Injuries to the spleen, liver, bladder, gut, etc., are not an uncommon cause of preventable death and their proper clinical assessment is vital. The spleen,liver, retroperitoneum, small bowel, kidneys, bladder, collorectum, diaphragm, and pancreas tend to be the most commonly injured organs.
Signs and Symptoms of Blunt Injuries
Abdominal injuries can be masked by injuries elsewhere, e.g fractured limbs, fractured ribs or spinal cord, and head injuries, and may also develop slowly. If a patient has multiple injuries, assume the abdomen is involved until this is ruled out. Organomegaly makes the involved organs more vulnerable to abdominal trauma, so be cautious with children with pre-trauma splenomegaly.
Nota Bene: Unexplained shock in a trauma patient should point towards an intra-abdominal bleed.
Clinical Features
Of important value are the vital signs (pulse rate, blood pressure, respiratory rate, temperature). There maybe be obvious bruises or abdominal wall indicates the most likely site of injury. Abdominal distension could be due either to gas leaking from a ruptured viscous or from blood from injured solid organ(s) or to torn blood vessels. This is a serious sign. Heamaturea occurs in bladder injuries and haematochezia in rectal injuries.
The absence of bowel sounds or sustained shock despite resuscitation mandates urgent intervention.
Investigations
- Plain abdominal and chest x-rays may show existing fractures, foreign bodies, gas under the diaphragm, or bowel loops in the chest. Order abdominal ultrasound or CT scans as applicable.
- Total blood counts are useful for serial assessments.
- Group and cross-match blood in intra abdominal bleed is suspected.
- Bloody nasogastric aspirate may indicate upper gastrointestinal tract injuries
- Peritoneal lavage is indicated in the following patients:
- Patients with spinal cord injury.
- Those with multiple injuries with unexplained shock.
- Obtunded patients with possible abdominal injury.
- Intoxicated patients in whom abdominal injury is suggested.
- Patients with potential intra-abdominal injury who will undergo prolonged anaesthesia for another procedure.
- Where available abdominal ultrasound is a useful diagnostic tool.
Management
- Maintain airway and breathing.
- Is your patient in shock? (Has low BP, high pulse rate, cold clammy extremities, etc). Take blood samples for later grouping and cross matching and transfer samples with the patient.
- Clean, stitch, and dress small superficial wounds, but do not let this adversely delay referral. Management at level 2 and 3 is limited mainly to patient resuscitation in order to stabilize the patient.
- Give tetanus toxoid 0.5ml STAT.
- Start antibiotics Ceftriaxone 1g QID+metronidazole 400 mg TDS IV as appropriate
- Keep the patient warm
- Closely monitor BP, Pulse rate, respiratory rate, temperature,and urine output.
- Measure abdominal girth, as this may prove useful in follow up of patients’ progress
- If not sure of wound depth, explore the wound directly under local anaesthesia.
- Explore penetrating wounds early.
- In blunt trauma, manage according to clinical findings and how they evolve over time. Mild symptoms are managed conservatively, while deterioration is managed by exploration.
- Indications for laparotomy in blunt trauma include:
- Persistent abdominal tenderness and guarding.
- Persistent unexplained shock
- Paralytic ileus
- Positive radiological or ultrasound findings of pneumo-peritoneum or multiple air-fluid levels
- Positive peritoneal lavage or ultrasound findings
- Manage specific organ injuries at laparotomy.
- Inform receiving facility when the referral has left the referring facility as trauma needs urgent attention on arrival.
- At discharge, provide adequate documentation to be sent back to referring facility.