**7. Discussion**

Globally, injuries are increasing and cause significant health problems worldwide. The greater burden of trauma is reported in middle- and low-income countries and approximately 90% of injury-related deaths happen in these countries [21]. This is a painful fact, as there is published evidence that "if injury mortality rates in low- and middle-income countries were reduced to rates in high-income countries, 2,117,500 lives could be saved per year" [22]. All body organs are vulnerable to the impacts of trauma. However, some body regions are more susceptible than others. Abdominal injuries are the most common type of injuries sustained during trauma event. Development of various complications during the course of management has been documented as a major driver leading to mortality and morbidity among traumatic abdominal patients. However, strategies for avoiding the occurrence of these complications have not been described. In this chapter we discussed systematic approaches for avoiding the complications associated with management of traumatic abdominal patient. Moreover, risk factors leading to the occurrence of these complications, and commonly occurring complications and some rare complications but with higher potential to cause mortality and morbidity have been discussed. We defined complication as an occurrence which is avoidable.

In order to avoid complications associated with the management of abdominal trauma, it is crucial to have maximal knowledge of anatomy and physiological processes of abdominal organs. We have highlighted essential points regarding to the anatomy and physiological process of liver, spleen and GIT because they are mostly injured organs during abdominal trauma. Moreover, anatomy of pancreas has been described because of its intimate relationship with vital vascular structures and common serious danger for both penetrating and blunt injury to the pancreas is the risk of injury to these great vessels. As it was asserted pancreas may obscure the site of bleeding and extensive mobilization or transection of the pancreas may be required in order to control the bleeding vessel.

The comprehensive management of abdominal trauma is a major determinant for the survival of abdominal trauma victim. The framework (primary phase, secondary phase and tertiary phase) of trauma management should be applied to the management of abdominal trauma. In principle all trauma patients should be managed by following the accident and trauma life support (ATLS) protocols. These protocols are also of the first priority while managing traumatic abdominal patient. These protocols contain all interventions aimed to prevent deaths. But also, these interventions influence all other steps of the traumatic abdominal management. Most importantly in this chapter we described ATLS interventions to offer to traumatic abdominal patients as shown in **Tables 2**–**4**. Evidence has shown that prehospital care services can optimizes ATLS interventions and improves patient outcomes [23]. However, most of the developing countries do not have formal prehospital care. And possibly this contribute to reported unacceptable mortality and morbidity associated with trauma in these countries. More studies are needed in order to determine barriers stopping developing countries to have formal prehospital care services.

Classically, as shown in this chapter there are various complications associated with the management of abdominal trauma and contribute to poor outcomes. Numerous risk factors leading to the occurrence of these complications have been discussed. In broadly speaking, risk factors discussed are: (1) *Individual and community related risk factors, (2) Weak health system and trauma care system related risk factors, (3) mechanisms of abdominal trauma related risk factors, (4) Abdominal trauma*

*with concurrent and multiple injuries related risk factors, and (5) treatment approach related risk factors.* By closer look at these factors, it appears that most of them are preventable, suggesting that, multiple tiers and more integrative processes are needed in order to avoid the occurrence of complications associated with the management of abdominal trauma.

Apparent of individual and community related risk factors as factors contributing to the occurrence of complications associated with abdominal trauma indicate that more efforts are needed to in order to enhance the prevention strategies at the individual and community level. "Human beings are regarded as rational decision makers whose knowledge informs their actions. The knowledge regarding health promotion and disease prevention is mostly insufficient or not well perceived by many world's people" [9]. Mentoring and educating various individuals and communities positively about the strategies designed to prevent the occurrence of abdominal trauma and to have peaceful community is an effective way for mitigating all burden associated with abdominal trauma. Such mentorship would bring the best outcomes by changing unhealthy behaviors leading to physical violence and this in turn would leads to the reduction of abdominal trauma and complications associated with its management.

Moreover, in this chapter weak health system is considered among the most profound factors leading to the occurrence of complications associated with the management of abdominal trauma. Weak health system is mainly found in developing countries where a greater burden of trauma is reported. In overall, "to ensure optimal health status of the people in developing countries, we need a strong health system, we shall surely have it if all health concerned stakeholders understand and put into the consideration the fact that achieving optimal good health status is an important and primary goal to be primarily considered in all planned actions" [9]. Strong health system can lead to the fruition of existence of standard trauma care system of which abdominal trauma patients can also profit.

