REVIEW URRENT C OPINION

Isolated abdominal trauma: diagnosis and clinical management considerations Andreas A. Prachalias and Elissaios Kontis

Purpose of review The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma. Recent findings Progress in the management of trauma patients increasing survival includes a multidisciplinary approach involving multiple specialties at presentation. If immediate surgical intervention is needed, ‘damage control’ is the best option; if not, it has been proven that conservative management is superior to operative, in terms of survival for the majority of intraabdominal injury. ‘Open abdomen’ should be performed in major abdominal traumas when indicated. Early enteral feeding is beneficial, even in the presence of ‘open abdomen’. Summary Abdominal trauma is a complex injury; the multidisciplinary approach has made nonoperative management feasible and effective. When surgical intervention is needed, it should be performed in an orderly fashion, within the context of the overall management. Keywords abdominal trauma, clinical management, diagnosis

INTRODUCTION Abdominal trauma affects predominantly younger people and is a leading cause of mortality within this age group, with an expected increase of its prevalence [1]. From the historic warfare-inflicted injuries to casualties encountered in an urban emergency department, abdominal trauma remains a surgical disease with grave burden to society, warranting the utmost qualities of a surgeon. Progress in the management of trauma patients increasing survival is the concept of a multidisciplinary approach involving multiple specialties [2 ] and that of ‘damage control’ [3]. Those concepts represent a deeper understanding of the complex pathophysiological mechanisms involved in trauma; abdominal trauma is a complex injury within a complex cavity. The scope of the present study is to review the topics of initial assessment, diagnosis and management of abdominal trauma.

should be assessed in a structured and systematic manner, which will guide through diagnostic tests and contribute to decision-making about treatment. To this end, the well established courses of Advance Trauma Life Support (ATLS) [4] and its extension Pre-Hospital Trauma Life Support (PHTLS) [5], have had a significant overall impact [6]. Within the context of the present review of an isolated abdominal trauma, the two most important questions to be answered are mechanism of injury and cardiovascular stability.

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PRESENTATION AND INITIAL ASSESSMENT OF THE TRAUMA PATIENT Trauma is a complex disease that may affect multiple sites of the body. In this context, patients www.co-criticalcare.com

Mechanism of injury Injuries are categorized to blunt and penetrating trauma. Initial assessment should also take into Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK Correspondence to Andreas A. Prachalias, MD, Consultant Surgeon, Liver Transplant, Hepatobiliary and Pancreatic Surgery, Lead Clinician for HPB Surgery, Institute of Liver Studies, King’s College Hospital, Denmark Hill, SE5 9RS. Tel: +44 2032991144; fax: +44 0 2032993575; e-mail: [email protected] Curr Opin Crit Care 2014, 20:218–225 DOI:10.1097/MCC.0000000000000074 Volume 20  Number 2  April 2014

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Isolated abdominal trauma Prachalias and Kontis

KEY POINTS  A multidisciplinary approach should be initiated at the time of presentation of every trauma patient.  If immediate surgical intervention is needed, ‘damagecontrol’ is the best option, followed by resuscitation in the ICU.  The majority of intraabdominal traumas can be managed conservatively.  In ‘damage-control’, temporary abdominal closure is preferred.  Definitive treatment should take place when the maximal effect of resuscitation has been achieved.

account the kinetic energy involved, that is for a blunt trauma a high velocity road traffic accident or for a penetrating trauma a high velocity projectile. High suspicion is warranted in high kinetic energy traumas, as there could be delayed presentation of injuries not apparent in primary assessment, for example aorta injuries [7] or diaphragmatic rupture [8]. In addition, the cavitation associated with injury from high velocity projectiles influences treatment options [9].

