Abdominal and pelvic injuries

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Chapter 71 Abdominal and pelvic injuries

Colin McArthur

Although important abdominal injuries are present in only 16–27% of hospital trauma admissions,1 abdominal and pelvic injuries can represent up to 60% of missed diagnoses in preventable trauma deaths.2 Most abdominal and pelvic injuries are caused by blunt trauma; penetrating aetiologies account for 6–21% of cases, depending on the society concerned.1,3 Important considerations with abdominal and pelvic injuries are:

• potential for severe haemorrhage
• difficulties in diagnosing visceral injury
• severity of associated injuries (e.g. chest and head)
• complications, especially sepsis

MECHANISMS OF INJURY

BLUNT INJURIES

Road crashes account for most abdominal and pelvic blunt injuries. Injuries may also result from falls, assaults and industrial accidents.1 Associated injuries are frequent, involving the thorax (most common), head and extremities. Seat belts and airbags reduce mortality in motor vehicle crashes (mainly by limiting brain injury), but are associated with more lower body injuries. Abdominal and pelvic injuries are more likely with vehicular side-on collisions, and when crashes result in a deformed steering wheel.4

PENETRATING INJURIES

Stab and gunshot wounds account for most penetrating injuries to the abdomen.

STAB AND LACERATION WOUNDS

Entry sites do not accurately predict the nature of deeper injury. Penetration of the thoracic cavity should be suspected with upper abdominal wounds; conversely, lower chest wounds may involve abdominal structures. Selective management of haemodynamically stable patients using investigation algorithms that accurately predict intra-abdominal injury has superseded mandatory laparotomy.5

GUNSHOT WOUNDS

Injuries depend on missile calibre, and its velocity and trajectory. Intra-abdominal, thoracic and multiple organ injuries and mortality are substantially greater than with stab wounds. Laparotomy should be performed in all cases with haemodynamic instability, peritonitis or a clinically unevaluable abdomen. A non-operative approach for solid organ injury6 carries the risk of missed bowel injury.

INITIAL TREATMENT AND INVESTIGATIONS

RESUSCITATION

Ensuring adequacy of airway, ventilation and oxygenation are immediate priorities. However, circulatory resuscitation should not delay surgery for uncontrolled haemorrhage.7 End-points for replacement of blood volume are controversial.8 If rapid surgical haemostasis is provided in penetrating trauma, delaying or limiting fluid resuscitation before surgery may improve outcome.9 Pneumatic antishock garments provide no benefit.7,10

CLINICAL ASSESSMENT

A full clinical examination (including the back) by experienced clinicians is most important. The mechanism of injury may direct attention to particular anatomical areas.4

• Contusions, external wounds and their relationship to underlying viscera are noted
• Abdominal distension, tenderness and peritonism are sought but auscultation for bowel sounds is not useful
• The rectum is examined for prostatic position, anal tone, blood or other evidence of injury
• Gastric aspirate and urine are inspected for blood

Isolated penetrating injuries present few diagnostic problems, but the decision to explore the abdomen can be difficult. Blunt abdominal trauma is often part of multiple injuries, and is more difficult to diagnose clinically, except when abdominal signs are obvious.

Nevertheless, in conscious patients, serial assessments can accurately identify those with significant intra-abdominal pathology. In the presence of impaired consciousness,intellectual disability or spinal, chest or pelvic injury, clinical assessment is unreliable. Other more visually spectacular injuries may also divert attention from the abdomen.

Laparotomy is indicated on clinical grounds when there is:

• shock with signs of intra-abdominal haemorrhage (e.g. peritonism or increasing distension)
• evisceration or peritonism without shock in penetrating trauma

In all other situations where clinical examination is inadequate, further investigations must be undertaken.11

PLAIN X-RAYS

A chest X-ray (preferably erect) is essential. It may demonstrate free intraperitoneal gas, herniation of abdominal contents through a ruptured diaphragm, or other abnormalities. Plain films of the abdomen are of no benefit. An anteroposterior pelvic X-ray is indicated for all victims of blunt trauma, except conscious patients with normal pelvis on examination.12

INVESTIGATIONS FOR OCCULT ABDOMINAL INJURY

ULTRASONOGRAPHY

Focused abdominal sonography for trauma (FAST) can be performed rapidly in the resuscitation room without compromising ongoing treatment. It requires significant training to achieve acceptable accuracy,13 and although highly specific, its sensitivity of around 85%14 is less than that of peritoneal lavage or CT in detecting free intra-abdominal fluid following either blunt15,16 or penetrating17 trauma. FAST can also identify pericardial fluid, but not hollow viscus injury or the nature of solid organ injury.16 FAST may reduce the need for other investigations,18 but the small but important false-negative rate must be considered in determining its role in abdominal assessment algorithms.

PERITONEAL LAVAGE

Diagnostic peritoneal lavage (DPL)19 is indicated in blunt trauma when there is haemodynamic instability or uncertain clinical findings, and in penetrating trauma when peritoneal breach is suspected.

Open and closed (percutaneous guidewire) methods are both satisfactory.20

DPL is unjustified when an indication for laparotomy already exists. It is relatively contraindicated in pregnancy, significant obesity and previous abdominal surgery.

