Abdominal trauma

                                                          Diagnosis & Treatments


Diagnosis

Ten percent of people with polytrauma who had no signs of abdominal injury did have evidence of such injuries using radiological imaging. Diagnostic techniques used include CT scanning, ultrasound, and X-ray. X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. Diagnostic laparoscopy or exploratory 
laparotomy may also be performed if other diagnostic methods do not yield conclusive results.


Ultrasound

Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, and it is a noninvasive procedure and relatively safe. CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. A normal ultrasound does not rule out all injuries.


CT Scan

People with abdominal trauma frequently need CT scans for other trauma (for example, head or chest CT); in these cases abdominal CT can be performed at the same time without wasting time in patient care.

CT is able to detect 76% of hollow viscous injuries so people who have negative scans are often observed and rechecked if they deteriorate. However, CT has been demonstrated to be useful in screening people with certain forms of abdominal trauma in order to avoid unnecessary laparotomies, which can significantly increase the cost and length of hospitalizations.  A meta-analysis of CT use in penetrating abdominal traumas demonstrated sensitivity, specificity and accuracy >= 95%, with a PPV of 85% and an NPV of 98%. This suggests that CT is excellent for avoiding unnecessary laparotomies but must be augmented by other clinical criteria to determine the need for surgical exploration (23.37positive likelihood ratio, 0.05 negative likelihood ratio).


Peritoneal lavage

Diagnostic peritoneal lavage is a controversial technique but can be used to detect injury to abdominal organs: a catheter is placed in the peritoneal cavity, and if fluid is present, it is aspirated and examined for blood or evidence of organ rupture. If this does not reveal evidence of injury, sterile saline is infused into the cavity and evacuated and examined for blood or other material. While peritoneal lavage is an accurate way to test for bleeding, it carries a risk of injuring the abdominal organs, may be difficult to perform, and may lead to unnecessary surgery; thus it has largely been replaced by ultrasound in Europe and North America.


Classification

Abdominal trauma is divided into blunt and penetrating types. While penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, diagnosis of blunt abdominal trauma is more likely to be delayed or altogether missed because clinical signs are less obvious.Blunt injuries predominate in rural areas, while penetrating ones are more frequent in urban settings. Penetrating trauma is further subdivided into stab wounds and gunshot wounds, which require different methods of treatment.

Treatment

Abdominal trauma requires urgent medical attention and sometimes requires hospitalization. The initial treatment involves stabilizing the person enough to ensure adequate airway, breathing, and circulation, and identifying other injuries. Surgery may be needed to repair injured organs. Surgical exploration may be necessary for people with penetrating injuries and signs of peritonitis or shock. 

Laparotomy is often performed in blunt abdominal trauma, and is urgently required if an abdominal injury causes a large, potentially deadly bleed.The main goal is to stop any sources of bleeding before moving onto any definitive find and repair any injuries that are found.Due to the time sensitive nature, this procedure also emphasizes expedience in terms of gaining access and controlling the bleeding, thus favoring a long midline incision. Intra-abdominal injuries are also frequently successfully treated nonoperatively as there is little benefit shown if there is no known active bleeding or potential for infection. 

The use of CT scanning allows care providers to use less surgery because they can identify injuries that can be managed conservatively and rule out other injuries that would need surgery. Depending on the injuries, a person may or may not need intensive care. For injuries that penetrate the 
peritoneal cavity  (penetrating abdominal trauma), prophylactic (preventative) antibiotics are often adminitered with the goal of reducing the risk of sepsis and septic complications, including 
septicaemia, abscesses in the abdomen, and wound infections. The effectiveness of the use of antibiotics prophylactically for penetrating abdominal trauma has not been well studied and there is no strong evidence to support one particular antibiotic type or dose over another. The length of time that these antibiotics should be used for is also not clear.


Prognosis

If abdominal injury is not diagnosed promptly, a worse outcome is associated. Delayed treatment is associated with an especially high morbidity and mortality if perforation of the gastrointestinal tract is involved.


Epidemiology

Most deaths resulting from abdominal trauma are preventable; abdominal trauma is one of the most common causes of preventable, trauma-related deaths.