Cardiovascular stability The cardinal question affecting the management of all trauma patients: despite the controversies in the type or the volume of fluid to be administered [10,11], resuscitation with intravenous fluids of every trauma patient entering the hospital is pivotal [5]. Hemorrhagic shock is the major cause of early mortality in trauma patients [12]. The goals of fluid resuscitation include maintenance of cerebral and myocardial perfusion, appraisal for a massive ongoing hemorrhage and correction of the ‘lethal triad’ of acidosis, coagulopathy and hypothermia [13,14]. A patient with abdominal trauma who is cardiovascularly unstable after appropriate resuscitation with fluids, blood products and inotropic support often warrants laparotomy and surgical haemostasis [2 ,15]. &

unstable after resuscitation needs no further diagnostic tests.

Physical examination Physical examination should be thorough and address the whole body. Clinical examination of the abdomen should be done to all trauma patients. However, the clinical examination of the abdomen is less sensitive in the setting of depressed level of consciousness secondary to head injury, alcohol and/or drug intake or in the setting of severe spinal cord injuries [16,17]. An objective evaluation of the abdomen is recommended for all patients with blunt abdominal trauma and a major trauma mechanism and/or equivocal physical examination and/or multiple extra-abdominal injuries [18,19].

Objective evaluation of the abdomen Objective evaluation of the abdomen refers to diagnostic modalities producing verifiable evidence of visceral injury. Peritoneal tap/paracentesis and diagnostic peritoneal lavage Peritoneal tap was the first method used for detecting haemoperitoneum but its sensitivity depends markedly from the amount of blood within the peritoneal cavity, and therefore it is no longer recommended [20]. Diagnostic peritoneal lavage (DPL) has been found to be more sensitive in detecting haemoperitoneum, and thus has replaced the peritoneal tap [20]. DPL is highly sensitive; however, it does not identify specific organ injury or retroperitoneal and diaphragmatic injuries, and may interfere with the interpretation of subsequent computed tomography (CT) scans. Currently, it is limited to unstable patients with blunt abdominal trauma [21]. Focused assessment for the sonographic examination of the trauma patient Focused assessment for the sonographic examination of the trauma patient (FAST) is used to assess seven areas of the body; from top to bottom: pericardium, pleural cavities, liver, spleen and paracolic gutters and pelvis [2 ]. Despite the initial disbeliefs, currently, FAST is part of the initial assessment of every major trauma patient during the primary and secondary assessment [2 ,20]. The advantages of FAST are that it is both specific and sensitive, noninvasive, repeatable and does not require transfer of the patient [2 ]; however, a negative FAST does not abolish the need for a CT scan [22]. The two main &

DIAGNOSIS OF INTRAABDOMINAL VISCERAL INJURY Diagnosing an intraabdominal visceral injury necessitates understanding of the mechanism of injury and a systematic approach within a clinical context, that is a patient presenting with penetrating abdominal trauma and who is cardiovascularly

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indications for FAST are: a hypotensive patient with blunt abdominal trauma and a stable patient with penetrating injury to the abdomen [23]. Computed tomography CT is the method of choice for diagnosing intraabdominal injury [20]. It has been found to be extremely sensitive and specific for the injury of solid intraabdominal organs, thus many grading systems for organ injury are based on CT findings. However, it is less sensitive for diagnosing bowel and diaphragmatic injuries [24–26]. The sensitivity of CT scan for bowel injuries can be enhanced with a ‘triple-contrast CT’, that is with the addition of contrast enema [27], if clinical need so dictates. Overall, CT scan is the method of choice for assessing abdominal trauma. The widespread implementation of CT scan in trauma patients, along with proper physical examination, has made feasible the nonoperative management of abdominal trauma [20]. However, it has a significant prerequisite: it refers only to a haemodynamically stable patient. Diagnostic laparoscopy Diagnostic laparoscopy is a controversial issue. Surely, direct visualization of the intraperitoneal cavity can diagnose penetration of the peritoneal cavity and injury to solid organs and the diaphragm [28]. However, it requires extra time to set up the theatre, it is difficult to examine the entire gastrointestinal tract and the examination of the retroperitoneum is problematic [20]. Diagnostic laparoscopy may be the most appropriate way to exclude diaphragmatic injury in a patient with thoracoabdominal injury [29,30], but within the context of an isolated abdominal injury diagnostic laparoscopy is of little value.

