88: Abdominal Trauma

Key Points

• A normal physical examination cannot be used as the sole means to exclude significant injury in patients with abdominal trauma.

• Hemodynamically unstable patients with penetrating injuries into the peritoneal cavity or blunt abdominal trauma and evidence of intraperitoneal hemorrhage require emergent laparotomy.

• Gunshot wounds that violate the peritoneum require operative exploration because of the high likelihood of injury.

• In patients with blunt abdominal trauma, negative computed tomograhy imaging has an excellent negative predictive value for excluding significant injury.

Introduction

Victims of abdominal trauma can present with intraperitoneal, retroperitoneal, and intrathoracic injuries. Intraperitoneal structures at a high risk of injury include the solid organs (liver and spleen), hollow viscera (small and large intestines), and diaphragm, whereas commonly involved retroperitoneal structures include the kidneys and genitourinary (GU) tract, duodenum, pancreas, and portions of the large intestine. The initial evaluation and management of patients with abdominal trauma can be divided by the mechanism of injury into blunt and penetrating pathways. Motor vehicle collisions (MVC) and significant falls account for the majority of cases of blunt abdominal trauma, whereas stab wounds (SW) and gunshot wounds (GSW) account for most cases of penetrating trauma. Keep in mind that the location of an entrance wound can frequently be misleading. Although a wound located on the anterior abdomen is obviously a high-risk injury, alternative sites (lower chest, pelvis, back, or flank) can also result in significant intraperitoneal (or retroperitoneal) injury depending on the trajectory of the bullet, knife, or other wounding implement.

When evaluating patients with penetrating trauma, the abdomen can be divided up into 4 distinct zones to help predict which anatomic structures are at risk of injury. The anterior abdomen extends between the anterior axillary lines from the costal margins down to the inguinal ligaments (Figure 88-1). The thoracoabdominal region extends circumferentially around the entire trunk between the costal margins inferiorly and the nipple line or inferior scapular borders superiorly (Figure 88-2). Trauma to this region can injure intrathoracic and intraperitoneal structures as well as the diaphragm. The flanks compose the third anatomical zone and extend between the anterior and posterior axillary lines from the costal margins to the iliac crests. Consider injuries to both intraperitoneal and retroperitoneal structures in this region. The final anatomical zone is the back, which extends between the posterior axillary lines from the inferior scapular borders to the iliac crests. Trauma to this region is most likely to result in retroperitoneal injury.

MVCs account for the majority of cases of significant blunt abdominal trauma across all demographic groups, with the spleen by far the most commonly involved organ. With penetrating trauma, abdominal SWs are roughly 3 ...