Torso and abdominal trauma

Overview

The torso (chest, abdomen and pelvis) is where most preventable trauma deaths from bleeding happen. Bailey & Love notes that about 39% of trauma deaths are due to haemorrhage, mostly from torso injury.

Blood in the abdomen is not irritant at first, so the abdomen can look soft while the patient bleeds to death. Examination is also unreliable in head injury, intoxication, spinal cord injury and distracting injuries. The approach is therefore driven by physiology: is the patient stable or not?

Anatomy for trauma

Junctional zones (neck–chest, chest–abdomen, abdomen–pelvis–groin) are hard to diagnose and approach, and should be investigated as if both cavities are injured.

Mechanism and organs injured

• Compression/crush bursts solid organs and ruptures hollow ones.
• Deceleration tears organs at fixed points: liver and spleen at their ligaments, small bowel "bucket handle" mesenteric tears.
• Lap belt injuries: mesentery tears, rupture of small bowel or colon, Chance fracture of a lumbar vertebra, pancreatic or duodenal injury.
• Bicycle handlebar or steering wheel blow to the epigastrium: duodenal and pancreatic injury.

Assessment

• Primary survey first. Hypotension with abdominal injury is bleeding until proven otherwise.
• Look: bruises (a transverse seat-belt sign), wounds front and back, evisceration, distension, perineal and scrotal bruising, blood at the urethral meatus.
• Feel: tenderness, guarding, rigidity (peritonitis). Gently check the pelvis once; do not rock it repeatedly.
• Rectal examination: blood (bowel injury), sphincter tone (cord injury), bony fragments, high-riding prostate (urethral disruption).
• Gastric tube (orally if skull base fracture suspected) and urinary catheter (only after excluding urethral injury). Delay the catheter until FAST is done, because a full bladder improves the pelvic window.
• Blood in the gastric aspirate or rectum after penetrating trauma suggests visceral injury.

Investigations: FAST, DPL and CT

FAST windows

1. Pericardial sac (subxiphoid)
2. Hepatorenal pouch (Morison pouch), right upper quadrant
3. Splenorenal recess, left upper quadrant
4. Pelvis (pouch of Douglas or rectovesical pouch)

eFAST adds both pleural spaces for pneumothorax and haemothorax.

DPL

• Empty the stomach and bladder first. Insert a catheter below the umbilicus, aspirate, then run in 1 L of warm Ringer lactate and let it drain back.
• Use an open supraumbilical approach in pelvic fracture (to avoid the pelvic haematoma) and late pregnancy.
• Positive: aspiration of 10 mL or more of blood (in unstable patients), bile, bowel content or vegetable fibre; returned lavage fluid containing red cells above 100 000 per µL or white cells above 500 per µL (Bailey & Love). Lavage fluid appearing in a chest drain means diaphragm injury.
• Relative contraindications: previous abdominal surgery, morbid obesity, advanced cirrhosis, coagulopathy. The only absolute contraindication is an existing indication for laparotomy.

Other tools

• Plain films in penetrating trauma: put metal markers on every wound to judge the track and count missiles.
• Diagnostic laparoscopy: useful in stable penetrating thoracoabdominal wounds to find diaphragm or peritoneal breach. Never in an unstable patient.
• Local wound exploration: for anterior stab wounds, to see whether the fascia is breached.

Indications for laparotomy

• Blunt trauma with hypotension and a positive FAST or clinical signs of intraperitoneal bleeding (or no other source)
• Hypotension with a penetrating wound through the anterior fascia
• Gunshot wound crossing the peritoneal cavity or visceral/vascular retroperitoneum
• Evisceration of omentum or bowel
• Peritonitis
• Bleeding from the stomach, rectum or urinary tract after penetrating injury
• Pneumoperitoneum, retroperitoneal gas or a ruptured hemidiaphragm on imaging
• Positive DPL (blood, bowel content, bile, vegetable matter)
• CT showing injury needing repair (pancreatic duct, bowel, intraperitoneal bladder, renal pedicle)

Penetrating wounds: stab vs gunshot

• Gunshot wounds that enter the peritoneum cause significant injury in nearly all cases, so most go to laparotomy.
• Stab wounds injure intraperitoneal organs in about 30%; stable patients without peritonitis or evisceration can be managed selectively: local wound exploration, serial examination over 24 hours (with or without serial FAST), CT or laparoscopy.
• Flank and back stab wounds: serial examination or double/triple contrast CT.
• Give prophylactic antibiotics before surgery in all penetrating abdominal wounds; a single dose is enough unless contamination is heavy.

Specific organ injuries

Spleen

• Commonest solid organ injured in blunt trauma; suspect it with left lower rib fractures.
• Stable patient (especially children): non-operative management with CT, observation and, where needed, angioembolisation. Most failures occur in the first 12 hours.
• Unstable patient: laparotomy; options are packing, repair (splenorrhaphy), mesh wrap or splenectomy, which is safest in an unstable, multiply injured patient.
• After splenectomy: platelet and white counts rise for a while (can mimic sepsis); give pneumococcal and Haemophilus influenzae type b vaccines (meningococcal as per local policy), which Bailey & Love times at about 2–3 weeks after surgery.