ABDOMINAL TRAUMA Table 1 presents a detailed description of grading of injury for every organ mentioned hereafter.

angiography and embolization [31]. Approximately, 14% of all liver traumas are currently being managed operatively [34], and usually refer to unstable patients with complex hepatic injuries that are taken directly for laparotomy. When a liver trauma is identified during an emergency laparotomy, the various surgical options should be escalated in an orderly fashion. Packing is the ‘gold standard’. If packing fails to control the bleeding it is usually due to either significant arterial injury or juxtahepatic venous and/or inferior vena cava (IVC) injury. Inflow occlusion can help to improve the efficiency of packing in cases of arterial injury until definitive control. If the above manoeuvres control the bleeding, damage control laparotomy should be completed followed by resuscitation in the ICU and angiography, if needed [31,35]. If the above manoeuvres fail to control the bleeding, complex surgical strategies will be required if injuries involve the confluence of hepatic veins or IVC with often unfavourable outcome. One should diagnose whether it is arterial bleeding or venous bleeding. In the case of arterial bleeding, selective hepatic artery ligation can be considered, whereas in venous bleeding from hepatic veins or IVC, a shunting procedure such as cavoatrial shunt or femoral-axillary bypass should be consider, although it carries grave mortality [35]. The time for a ‘second-look’ laparotomy is not well defined, but the best time may be when the ‘lethal triad’ has resolved or been adequately addressed. During the ‘second-look’ laparotomy, any resection in the form of debridement can be performed if indicated [36].

Splenic trauma The spleen is the most commonly injured organ in blunt abdominal trauma [37], and represents another example of paradigm shift toward nonoperative management. Again the precise grading of splenic injury [33] had a significant impact. For Grade III or IV splenic injuries, there is however ongoing debate as to whether conservative management is the best option [38,39 ]. The preservation of splenic function is the ultimate goal and splenectomy should not be decided easily; however, when severe splenic injury is associated with multiple injuries to other sites, the risks of conservative management may outweigh the benefits. &

Liver trauma The liver is the largest intraabdominal organ, thus it is very often injured both in penetrating injuries (‘large target’) and blunt abdominal trauma (‘large mass’ due to inertia) [16]. Today, the diagnosis of liver trauma is usually made by means of FAST or CT [31]. Liver trauma is the most typical example of paradigm shift toward the nonoperative management of intraabdominal injuries [32]. To this end, the detailed grading system had a significant contribution [33]. The majority of liver traumas today can be managed conservatively with or without 220

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Pancreatic and duodenal trauma Pancreatic and duodenal injuries may result from either penetrating or blunt injuries, although are more common after penetrating injuries [16]. Because of its anatomic location, isolated pancreatic Volume 20  Number 2  April 2014

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Isolated abdominal trauma Prachalias and Kontis Table 1. Scaling system for organ-specific injuries according to the American Association for Trauma Surgery Organ

Injury type

Description of injury

Liver (1994 revision) I

Hematoma

Subcapsular, 75% of hepatic lobe or >3 Couinaud’s segments within a single lobe

II III

VI

Vascular

Juxtahepatic venous injuries; i.e., retrohepatic vena cava/central major hepatic veins

Vascular

Hepatic avulsion

Spleen (1994 revision) I

Hematoma

Subcapsular, 3 cm parenchymal depth or involving trabecular vessels

IV

Laceration

Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen)

