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Abdominal trauma has a high priority in the diagnosis and treatment of a patient with multiple injuries. Both blunt and penetrating injuries may be isolated or multiple and they are often combined with extraabdominal trauma. A close cooperation between surgical and other specialties is often needed. Transport from a smaller hospital to a center with full diagnostic and therapeutic facilities may be advantageous.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
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20% of patients with multiple injuries have abdominal injuries. Patients with massive symptoms and signs indicating abdominal injury should receive high priority in the treatment of the multiple injury patient, second only to injuries to airways and thorax. The unstable critically ill patient must undergo laparotomy without further investigation. In a patient in extremis, however, left emergency thoracotomy and clamping of the descending aorta should be performed prior to the laparotomy. Extensive abdominal haemorrhage should be treated first with a tamponade to control the bleeding, after which the patient should receive further transfusions and treatment to correct acidosis. It is then possible to proceed with further necessary surgical repair. In many patients with multiple injuries, however, the problem is to diagnose the abdominal injury. Peritoneal lavage is a sensitive but unspecific method of diagnosis, and the discovery of blood in the lavage fluid is not an absolute indication for laparotomy. Sometimes injuries to parenchymatous organs may be treated without operation. This necessitates good clinical judgment, available adequate diagnostic imaging techniques and repeated examinations by an experienced surgeon.
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When head and blunt abdominal injuries are combined, the head injury is often afforded too much attention and the abdominal injury too little, especially when the patient is unconscious. If mismanaged, the abdominal injury is often the more serious threat to life. Except for extradural hemorrhage, neurosurgical intervention, when indicated, can be delayed until the patient has been thoroughly evaluated for the presence of extra cranial injuries with higher therapeutic priority. Abdominal examination of the unconscious or uncooperative patient is difficult. Tenderness as a sign of abdominal injury cannot be elicited. Abdominal rigidity (in the absence of rigid extremities), a silent abdomen, shock, and extreme restlessness may indicate intra-abdominal changes. Abdominal paracentesis is a valuable diagnostic aid, and the finding of blood, bile-stained fluid, intestinal contents or air is an indication for immediate laparotomy. Once all injuries are known, priorities for treatment can be assigned. Often head and abdominal injuries can be treated concomitantly.
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The purpose of this study was to evaluate the usefulness of abdominal ultrasonic tomography, among other methods, to detect visceral lesions in multiple traumas of the abdomen. Forty-seven case-records of abdominal traumas observed over an 8-month period were selected. We used a real-time sectorial ultrasound scanner with a 3.5 MHz probe. Positive results were obtained in 11 patients who were operated upon. None of the 33 patients with negative results and only one of the 3 patients with doubtful results underwent surgery. We found that suggestive symptoms were compatible with the absence of any severe visceral lesion and, conversely, that patients with multiple traumas but little suggestive symptoms could present with one or several intra-abdominal lesions. Abdominal ultrasonic tomography can rapidly be performed and its indications are different from, but wider than, those of peritoneal lavage. It is a safe and reliable emergency examination which does not interfere with resuscitation procedures.
Peritoneal lavage is a sensitive method of detecting intra-abdominal injuries following closed abdominal injury. Our indications for peritoneal lavage are: severe head injury, severe thoracic injury, unexplained hypotension in a patient with possible blunt abdominal injury and patients on artificial ventilation. We present 40 patients with multiple injuries who underwent peritoneal lavage for suspected closed abdominal injury. Twenty-two lavages were positive and 19 laparotomies were performed, of which 18 revealed intra-abdominal injuries. Eighteen lavages were negative; no laparotomy was performed in this group. There was one false positive, but no false negative lavage.
Intra-abdominal injuries of the bowel, mesentery, and mesenteric vessels were found at laparotomy in two patients with nonpenetrating gunshot wounds of the abdominal wall. The mechanism of wounding is thought to be the temporary cavity around the wound tract. The importance of complete angiographic investigation and early exploratory laparotomy is stressed.
The present work deals with the problem of abdominal injuries in polytraumatized patients. The results were obtained from a retrospective study of the records of 530 polytraumatized patients treated at the Central Hospital of the German Federal Armed Forces (Bundeswehr). In all, 193 of these patients had abdominal injuries. The overall mortality was 23.8% (n = 126): mortality among the patients with abdominal injuries was 26% (n = 50). Abdominal injuries alone led to death in 9.1% (n = 1), but mortality increased to 18.4% when at least one extra-abdominal injuries was also present. A combination of abdominal injuries and two or more extra-abdominal lesion led to a mortality rate of 27%. Mortality was found to be age- and sex-related: in young children and patients over 55 years (especially those around 70) mortality was 33.3%-72%. Among the cases with fatal outcome there was a female-to-male ratio of 3:2. The most common causes of death were: hemorrhage shock (62.3%), head injuries (37.7%), septicemia (8.1%), pneumonia, and ARDS (5.4% each). Within the last eight years we have used the following supplementary examination methods: computed tomography, peritoneal lavage, and ultrasonography. The retrospective study has shown that CT is not the examination of choice. The reliability with lavage and ultrasonography was approximately the same, but lavage was found to be more dangerous. Therefore, we abandoned lavage and used sonography only. However, we are of the opinion that any surgeon should use the examination method that has yielded the best results for him or her, to ensure the best possible outcome for the patient.
Seat belts reduce the severity of trauma in car accidents. There is a definite decrease in the percentage of head injuries, while abdominal lesions seem to increase. Experimental and clinical investigations show a predominance of abdominal wall injuries and liver ruptures. The seat belt syndrome requires close observation of the patient in the intensive care unit. An increasing number of late intestinal obstructions after a seat belt injury due to lesions of the intestinal wall are reported.