Certain complications develop as consequence of chosen management approach. Numerous investigators have favored the use of non-operative approach for any stable traumatic abdominal patients regardless the types of abdominal injuries sustained. Probably, this is a good approach in developed countries because of the fact that, the decision for using NOM is made with the support of findings of certain advanced imaging modalities. This is contrary to developing countries where there are shortages of imaging modalities. In developing countries the decision for using NOM is mainly based on clinical findings. This is very dangerous because numerous traumatic abdominal patients present with no external features of intra-abdominal organs injuries. Negative abdominal examination findings do not warrant absence intraabdominal injuries. Evidence has shown that, about half of the bleeding in the peritoneal cavity or retroperitoneum manifests itself with few or no symptoms and that about 31% of cases of abdominal trauma deaths occur when there are no external features indicating intraabdominal injuries [24].

As asserted in this chapter, both penetrating and blunt abdominal trauma can be managed either by nonoperative or operative approach. In past it used to be mandatory to perform laparotomy for all Gunshot wounds however; evidence has shown that some Gunshot wound's patient can be managed nonoperatively [25]. Other main indicators for operation regardless the types of injuries sustained include hemodynamic instability and presence peritonism and positive finding of certain imaging modalities. Studies have confirmed that various imaging modalities can support to detect intraabdominal organs injuries after trauma.

Specifically FAST is essential for assessing blunt abdominal trauma and about 93% sensitive and 99% specificity have been reported [24]. Otherwise CT scan is gold standard investigation for detecting various abdominal organs injuries. According to the study done in Iran of which 100 patients were enrolled and it was confirmed that CT scan has highest sensitivity for detecting various abdominal injuries. Typically the results of CT in detecting various abdominal injuries in this study are as follows: liver (100%) and spleen (86.6%), specificity for detecting retroperitoneal hematoma (100%) and injuries to kidney (93.5%) [26]. Additionally the accuracy of CT images for detecting injuries of spleen, liver, kidney and retroperitoneal hematoma were reported to be 96.1, 94.4, 91.6, and 91.6% respectively. Imaging modalities assist to make rational decision regarding the best management approach for stable blunt abdominal trauma patients. However, despite their potentials in detecting intraabdominal organs injuries they are mostly not available in most hospitals of developing countries [27] possibly because they are too expensive. Thus, in these countries blunt abdominal trauma patients are likely to be managed with wrong approach. This probably leads to poor outcome and the most dangers are likely to happen to those patients who sustain retroperitoneal injuries because without CT scan it is hard to detect these injuries.

Despite decades of dramatic advance in treatment and prevention of trauma, globally trauma continues to be a major public health problem. More than 5 million individuals perish every year as a consequence of injuries. This is responsible for about 9% of the world's deaths, approximately 1.7 times the number of mortalities that result from HIV/AIDS, tuberculosis and malaria combined. It is not clear why trauma has not been given great priorities in some countries. There has been clear stated target that "*by 2020, halve the number of global deaths and injuries from road traffic accidents"* [25]. In the context of most developing countries evidence indicates that, this goal has not been achieved. What remains to be understood is that, what caused the failure and which interventions are being taken in order to achieve this missed achievement of targeted goal? This evidence of failure indicates that, if we are in the pace of preventing and ensuring proper management of traumatic patients, we still need multiple tiers of influence of which some of them would be to solve old problems with new solutions. Road traffic accident is responsible for about 75% of blunt abdominal trauma [24]. As such mitigating road traffic accidents would favor the reduction the burden of abdominal trauma. But also, there is a need for designing new ways for avoiding the occurrence of other physical violence leading to injuries. The emphasis should be directed to designing new ways for maintaining optimal peace in many parts of the world.

As the World continues to advance solving old problems with new solutions is an effective and efficient way for mitigating various problems of Worlds' populations. Scientists have devised various approaches to use in order to mitigate the burden of abdominal trauma. In **Table 12** we highlighted essential points of various strategies devised by scientists in order to mitigate the burden of abdominal trauma. Intuitively some of stated strategies require high level of expertise and should be done with support of modern technologies. Thus, there are likely not to be available in most of developing countries. As such unacceptable poor outcomes to traumatic abdominal patients are ever reported. Thus, one would affirm the principles of preventing all factors leading to the occurrence of abdominal trauma as real solutions for avoiding the complications associated with abdominal trauma management in many countries.

