. -intestinal injury . - kidney injury. -retroperitoneal haematoma. -pancreatic injury. -vascular abdominal injury. 7. Summary & conclusion. 8. References. 9. Arabic summary. References 1- Burch J.M., Fransiose R.J., Moore E.E., (2007): Trauma, in Schwartz's principles of surgery By F. Challes Burnicardi., Timothy B., Dana k . Andersen, David L. D., Hunter J G., Raphael E .,(editors) 8th ed , New York: ill MCGraw- Hill., Chapter 6:p122-162 2-David B. H ., Coimbra R., Acosta J., 2007: Management of acute trauma "trauma and Critical care" In sabiston textbook of surgery, the biological basis of modern surgical practice" 18 edition by town send, Saunders, an imprint of Elsevier . section III, chapter 20 . 3- Dennis R.W., Marshall A., Deshmukh H., et al., (2009): Abdominal wall injuries occurring after blunt trauma : incidence and grading system: The Am J Surg (2009) 197, 413–417 4- Ekeh A.P., Walusimb M., Brigham E., et al.,(2009): The prevalence of incidental finding on abdominal computed tomography scans of trauma patient : J Emerg Med 2009. 5-Jansen et al., (2009): investigation and management of BAT in recent advanced in surgery by Taylor I., Johnson C .,(editors)(32) Chapter 8: p93-105 6- Soyuncu S., Cete Y., Bozan H., Kartal M., Akyol A.J.,: Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intra-abdominal haemorrhage in blunt abdominal trauma Injury, Int. J. Care Injured (2007) 38, 564—569 7-Stahel1 P. F., Moore E. E : Current trends in resuscitation strategy for the Injury, Int. J. Care Injured (2009) 40S4, S27–S35 multiple injured patient 8- Udeani J., et al., ( 2008):Blunt abdominal trauma , emedicine p1- 22: <http://emedicine.medscape.com/article/433404-print>.