**3. Risk factors leading to the occurrence of complications associated with management of abdominal trauma**

In addition to understanding anatomy, physiology of abdominal organs and the framework of management for traumatic abdominal patient, it is essential to know other risk factors leading to complications associated with the management of abdominal trauma. Recognizing these predisposing factors can support in planning and enhancing designed measures which aim to avoid the occurrence of the complications associated with abdominal trauma.

#### **3.1 Individual and community related risk factors**

Certain complications associated with the management of abdominal trauma are highly common because of individual and community influence. The common known fact is that, life is made at home and repaired at the hospital. The violation of this fact is seen for individuals who sustain abdominal trauma for whatever the cause and delay to present to the health facility.

For one or more reason (s) some traumatic abdominal patients do not seek immediate medical care for their injury. Ignorance is among the factors stopping some individuals and communities from seeking immediate medical care after trauma event. This is commonly seen in developing countries. In developing countries there are still remarkable dual management approaches for traumatic patients [7]. Some traumatic abdominal patients are first seen by traditional healers. The traditional healers have insufficient knowledge and capacity to support quick restoration of functions of injured abdominal organs. Due to failure of the treatment started by traditional healers, traumatic abdominal patients are further referred to the health facility in delayed time. However, due to the delay the standard of management is compromised, which is a major factor leading to complications associated with management of abdominal trauma.

Furthermore, all individuals and communities of the World are suspected to maintain peace which is one of the 17 sustainable development goals (SDG) maximally all the time. With the current ambitions of various countries to achieve SDGs, peace (SDGs 16) is highly needed. All 17 SDGs integrate each other. Specifically integrating SDGs 3 (good health and wellbeing) and SDGs 16 (peace and justice) would favor the mitigation of injuries in various communities; in fact one of the targets of SDGs 3 is to halt number of global deaths and injuries from road traffic accident by 2020. However, evidences indicate that, wars, conflicts [8, 9] and road traffic accident continue to affect many individuals and communities in many parts of the world. Inflicting various types of injuries including abdominal injuries is among the common worst outcomes of un-peaceful communities. Intentional abdominal injuries are likely to be penetrating. Evidences have shown that penetrating abdominal injuries are associated with many complications such as infections, bleeding etc. Thus, high incidence of penetrating abdominal trauma in a community associates with occurrence of many complications that occur during its management.

#### **3.2 Weak health system and trauma care system related risk factors**

Weak health system of various countries is among the profound factors leading to complications of various diseases or event. Many countries continue to lack strong health system. Weak health system is profoundly found in most of developing countries [9] yet majority of the diseases and events including abdominal trauma happen in these countries. One of the indicators of a weak health system is continuous occurrence of high mortality and morbidity related to trauma ever reported in these counties. Weak health system seemingly marks the negligence of various countries to their populations. For instance, evidence has shown that the spectrum of trauma has increased due to: (1) increased urbanization, (2) use of automobiles, (3) use of firearms. These factors have also led to higher prevalence of abdominal trauma. As of such high prevalence of trauma, one would suspect strong health system (with standard trauma care as component) to be available all the time. However, in many countries this element has been ignored, thus, complications continue to occur among traumatic abdominal patients at any stage of their management.

Likely in developing countries majority of traumatic abdominal patients are still managed at the substandard centers due to weak trauma care system and due to this instance complications develop. Weak trauma care system can be marked by: (1) Inadequate trained trauma care providers to manage abdominal trauma, (2) Lack of pre-hospital services for traumatic abdominal patients, (3) Absence of appropriate referral system for traumatic abdominal patient, (4) lack of interprofessional collaboration while managing traumatic abdominal patient, (5) Negative attitudes of trauma care providers towards traumatic abdominal patients, and (6) Lack of equipments and infrastructure to use while managing traumatic abdominal patients.

#### *3.2.1 Inadequate trained trauma care providers to manage abdominal trauma*

Traumatic abdominal patient should be managed by trained health workers whose knowledge is enough to help to make rational decision regarding management approach. As mentioned earlier the main goal of management of traumatic abdominal patient should be to restore the function of abdominal organs as quick as possible. Lack of trained trauma care providers to provide timely interventions at any stage of

management reduces the chance of survival and those who survive are likely to remain with permanent disabilities.

### *3.2.2 Lack of pre-hospital care services for traumatic abdominal patient*

For many years trauma has been a neglected epidemic worldwide. The history marks increased mortality and morbidity related to trauma because of such neglect [10]. With the recognition of such neglect in 2000 WHO affirmed the use of prehospital care interventions as one way for mitigating the mortality and morbidity associated with any kind of trauma. However, many countries especially developing countries have not adopted the principles of prehospital care optimally yet majority of trauma cases happen in these countries as such poor outcomes including: deaths, prolonged hospital stay and development of complications are still reported at unacceptable level.

Three levels of deaths associated with trauma have been recognized; level 1 (immediate deaths encompass deaths which occur quickly due to overwhelming injuries, level 2 (intermediate deaths encompass deaths which occur within several hours after trauma event and notably result from treatable conditions) and level 3 (delayed deaths encompass deaths which occur within days or weeks after trauma event). Evidences have shown that most of these deaths can be prevented by providing timely prehospital care interventions. Trauma care provider should know conditions which are likely to kill the patient and appropriate tasks to perform in order to prevent such deaths at any of these levels. Traumatic abdominal patient may die at any of these stages due to lack of prehospital care interventions. Examples of conditions which can cause death to abdominal trauma victim at any of these stages are shown in **Table 6**.


#### **Table 6.**

*Levels of deaths associated with trauma and likely interventions which can prevent the occurrence of such deaths.*

#### *3.2.3 Absence of appropriate referral system for traumatic abdominal patient*

The transfer of traumatic abdominal patient may encompass transportation from the scene to health facility or inter-facilities transfer. Depending on the severity of abdominal injury, the patient might need management interventions at different levels of trauma centers. To accomplish such task, an appropriate referral system should be available all the time. Lack of appropriate referral system disturbs the standard of management which is among the prominent factors leading to complications and even sometimes death of abdominal trauma victim.

### *3.2.4 Insufficient inter-professional collaboration while managing traumatic abdominal patient*

Insufficient inter-professional collaboration while managing abdominal trauma patient may increase the occurrence of complications due to: lack of proper communication, increased rates of errors, insufficient assessment of the patient etc.