V

Laceration

Completely shattered spleen

Vascular

Hilar vascular injury that devascularizes spleen

Hematoma

Minor contusion without duct injury

Pancreas I

Laceration

Superficial laceration without duct injury

Hematoma

Major contusion without duct injury or tissue loss

Laceration

Major laceration without duct injury or tissue loss

III

Laceration

Distal transection or parenchymal injury with duct injury

IV

Laceration

Proximal transection or parenchymal injury involving ampulla

V

Laceration

Massive disruption of pancreatic head

Hematoma

Involving single portion of duodenum

II

Duodenum I

Laceration

Partial thickness, no perforation

Hematoma

Involving more than one portion

Laceration

Disruption 75% of circumference of D2

II

Disruption 50–100% of circumference of D1, D3, D4 Involving ampulla or distal common bile duct V

Laceration

Massive disruption of duodenopancreatic complex

Vascular

Devascularization of duodenum

Stomach I

Contusion/hematoma Partial thickness laceration

II

Laceration 10 cm in distal 2/3 stomach

IV

Tissue loss or devascularization 2/3 stomach

Small bowel I

Hematoma

Contusion or hematoma without devascularization

Laceration

Partial thickness, no perforation

II

Laceration

Laceration 50% of circumference without transection

IV

Laceration

Transection of the small bowel

V

Laceration

Transection of the small bowel with segmental tissue loss

Vascular

Devascularized segment

Hematoma

Contusion or hematoma without devascularization

Laceration

Partial thickness, no perforation

II

Laceration

Laceration 50% of circumference without transection

IV

Laceration

Transection of the colon

V

Laceration

Transection of the colon with segmental tissue loss

Vascular

Devascularized segment

Contusion

Microscopic or gross hematuria, urologic studies normal

Colon I

Kidney I

Hematoma

Subcapsular, nonexpanding without parenchymal laceration

II

Hematoma

Nonexpanding perirenal hematoma confirmed to renal retroperitoneum

Laceration

30%) with pancreatic trauma have normal serum amylase [42,43 ]. In haemodynamically stable patients, the method of choice for diagnosing pancreatic injuries is CT with pancreatic parenchyma phase, which is often not included in most trauma protocols, thus up to 40% of pancreatic injuries may be missed during initial imaging [44,45]. A detailed and &

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comprehensive grading of pancreatic and duodenal trauma is available from the American Association for the Surgery of Trauma [46]. Operative management of pancreatic trauma follows again the principles of haemodynamic stability but surgical strategies depend upon two factors: site of pancreatic injury (i.e. proximal-head vs. distal-neck, body, tail) and integrity of major pancreatic duct. For the unstable patient, the best option is damage control. For contusions or lacerations without ductal injury, conservative management may be the most appropriate approach. When ductal injury is associated with distal pancreatic injury, distal pancreatectomy is warranted [40]. When it is associated with the head of pancreas, drainage is the best option [40]. Pancreatoduodenectomy should be considered only when there are associated injuries of the duodenum and common bile duct, and the traumatic force has done most of the ‘dissection’ with the restoration of continuity being done in a later stage [40,47–50]. An important adjunct in the medical management of pancreatic trauma is prophylactic octreotide administration; however, its use has not been unanimously accepted [40,51].

Gastric, small bowel and colon trauma Gastrointestinal tract injuries are rare in general, and more commonly occur after penetrating rather than blunt abdominal trauma [16]. The colon is the commonest injured portion of the gastrointestinal tract and is the second most frequent organ injured after gunshot wounds and the third after stab wounds to the abdomen [16]. The diagnosis of hollow viscous injury is challenging, if no signs of peritonitis are present, as CT scan may be inconclusive [25,26], causing delay to treatment. In this context, DPL has been proposed as a tool to exclude hollow organ perforation prior to committing to nonoperative management [21]. Treatment of hollow viscous injury could be either primary repair or resection depending on the extent and nature of injury [52,53]. Primary repair in cases of colonic injury is still controversial with colonic diversion being the most commonly performed procedure [54]. Existing level I and II evidence will eventually shift the practice toward primary repair of colonic injuries [55,56]. The repair is done during the initial laparotomy only if the physiological status of the patient permits.

