ABDOMINAL INJURIES

Injuries to the spleen, liver, bladder, gut, etc., are not an uncommon cause of preventable death and their proper clinical assessment is vital. The spleen, liver, retroperitoneum, small bowel, kidneys, bladder, colorectum, diaphragm, and
pancreas tend to be the most commonly injured organs.

Signs and Symptoms of Blunt Injuries

Abdominal injuries can be masked by injuries elsewhere, e.g., fractured limbs, fractured ribs or spinal cord, and head injuries, and may also develop slowly. If a patient has multiple injuries, assume the abdomen is involved until this is ruled
out. Organomegaly makes the involved organs more vulnerable to abdominal trauma, so be cautious with children with pretrauma splenomegaly.

  • Unexplained shock in a trauma patient should point towards an intra-abdominal bleed.

Clinical Features

  • Of important value are the vital signs (pulse rate, blood pressure, respiratory rate, temperature).
  • There may be obvious bruises or abdominal wall wounds.
  • Pain
  • localized tenderness, or rigidity of the abdominal wall indicates the most likely site of injury.
  • Abdominal distension could be due either to gas leaking from a ruptured viscous or from blood from injured solid organ(s) or to torn blood vessels. This is a serious sign.
  • Haematurea occurs in bladder injuries and haematochezia in rectal injuries.
  • The absence of bowel sounds or sustained shock despite resuscitation mandates urgent surgical intervention.

Investigations

  • Plain abdominal and chest x-rays may show existing fractures, foreign bodies, gas under the diaphragm, or bowel loops in the chest. Order abdominal ultrasound or CT scans as applicable.
  • Total blood counts are useful for serial assessments.
  • Group and cross-match blood if intra abdominal bleed is suspected.
  • Bloody nasogastric aspirate may indicate upper gastrointestinal tract injuries.
  • Peritoneal lavage is indicated in the following patients:
    • Patients with spinal cord injury.
    • Those with multiple injuries and unexplained shock.
    • Obtunded patients with a possible abdominal injury.
    • Intoxicated patients in whom abdominal injury is suggested.
    • Patients with potential intra-abdominal injury who will undergo prolonged
      anaesthesia for another procedure.
  • Where available abdominal ultrasound is a useful diagnostic tool

Management

  • Maintain airway and breathing.
  • Is your patient in shock? (Has low BP, high pulse rate, cold clammy extremities, etc.) Take blood sample for later grouping and cross matching andtransfer sample with patient.
  • Clean, stitch, and dress small superficial wounds, but do not let this adversely delay referral.
  • Give tetanus toxoid 0.5ml STAT.
  • Start antibiotics crystapen 1g QID + metronidaxole 400mg TDS IV as appropriate.
  • Keep patient warm.
  • Closely monitor BP, pulse rate, respiratory rate, temperature, and urine output.
  • Measure abdominal girth, as this may prove useful in follow up of patients’ progress.
  • If not sure of wound depth, explore the wound directly under local anaesthesia.
  • Explore penetrating wounds early.
  • In blunt trauma, manage according to clinical findings and how they evolve over time. Mild symptoms are managed conservatively, while deterioration is managed by exploration.
    • Indications for laparotomy in blunt trauma include:
      1. Persistent abdominal tenderness and guarding.
      2. Persistent unexplained shock
      3. Paralytic ileus
      4. Positive radiological or ultrasound findings of pneumo-peritoneum or multiple air-fluid levels
      5. Positive peritoneal lavage or ultrasound findings
    • Manage specific organ injuries at laparotomy.
  • Inform receiving facility when the referral has left the referring facility as trauma needs urgent attention on arrival.
  • At discharge, provide adequate documentation to be sent back to referring facility