More so, in this chapter we described various complications such as shock, sepsis etc. associated with the management of abdominal trauma. Infections were described


#### **Table 14.**

*Advantages of light over alternative disinfectants, biocides, and anti-infectives.*

as dreaded complication to associate with management abdominal trauma. Most importantly, we described strategies for preventing the occurrence of infections. We highly recognized the potential of antimicrobials in terms of mitigating infections however; due to notable resistance, high virulence of some microbes and unavailability of antimicrobial agents in some hospitals as factors limiting effectiveness and usability of antimicrobial agents; We additional described use of light based technology as new way to use for mitigating infections among traumatic abdominal patient. As shown in **Table 14** light based technology has substantial advantages over alternative disinfectants, biocides, and anti-infectives. What remains unknown is the safety and how this technology can be used effectively and efficiently to mitigate infections. The greater considerations should be given to developing countries because most of the infectious complications are reported in these countries.

#### **8. Conclusion**

In this chapter we discussed various aspects related to complications associated with management of abdominal trauma. The main goal of this chapter has been to describe strategies which can be used to avoid the occurrence of complications associated with the management of abdominal trauma. As real fact abdominal trauma is persisted old problem which must be solved with new solutions. To achieve such task a great deal of emphasis should be dedicated to preventing the occurrence of abdominal trauma. Truly, without stopping the occurrence of abdominal trauma, complications associated with its management will continue to occur. Timely initiation of evidence-based management protocols for abdominal trauma can improve patient outcomes. Evidences have shown that, management of traumatic abdominal patient at standard trauma centers coupled with optimal use of modern technology favors the benefits of decreasing mortality and morbidity associated with abdominal trauma. In fact various countries especially developed countries have endorsed the availability of standard trauma care and modern technology to be used while managing traumatic abdominal patient. Greater disparities exist between developed and developing countries in terms of tackling various cases of trauma. What remains unknown is how to eliminate these disparities? New strategies should be designed in order to eliminate such disparities. All worlds' countries have adopted the agenda to achieve sustainable development goals by 2030. It has been strongly affirmed that none should be left behind. Putting more efforts in solving abdominal trauma with new solutions is an effective way to use for supporting traumatic abdominal patient to move with others in the journey towards achieving sustainable development goals.

### **9. Future prospectus**

Many publications have affirmed that, majority of trauma cases happen in middle and low income countries. However, data showing specifically epidemiology of trauma per body region are not available in these countries. For instance there is lack of data showing epidemiology of abdominal trauma in developing countries and as real fact it is hard to know extent of the complications associated with the management of abdominal trauma in these countries. Designing a new strategy for collecting trauma data per body region will support to develop new strategies that will be used to mitigate the burden of such certain injuries. Moreover, uses of imaging modalities are highly essential in terms of improving management outcomes for trauma patient. However, there is still shortage of these imaging modalities in most of developing countries probably due to the fact that, these imaging modalities are very expensive. Dealing with companies which manufacture equipments of imaging modalities to ensure cost effectiveness for these equipments will support in terms of availability of these imaging modalities in developing countries and this will be one of the new solutions for solving abdominal trauma plus among others.

One of the targets of SDGs 3 has been to halt number of global deaths and injuries from road traffic accidents. This target was to be achieved by 2020; however, globally a road traffic accident which is the major cause of blunt abdominal trauma continues to happen at unacceptable level. Rethinking on new strategies for achieving this designed target which aim to mitigate global deaths from injuries will support to reduce complications associated with trauma. Moreover, many communities and countries continue to lack peace, which is among the leading cause of abdominal trauma and other injuries. Various authorities from all parts of the world should look for the new ways of maintaining peace and this will reduce suffering caused by physical violence for many people.

#### **Acknowledgements**

Firstly, I would like to acknowledge my dear DIANE UMWALI, my parents JOTHAM KAMEGELI AND KESIE NYIRANGEJEJAHO, and my Elder brother GERARD NKUNZURWANDA for their profoundly constructive, supportive and inspiring ideas, and financial support given to me while preparing this chapter. Secondary, I sincerely thank the Government of RWANDA for its profoundly commitments and ambitions towards: (1) achieving sustainable development goals by 2030 and vision 2050, (2) optimizing health status of all Rwandans, (3) empowering the youths, and (4) creating strong communities which love life and development more than any other things etc. Without these commitments this work would have not come into the reality.

#### **Conflict of interest**

The author declare no conflict of interest.
