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Abdominal trauma has a high priority in the diagnosis and treatment of a patient with multiple injuries. Both blunt and penetrating injuries may be isolated or multiple and they are often combined with extraabdominal trauma. A close cooperation between surgical and other specialties is often needed. Transport from a smaller hospital to a center with full diagnostic and therapeutic facilities may be advantageous.
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Nonpenetrating abdominal injuries are commonly seen in a general hospital. High speed traffic accidents are responsible for the majority of these injuries. The mortality rate is high. Deaths were from associated injuries, failure to recognize abdominal trauma, hemorrhage and from acute renal insufficiency. Careful observation of every severely injured person, vigorous treatment of hemorrhagic shock with whole blood, and prompt surgical intervention when indicated will improve the mortality figures.
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PURPOSE: Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury. METHODS: Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine. RESULTS: Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this. DISCUSSION: Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.
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20% of patients with multiple injuries have abdominal injuries. Patients with massive symptoms and signs indicating abdominal injury should receive high priority in the treatment of the multiple injury patient, second only to injuries to airways and thorax. The unstable critically ill patient must undergo laparotomy without further investigation. In a patient in extremis, however, left emergency thoracotomy and clamping of the descending aorta should be performed prior to the laparotomy. Extensive abdominal haemorrhage should be treated first with a tamponade to control the bleeding, after which the patient should receive further transfusions and treatment to correct acidosis. It is then possible to proceed with further necessary surgical repair. In many patients with multiple injuries, however, the problem is to diagnose the abdominal injury. Peritoneal lavage is a sensitive but unspecific method of diagnosis, and the discovery of blood in the lavage fluid is not an absolute indication for laparotomy. Sometimes injuries to parenchymatous organs may be treated without operation. This necessitates good clinical judgment, available adequate diagnostic imaging techniques and repeated examinations by an experienced surgeon.
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OBJECTIVE: To describe the retroperitoneal organ injury pattern after anterior penetrating abdominal injury in children. SETTING: The paediatric surgical department of a university teaching hospital. PATIENTS AND METHODS: All children presenting with firearm and stab wounds to the anterior abdomen between January 1983 and April 2001. RESULTS: Forty-nine children (34%) with penetrating anterior abdominal wounds had retroperitoneal organ injury. The most injured organs were the descending colon in 17 patients (35%), ascending colon in eight patients (16%), and kidney in seven (14%). The most commonly associated injured organ was the small bowel. Postoperative septic complications were seen in 10 patients (20%). The most common postoperative complication was wound infection. When we compared patients with intraperitoneal organ injury with patients with retroperitoneal injury, there was no difference in parameters such as age, associated organ injury, morbidity and mortality between both groups. The main causative factor of retroperitoneal injuries was shotgun wounds, whereas it was stabbing in intra-abdominal injuries (P<0.05). The number of injured organs and the hospital stay is significantly greater in retroperitoneal organ injuries, and the trauma scores such as the Injury Severity Score (P<0.001) and the Penetrating Abdominal Trauma Index (P<0.001) were found to be significantly higher. CONCLUSION: Retroperitoneal organ injury is commonly associated with anterior penetrating abdominal trauma. Even if there is no preoperative sign of retroperitoneal organ injury, an exploratory laparotomy and a meticulous retroperitoneal exploration should also be performed for associated retroperitoneal organ injury.
Recognise the possibility of abdominal injury. Two major types of abdominal injury may be present in war, blunt and penetrating. In either case, early surgery is essential. With blunt injuries, a high index of suspicion is required. Diagnosis in the early stages may be very difficult. Serial examination is required; even then, evacuate early. Aids to diagnosis include: DPL, FAST, CT Casualties with penetrating injuries must be given the highest priority for evacuation and surgical evaluation. Penetrating injury to the loin, back, buttocks, lower chest and thighs, should raise suspicion of intra-abdominal injury. Management of abdominal injury follows normal BATLS protocol and includes: Primary survey: Remember the A B C D E routine. Resuscitation: This involves: Continued oxygenation Appropriate therapy for hypovolaemic shock (refer to Chapter 5) Continued monitoring of response by assessment of vital signs, aided by additional parameters such as pulse oxymetry and blood gas analysis, when available. Placement of nasogastric tube and bladder catheter. Secondary survey: Following stabilization, but not before, you may proceed to full assessment of the mechanism and location of injury. This demands a full secondary survey and continued monitoring of the casualty.
When head and blunt abdominal injuries are combined, the head injury is often afforded too much attention and the abdominal injury too little, especially when the patient is unconscious. If mismanaged, the abdominal injury is often the more serious threat to life. Except for extradural hemorrhage, neurosurgical intervention, when indicated, can be delayed until the patient has been thoroughly evaluated for the presence of extra cranial injuries with higher therapeutic priority. Abdominal examination of the unconscious or uncooperative patient is difficult. Tenderness as a sign of abdominal injury cannot be elicited. Abdominal rigidity (in the absence of rigid extremities), a silent abdomen, shock, and extreme restlessness may indicate intra-abdominal changes. Abdominal paracentesis is a valuable diagnostic aid, and the finding of blood, bile-stained fluid, intestinal contents or air is an indication for immediate laparotomy. Once all injuries are known, priorities for treatment can be assigned. Often head and abdominal injuries can be treated concomitantly.