Liver

• Second commonest in blunt trauma, commonest in stab wounds. Most injuries are minor and settle without surgery in a stable patient (CT first).
• At laparotomy, the four Ps: Push (bimanual compression), Pringle (clamp the hepatoduodenal ligament to stop hepatic artery and portal vein inflow), Plug (tamponade a track with a balloon or tube), Pack (perihepatic packing).
• The hepatic artery can be ligated; the portal vein must be repaired or shunted (ligation carries over 50% mortality).
• Leave a closed suction drain.

Pancreas and duodenum

• Both lie in the retroperitoneum, so injury is hidden and diagnosed late. CT is the main test; amylase is unreliable.
• Duodenal rupture: unrestrained driver in a frontal crash or a handlebar blow. Clues: blood in the gastric aspirate, retroperitoneal gas on X-ray or CT. Small tears are repaired; complex ones get damage control and pyloric exclusion.
• Pancreas: distal injuries with duct damage need distal pancreatectomy; proximal injuries are treated conservatively with drainage. A Whipple procedure is almost never done as an emergency.

Hollow viscus

• Small bowel: common in blunt (deceleration, seat belt) and penetrating trauma. Repair simple holes; resect destroyed segments.
• Stomach: usually penetrating; always look for a back wall (exit) hole.
• Colon: primary repair if contamination is limited and the patient is stable; otherwise close off ("clip and drop") and decide on a stoma later.
• Extraperitoneal rectum: diverting colostomy.

Urinary tract

• Kidney: CT with contrast; most are managed non-operatively, angioembolisation if bleeding.
• Bladder: cystogram with at least 300 mL of contrast, films full and after drainage. Intraperitoneal rupture (blow to a full bladder) needs surgical repair; extraperitoneal rupture (pelvic fracture) usually heals with catheter drainage.
• Urethra: blood at the meatus, scrotal or perineal bruising, high-riding prostate → retrograde urethrogram before any catheter. Posterior (membranous) injury goes with pelvic fracture; anterior (bulbar) with a straddle injury.

Retroperitoneal haematoma

Pelvic fractures

• Need great force; often with other injuries and intra-abdominal bleeding. Mortality in the unstable group remains high.
• Tile classification: A stable (lateral compression, ramus fractures); B rotationally unstable, vertically stable ("open book"); C rotationally and vertically unstable (vertical shear).
• Most bleeding is venous (about 85%) from the presacral plexus and fracture surfaces; arterial bleeding is commoner in the unstable patient.

Management of the unstable pelvic fracture:

1. Pelvic binder or sheet at the greater trochanters to close the pelvic volume (do this in the resuscitation room).
2. Blood products and tranexamic acid.
3. Exclude other sources (chest X-ray, FAST).
4. Extraperitoneal (preperitoneal) packing and/or external fixation for venous bleeding.
5. Angioembolisation for arterial bleeding.
6. Laparotomy only if FAST/CT shows major intraperitoneal blood.

Damage control surgery

Why: long operations in a patient with the lethal triad (hypothermia, acidosis, coagulopathy) are fatal.

Indications (Bailey & Love):

• Physiological: temperature below 34°C, pH below 7.2, lactate above 5 mmol/L, prolonged PT or PTT, more than 10 units of blood transfused, systolic below 90 mmHg for over an hour
• Anatomical: bleeding that cannot be controlled, complex liver and pancreas injury, retrohepatic caval injury, combined vascular and visceral injury
• Environmental: long operating time, inability to close the abdomen, need for a planned relook

Stages:

1. Patient selection
2. Stop bleeding and control contamination (ligate, shunt, staple bowel ends, pack)
3. Temporary abdominal closure (vacuum pack / plastic sandwich) and ICU resuscitation (warm, correct clotting and acidosis)
4. Definitive repair within about 24–72 hours
5. Abdominal wall closure

Damage control resuscitation goes with it: minimal crystalloid, early balanced blood products, permissive hypotension, tranexamic acid.

Abdominal compartment syndrome

• Raised intra-abdominal pressure after massive resuscitation, packing or tight closure.
• Effects: oliguria (reduced renal flow), reduced venous return and cardiac output, high airway pressures, gut ischaemia, raised intracranial pressure.
• Prevent by leaving the abdomen open when risk is high; treat by decompression.

Quick revision

• Blunt: spleen > liver > small bowel. Stab: liver. Gunshot: small bowel.
• Unstable + positive FAST = laparotomy; stable = CT.
• FAST: pericardium, Morison, splenorenal, pelvis; misses bowel, pancreas, diaphragm, retroperitoneum.
• DPL positive: ≥10 mL blood, >100 000 RBC/µL, >500 WBC/µL, bile or bowel content.
• Gunshot through peritoneum: laparotomy. Stable stab without peritonitis: selective.
• Liver: four Ps; Pringle does not stop hepatic vein bleeding; ligate artery, never portal vein.
• Spleen: non-operative if stable; vaccinate after splenectomy.
• Pelvis: binder at trochanters, packing, ex-fix, embolisation.
• Damage control: cold <34°C, pH <7.2, lactate >5; definitive surgery in 24–72 h.

Written by The House Job from standard references (ATLS Student Course Manual, 10th edition; Bailey & Love's Short Practice of Surgery, 27th edition).

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