Retroperitoneum: kidney, major vessels and adrenals Renal trauma is a rarity occurring in less than 5% of all trauma patients, with a preponderance of blunt

over penetrating injuries [57]. The kidney was one of the first organs to have an injury grading scale, which is still in use [58]. Overall management is toward nonoperative management. Laparotomy is usually done for another injury and rarely for an isolated renal injury. The trend in kidney injuries is to reconstruct if possible [59]. Blunt injuries of the major vessels are rare and associated with major trauma mechanism as well as injuries to the bowel or retroperitoneal organs such as the kidneys and other intraabdominal vessels such as the iliac vessels [60]. Patients with injuries to the major vessels, if they reach the hospital alive, have a grave mortality rate reported as high as 30% [7]. A penetrating injury to the major vessels is usually devastating. Finally, adrenal injury is an extreme rarity and usually either accompanies isolated injuries of the kidneys, or devastating abdominal traumas. Treatment is almost exclusively conservative [61].

FEATURES OF CURRENT SURGICAL MANAGEMENT The management of abdominal trauma has changed dramatically toward a nonoperative approach that increased survival [62]. This was made feasible because of the technical advancements in radiology, interventional radiology and endoscopy such as embolization or endoscopic retrograde cholangiopancreatography. Currently, only 20% of trauma patients will need an operation [62]. ‘Damage control’ laparotomy is the best option for a cardiovascularly unstable patient after abdominal trauma and is executed in three parts: initially, the goals are haemostasis and cessation of contamination of the peritoneal cavity as soon as possible with temporary abdominal closure; this is followed by the completion of resuscitation in the ICU, that is correction of acidosis, coagulopathy and hypothermia; and the final phase is the definitive management of injuries and abdominal closure [6]. ‘Open abdomen’ is critical in ‘damage control’: vigorous fluid resuscitation in conjunction with the lethal triad can lead to intraabdominal hypertension and abdominal compartment syndrome, which when undiagnosed leads to multiple organ dysfunction syndrome (MODS) [6,9,63,64 ]. MODS in trauma can also be triggered either by systemic inflammatory response syndrome due to tissue destruction (early MODS) or compensatory anti-inflammatory response syndrome due to surgical stress, bacterial infection or ischemia reperfusion injury [65]. The major cause of late mortality in trauma patients is sepsis-related complications. Therefore, every effort should be made to keep these patients out of the vicious cycle of sepsis. To

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this end, the ‘open abdomen’ is an ‘Achilles heel’ as it allows the communication of a sterile cavity to the environment. Two factors that can alleviate this issue are broad-spectrum antibiotics and enteral feeding, if not otherwise contraindicated. Enteral feeding preserves the physiological gut barrier function and preserves gut-associated lymphoid tissue, thus decreasing the translocation of bacteria to the blood, further intensifying the inflammatory response [66]. It has been proven that early initiation (within 24 h from injury) of enteral feeding can reduce mortality in trauma patients [67], as it addresses both the metabolic needs of a trauma patient and reduces the risk of gut-related septic complications. ‘Open abdomen’ previously was an inhibitory factor for enteral nutrition, but there is growing evidence that early initiation of enteral feeding is well tolerated and beneficial [68,69].

CONCLUSION In abdominal trauma increased survival can be achieved with a conservative approach, if the physiologic status of the patient allows it. If laparotomy is warranted, give the ‘best operation’ to the stable patient and the ‘quickest’ to the unstable. The goal in a major trauma patient is to survive ‘today’ to ‘fight’ again ‘tomorrow’, when the odds are in the patient’s favour. Acknowledgements None. Conflicts of interest The authors have no conflicts of interest to declare.

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Isolated abdominal trauma: diagnosis and clinical management considerations.

The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma...
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