Wednesday, May 17, 2017

Abdominal Trauma - An Overview

Blunt and penetrating abdominal injuries may damage major blood vessels as well as internal organs. Their most immediate life-threatening consequences are hemorrhage and hypovolemic shock; later threats include infection. The prognosis depends on the extent of the injury and on the organs damaged, but it’s generally improved by prompt diagnosis and surgical repair.

Blunt (nonpenetrating) abdominal injuries usually result from motor vehicle accidents, falls from heights, or athletic injuries; penetrating abdominal injuries, from stab or gunshot wounds.

Signs and symptoms
Depending on the degree of injury and the organs involved, signs and symptoms vary as follows

Penetrating abdominal injuries cause obvious wounds. For example, gunshots commonly produce both entrance and exit wounds, with variable blood loss, pain, and tenderness. These injuries can cause pallor, cyanosis, tachycardia, shortness of breath, and hypotension.
Blunt abdominal injuries can cause severe pain (such pain may radiate beyond the abdomen, for example, to the shoulders), bruises, abrasions, contusions, and distention. They may also result in tenderness, abdominal splinting or rigidity, nausea, vomiting, pallor, cyanosis, tachycardia, and shortness of breath. Rib fractures commonly accompany blunt injuries.
With both penetrating and blunt injuries, massive blood loss may cause hypovolemic shock. Generally, damage to a solid abdominal organ (liver, spleen, pancreas, or kidney) causes hemorrhage, whereas damage to a hollow organ (stomach, intestine, gallbladder, or bladder) causes rupture and release of the affected organ’s contents (including bacteria) into the abdomen, which, in turn, produces inflammation.

A history of abdominal trauma, signs and symptoms, and laboratory results confirm the diagnosis and help determine organ damage. Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. 

Diagnostic studies vary with the patient’s condition but usually include:
  • chest X-rays (preferably done with the patient upright) to show free air
  • examination of stool and stomach aspirate for blood
  • blood studies (decreased hemoglobin levels and hematocrit point to severe blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; typing and crossmatching help prepare for blood transfusion)
  • arterial blood gas analysis to evaluate respiratory status
  • serum amylase levels, which are commonly elevated in those with pancreatic injury
  • aspartate aminotransferase and alanine aminotransferase levels, which increase with tissue injury and cell death
  • excretory urography and cystourethrography to detect renal and urinary tract damage
  • angiography to detect specific injuries, especially to the kidneys
  • peritoneal lavage with insertion of a lavage catheter, to check for blood, urine, pus, ascitic fluid, bile, and chyle (a milky fluid absorbed by the intestinal lymph vessels during digestion) (In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.)
  • computed tomography scan to detect abdominal, head, chest, or other injuries
  • exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete
  • other laboratory studies to rule out associated injuries.
Abdominal injuries require emergency treatment to control hemorrhage and prevent hypovolemic shock, by infusion of I.V. fluids and blood components. Some abdominal injuries require surgical repair after stabilization, whereas others require immediate surgery. Blunt trauma to the spleen or liver may be treated with nonoperative management and close monitoring. Analgesics and antibiotics increase patient comfort and prevent infection. Most patients require hospitalization; if they’re asymptomatic, they may require observation for only 6 to 24 hours.

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