If required in these situations (or with pelvic fractures), the supraumbilical open method should be considered. DPL undertaken early remains reliable in the presence of pelvic fractures.21 DPL detects intraperitoneal injury with up to 98% accuracy,19 but its high sensitivity can result in a significant non-therapeutic laparotomy rate. Cell counts of lavage effluent are more accurate than qualitative methods, but hollow viscus injury is difficult to detect. Generally accepted criteria for a positive DPL are shown in Table 71.1.

Table 71.1 Criteria for positive diagnostic peritoneal lavage

Clinical
Initial aspiration of >10 ml frank blood
Egress of lavage fluid via chest tube or urinary catheter
Bile or vegetable material in lavage fluid

Laboratory   Blunt injury Penetrating injury Red cells Definite > 100 × 109/l > 20 × 109/l Indeterminate 50–100 × 109/l 5–20 × 109/l White cells 0.5 × 109/l > 0.5 ×109/l Amylase > 20 IU/l > 20 IU/l Alkaline phosphatase > 10 IU/l > 10 IU/l

COMPUTED TOMOGRAPHY (CT)

CT requires a still patient, a high-resolution scanner and experienced interpretation to match the sensitivity of peritoneal lavage. The value of enteral contrast is controversial.22 Cuts from the top of the diaphragm to the symphysis pubis following i.v. contrast are required. CT is particularly useful to assess the retroperitoneum and pelvic fractures, and to delineate the nature of abdominal injury (thus guiding non-operative management of some solid organ injuries). It may not detect all hollow viscus trauma, but multidetector row CT is more specific and sensitive for bowel injury.23 Magnetic resonance imaging offers no advantage over CT in evaluating acute abdominal trauma, and poses significant logistical problems.

The safety of undertaking CT in acute trauma depends on the degree of cardiorespiratory stability relative to the speed of scanning and access to resuscitation support.

CHOICE OF INVESTIGATION

• FAST is non-invasive, rapid and reasonably accurate when used by trained staff. It can screen for haemoperitoneum but negative studies should be followed by another investigation15,16
• DPL is invasive, takes some time and is accurate in identifying intraperitoneal bleeding or contamination, but may miss diaphragmatic injuries and does not examine the retroperitoneum. It is an alternative to FAST in unstable patients with blunt trauma, and stable patients with anterior stab wounds
• CT is non-invasive, time-consuming, accurate, and has a primary role in defining the location and magnitude of intra-abdominal injuries in stable patients with blunt trauma or penetrating trauma to the flank or back
• FAST, DPL and CT are complementary,24 and should all be available. If CT is unavailable, DPL rather than FAST is indicated in the stable patient with blunt trauma in whom clinical examination is inadequate

LAPAROSCOPY

Diagnostic laparoscopy may be useful in the haemodynamically stable patient. It is good at visualising the diaphragm and identifying a need for laparotomy, but may miss specific organ injuries, particularly of the bowel. Laparoscopy appears best suited for the evaluation of equivocal penetrating wounds.25

ANGIOGRAPHY

Selective angiography and embolisation are valuable in detecting and treating the source of major haemorrhage from spleen, liver, pelvis and retroperitoneal structures.

LAPAROTOMY

Laparotomy can be regarded as both therapeutic and diagnostic. Intra-abdominal injury may be detected by means discussed above, but often only laparotomy can accurately diagnose specific injuries. In severe and multiple trauma, the morbidity of a negative laparotomy is insignificant compared to the dire consequences of not diagnosing and treating a serious injury.

Operative treatment of more severe injuries with difficult haemostasis can cause a lethal triad of hypothermia, acidosis and coagulopathy. A ‘damage control’ laparotomy26 with control of haemorrhage and contamination, intraperitoneal packing, elective re-exploration and removal of packs 24–48 hours later should be performed.

• Angiography should be considered and may be required for inaccessible arterial bleeding
• Temporary prosthetic closure is often required to avoid elevated intra-abdominal pressure
• Survival is better when the decision to terminate the initial procedure is made earlier

SPECIFIC INJURIES

SPLEEN

The spleen is the organ most frequently injured by blunt trauma. Injuries vary from a small subcapsular haematoma to hilar devascularisation or shattered spleen, but are rarely fatal with good medical care.27 Diagnosis may be delayed in mild trauma. When associated chest or neurological injuries are severe, minor splenic injury may not initially be detected unless further investigation is undertaken. Fractures of the lower left ribs are a common association. Minor trauma may cause splenic injury when the spleen is enlarged (e.g. from malaria, lymphomas and haemolytic anaemias).

Immediate splenectomy is indicated in patients with splenic avulsion, fragmentation or rupture, extensive hilar injuries, failure of haemostasis, peritoneal contamination from gastrointestinal injury or rupture of diseased spleen.27 However, overwhelming infection by encapsulated organisms, such as Pneumococcus, can occur early or late (even years) after splenectomy in 0–2% of individuals. It is a particular risk following splenectomy in children and young adults. Polyvalent pneumococcal vaccine (Pneumovax) and haemophilus and meningococcal vaccines should be administered following splenectomy.28

If associated abdominal injuries have been excluded, a non-operative approach can give splenic salvage rates of over 80%. Arterial embolisation can further reduce the need for laparotomy.29 Failure rates are higher with higher grade injuries.28

Other treatment alternatives include operative procedures to conserve splenic tissue (e.g. topical haemostatic agents, suture repair, absorbable mesh, partial splenectomy and splenic artery ligation). Benefits of splenectomy with autotransplantation of splenic tissue are unproven.

