Comprehensive Summary of the Document "Abdominal and Pelvic Trauma" from ERC

Introduction and Significance

• Abdominal trauma accounts for approximately 10% of all trauma-related deaths and represents the largest proportion of potentially preventable fatalities.

• Blunt trauma is the most common mechanism in Europe (80% of cases), often presenting with associated injuries (polytrauma).

• Physical examination is notoriously insensitive, making early diagnosis challenging. There is a critical reliance on rapid adjunctive diagnostic studies to complete initial resuscitation and determine the need for surgical intervention (laparotomy).

Anatomical Regions of the Abdomen and Pelvis

The abdomen is defined as the region between the diaphragm, intergluteal fold, inguinal folds, and the back. It is clinically divided into four key areas:

1. Upper Abdomen (Intrathoracic): Liver, stomach, spleen, diaphragm, transverse colon. Can extend to the 4th intercostal space during expiration.

2. Lower Abdomen: Small and large intestines.

3. Pelvic Region: Bladder, urethra, rectum, uterus, ovaries, iliac vessels.

4. Retroperitoneal Space: Kidneys, ureters, adrenal glands, pancreas, duodenum, ascending/descending colon, aorta, and inferior vena cava. Injuries here are easily missed on initial assessment.

Initial Evaluation and Resuscitation (SVAT Protocol)

1. Primary Survey & Simultaneous Resuscitation (A-B-C-D-E): Airway, Breathing, Circulation, Disability (neurological status), Exposure/Environment.

2. Secondary Survey & Physical Examination:

   • Inspection: Must be complete (anterior, flanks, back, perineum). Look for wounds, contusions, abrasions, seatbelt signs, distension, and penetrating objects (which should only be removed in the operating room).

   • Palpation: Begins at ribs (10-20% association with liver/spleen injury), iliac crest, pubis, abdomen, and flanks. Deep tenderness is common, but overt peritonitis (rigidity/guarding) may be absent.

   • Limitations: Physical exam is unreliable, with a 50% rate of false positives and negatives. A negative exam does not rule out injury, especially in patients with altered mental status (TBI, intoxication, spinal cord injury).

Biomechanics and Injury Patterns

• Blunt Trauma: Often involves energy transfer. Key patterns include:

  • Lower Rib Fractures: 10% risk of liver injury, 20% risk of splenic injury.

  • Seatbelt Compression: Can cause hollow viscus injury (duodenum, small bowel) and lumbar spine fractures ("Chance fracture").

  • Pelvic Fractures: Associated with urethral injuries and significant retroperitoneal hematoma.

• Penetrating Trauma: Less frequent but more likely to require surgery. Gunshot wounds (80-90% require laparotomy) vs. stab wounds (25-30%).

Diagnostic Methods

The goal is not always a specific organ diagnosis but to determine if there is abdominal involvement requiring intervention (early hemorrhage "C" problem vs. late peritonitis/sepsis).

1. Focused Assessment with Sonography in Trauma (FAST):

   • Role: Rapid, bedside ultrasound to detect free fluid (blood) in pericardial, perihepatic, perisplenic, and pelvic spaces.

   • Use: Primarily in hemodynamically unstable patients to identify a source of bleeding (Sensitivity ~100%, Specificity ~96% for needing laparotomy).

   • Limitations: Poor for retroperitoneal injuries, hollow viscus injuries, and solid organ grading.

2. Computed Tomography (CT Scan):

   • Gold Standard for stable patients. Provides detailed imaging of solid organs, retroperitoneum, and bony structures.

   • Allows for Organ Injury Scaling (OIS) and is essential for planning non-operative (conservative) management.

   • Limitations: Requires patient stability for transport, less sensitive for early hollow viscus and diaphragmatic injuries.

3. Diagnostic Peritoneal Lavage (DPL):

   • Historical gold standard. Invasive procedure to detect hemoperitoneum.

   • Current Indications: Unstable patients with polytrauma where FAST is equivocal/unavailable, or suspicion of hollow viscus injury with unexplained free fluid on CT.

   • Positive Result: >10 ml of non-clotting blood is generally an indication for laparotomy.

4. Laparoscopy:

   • Indications: Mainly for evaluating stable patients with penetrating trauma (stab wounds, tangential gunshot wounds) to rule out peritoneal violation.

   • Contraindications: Hemodynamic instability, severe TBI.

5. Exploratory Laparotomy:

   • Absolute Indications: Gunshot wound to abdomen, evisceration, radiologic evidence of free intraperitoneal air (pneumoperitoneo), peritonitis, diaphragmatic rupture.

   • Relative/Evolutionary Indications: Persistent hypotension with evidence of abdominal injury, recurrent bleeding despite resuscitation, intraperitoneal bladder rupture.

Treatment Approaches

1. Non-Operative (Conservative) Management:

   • Application: Now standard for hemodynamically stable patients with blunt solid organ injuries (liver, spleen, kidney).

   • Requirements: Dedicated ICU/High Dependency Unit, 24/7 surgical and CT availability, established protocol, and serial clinical exams.

   • Adjuvant Therapy: Angioembolization is a key tool to control bleeding without surgery.

2. Operative Management:

   • The cornerstone for unstable patients and most penetrating injuries.

   • The decision for surgery is based on clinical status (hemodynamics) and diagnostic findings, not just the presence of an organ injury.

Special Considerations: Pelvic Fractures

• High-Energy Mechanism: Pedestrian vs. auto, motorcycle crashes, falls from height.

• High Mortality: Up to 50% for open fractures. Mortality is often due to exsanguination from venous and arterial plexuses or associated injuries.

• Management Priority: Hemorrhage control is difficult. Initial stabilization with a pelvic binder/sheeting, followed by angiography/embolization or surgical fixation, is critical.

Summary and Key Takeaway Points

• Priority 1: Restore and maintain vital functions (oxygenation, perfusion).

• Maintain a High Index of Suspicion: Based on mechanism (biomechanics) and associated injuries.

• Utilize Rapid Diagnostics: FAST for the unstable, CT for the stable patient. Early diagnosis is key to preventing mortality.

• Individualize Treatment: Choose between urgent laparotomy and conservative management based on patient physiology and injury pattern.

• Continuous Re-evaluation: Serial clinical exams are mandatory, as abdominal findings can evolve over time.