Investigation and Management of Blunt Abdominal Trauma Prof Dr abdominal distention

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					   Investigation and Management of
         Blunt Abdominal Trauma

Submitted for partial fulfillment of master degree in general



             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


 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.,

        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.,

        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.
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.
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:

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

 8- Udeani J., et al., ( 2008):Blunt abdominal trauma , emedicine p1-
22: <>.

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