**2.6. Laparoscopy**

**2.4. CT scanning**

78 Trauma Surgery

CT is noninvasive, qualitative, sensitive, and accurate for the diagnosis of intra-abdominal injury. Modern spiral scanners have greatly decreased the time required for obtaining high quality images. However, CT scanning remains expensive. CT scanning requires transport

CT scanning has a primary role in defining the location and magnitude of intra-abdominal injuries related to blunt trauma. It has the advantage of detecting most retroperitoneal injuries, but it may not identify some gastrointestinal injuries. The formation provided on the magnitude of injury allows for nonoperative management of patients with solid organ injuries. In the hemodynamically stable patient, CT scanning is an excellent diagnostic modality that is easy to perform. No diagnostic modality outperforms CT in the evaluation of intraperitoneal

Diagnostic peritoneal lavage (DPL) is designated to detect the presence of intraperitoneal blood, although its use has decreased significantly at many centers with the use of the FAST

from the acute care area and should not be attempted in the unstable patient.

**Figure 1.** Transducer positions for FAST: pericardial area, right and left upper quadrants, and pelvis.

as well as retroperitoneal injuries (**Figure 2**).

**2.5. Diagnostic peritoneal lavage**

Laparoscopy has an important role in stable patients with penetrating abdominal trauma. It can quickly establish whether peritoneal penetration has occurred and thus reduce the number of negative and nontherapeutic trauma laparotomies performed [5]. Laparoscopy has also been applied safely and effectively as a screening tool in stable patients with blunt abdominal trauma [6].

The use of laparoscopy, with or without CT scanning or DPL, is being studied. It is less invasive than traditional laparotomy and may shorten hospital stays and decrease patient costs, although it requires surgical consultation [7].

### **Positive**

20 mL gross blood on free aspiration (10 mL in children) ≥100,000 red cells/μL ≥500 white cells/μL (if obtained 3 h or more after injury) ≥175 units amylase/dL Bacteria on Gram-stained smear Bile (by inspection or chemical determination of bilirubin content) Food particles **Intermediate** Pink fluid on free aspiration 50,000–100,000 red cells/μL in blunt trauma 100–500 white cells/μL 75–175 units amylase/dL **Negative** Clear aspirate ≤100 white cells/μL ≤75 units amylase/dL

**Table 1.** Criteria for evaluation of peritoneal lavage fluid.

### **2.7. Emergency (exploratory) laparotomy**

Most patients with penetrating abdominal injuries will also require laparotomy given the high incidence of intra-abdominal injury once the fascia has been violated. Hemodynamically unstable patients sustaining blunt or penetrating trauma with a positive screening test [such as focused assessment with sonography for trauma (FAST) examination or diagnostic peritoneal lavage (DPL)] require laparotomy to control hemorrhage and evaluate for intra-abdominal injuries. Also patients with obvious diaphragmatic injury noted on chest X-ray require emergency laparotomy [8].

signs except hypovolemia. The abdomen may be flat and nontender. Patients whose extraabdominal bleeding has been controlled should respond to initial fluid resuscitation with an adequate urine output and stabilization of vital signs. If hypovolemia recurs, intra-abdominal

Physical examination Quick/no cost Useful for serial examinations, very limited by other injuries,

Quick/inexpensive Rapid results in unstable patient but invasive and may be

Quick/inexpensive Rapid detection of intra-abdominal fluid and pericardial

Slower/expensive Most specific for site of injury and can evaluate

coma, drug intoxication, poor sensitivity and specificity

overly sensitive for blood and not specific for site of injury, requires experience and may be limited if previous surgery

Abdominal Trauma

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http://dx.doi.org/10.5772/intechopen.76474

tamponade, may be limited by operator experience, large body habitus, subcutaneous air, poor for detection of bowel

retroperitoneum, very good sensitivity but may miss bowel

injury. Fairly sensitive but not highly specific

injury, risk of reaction to contrast dye

Injuries frequently associated with abdominal injuries are rib fractures, pelvic fractures,

Seek surgical consultation early in the management of patients with abdominal trauma, espe-

Rapid infusion of large amounts of crystalloids may disrupt the formation of the soft clot and dilute the clotting factors, leading to increased bleeding. Attempts to make the patient normotensive are not recommended. A more reasonable goal may be to obtain systolic blood pressure of 80–90 mmHg, or a mean arterial pressure of 70 mmHg. Crystalloids remain first-

The distribution of blunt and penetrating injury in a given population is highly dependent upon geographic location. Blunt injuries predominate in rural areas, while penetrating injuries

abdominal wall injuries, and fractures of the thoracolumbar spine (**Table 2**).

**Method Time/cost Advantage/disadvantage**

bleeding must be considered to be the cause.

**Table 2.** Comparison of diagnostic methods for abdominal trauma.

cially if the patient is hemodynamically unstable [9].

line fluids, followed by infusions of packed red blood cells [10].

**3. Surgical consultation**

Diagnostic peritoneal lavage (DPL)

Focused assessment with sonography for trauma

Helical computerized abdominal tomography

(FAST)

(CT)

**4. Fluid resuscitation**

**5. Types of injuries**

The tree main indications for exploration of the abdomen following blunt trauma are peritonitis, unexplained hypovolemia, and the presence of other injuries known to be frequently associated with intra-abdominal injuries. Peritonitis after blunt abdominal trauma is rare but always requires exploration. Signs of peritonitis can arise from rupture of a hollow organ, such as the duodenum, bladder, intestine, or gallbladder from pancreatic injury, or occasionally from the presence of retroperitoneal blood.

Emergency abdominal exploration should be considered for patients with profound hypovolemic shock and a normal chest X-ray unless extra-abdominal blood loss is sufficient to account for the hypovolemia. In most cases a rapidly performed FAST examination or peritoneal lavage will confirm the diagnosis of intraperitoneal hemorrhage. Patients with blunt trauma and hypovolemia should be examined first for intra-abdominal bleeding even if there is no overt evidence of abdominal trauma. Hemoperitoneum may present with no


**Table 2.** Comparison of diagnostic methods for abdominal trauma.

signs except hypovolemia. The abdomen may be flat and nontender. Patients whose extraabdominal bleeding has been controlled should respond to initial fluid resuscitation with an adequate urine output and stabilization of vital signs. If hypovolemia recurs, intra-abdominal bleeding must be considered to be the cause.

Injuries frequently associated with abdominal injuries are rib fractures, pelvic fractures, abdominal wall injuries, and fractures of the thoracolumbar spine (**Table 2**).