LIVER

The liver is the second most commonly injured organ after blunt abdominal trauma, and has been the most frequently missed injury in deaths from trauma.2 Diagnosis is made by laparotomy in unstable patients, or CT in stable patients. Injuries range from small subcapsular haematomas to major parenchymal disruption and laceration of hepatic veins or even hepatic avulsion.

CT assessment enables most patients to be managed without operation. Patients should be haemodynamically stable, have associated major abdominal injuries excluded, and be assessed repeatedly. Follow-up CT scans can show the resolution of injury, which typically takes 2–3 months. CT-guided percutaneous drainage, endoscopic retrograde cholangiopancreaticogram (ERCP) and angioembolisation can treat the complications of a non-operative approach such as bile leak, haemobilia, necrosis, abscess and delayed haemorrhage.28

If surgery is required, early determination of indications for a damage control approach is important. Peri-hepatic packing gives best haemostasis. Angiography may identify and treat uncontrolled arterial bleeding. Early complications of liver injury relate to the effects of hypoperfusion or massive blood transfusion. Late complications are usually associated with sepsis.30

GASTROINTESTINAL TRACT (GIT)

Injury to the GIT is more common following penetrating than blunt trauma. The very high likelihood of bowel injury in abdominal gunshot wounds should mandate laparotomy. Laparoscopy can be used to identify those with stab wounds for laparotomy when peritoneal violation cannot be excluded. Posterior stab wounds may damage retroperitoneal structures. CT examination with contrast enema may identify colonic injury better than clinical assessment or DPL.5

Blunt abdominal injuries to stomach, duodenum, small intestine, colon and their mesenteries are difficult to evaluate. Physical signs may be absent initially.

FAST or DPL may provide a general indication for laparotomy, but are not accurate in diagnosing isolated bowel trauma (especially of the duodenum) because of its retroperitoneal location.

CT is a sensitive indicator of free intraperitoneal air, but signs of duodenal perforation or haematoma are subtle, even with enteral contrast. Consequently, duodenal injury is often missed. A high index of suspicion should be maintained in patients with persistent abdominal pain and tenderness.31

Bleeding from mesenteric vessels is often self-limiting and may not require surgical control. However, vessel damage can cause ischaemia and infarction, and may require resection of affected bowel. Uncomplicated blunt or penetrating bowel injury can usually be managed by primary repair and anastomosis rather than colostomy.32 A faecal diversion procedure with delayed repair is indicated in significant peritoneal contamination.

PANCREAS

Blunt injuries to the pancreas require considerable force and are often associated with duodenal, liver and splenic trauma. CT is the most useful investigation. Acute hyperamylasaemia does not predict pancreatic or hollow viscus injury.33

Minor injuries require simple drainage and haemostasis. Severe injuries to the body and tail of the pancreas are best managed by distal pancreatectomy. Severe injuries involving the proximal pancreas and duodenum with intact ampulla and common bile duct can be treated by drainage alone if associated duodenal injury is simple to repair. Pancreaticoduodenectomy is required if there is disruption of the ampullary–biliary–pancreatic union or major devitalisation. Complications such as pancreatitis, fistula, abscess and pseudocyst are common.34,35

KIDNEY AND URINARY TRACT

Blunt injury to the urinary tract is more common than penetrating injury. Identification and treatment of other major injuries often take precedence. Gross haematuria should be investigated; CT is the examination of choice. Urinary extravasation may be missed unless a repeat scan 10–20 minutes after contrast injection is performed. Unless there is unexplained shock, microscopic haematuria does not require further investigation. Renovascular pedicle or ureteric injuries may not cause any haematuria. Most renal injuries resolve with expectant management. Lacerations involving the collecting system or injury to the renal pedicle usually require operative intervention, although restoration of renal function following long warm ischaemic times is unusual. If major renal injury is discovered at emergency laparotomy, intraoperative i.v. urography is prudent to ensure contralateral function and will identify urinary extravasation. Angioembolisation may be useful in controlling renal haemorrhage.36

Bladder rupture is commonly associated with pelvic fractures. Over 95% of patients have macroscopic haematuria. Retrograde cystography is the investigation of choice because CT has a high false-negative rate. Intraperitoneal bladder rupture requires operative repair and urinary drainage. Patients with sterile urine and extraperitoneal rupture can be managed with catheter drainage alone.37

Urethral trauma is caused by direct blunt injury, or occurs in association with pelvic injury. It should be suspected if there is blood at the urinary meatus, perineal injury or abnormal position of the prostate on rectal examination in the male. In the absence of these findings, cautious urethral catheterisation is appropriate. Treatment of urethral trauma is suprapubic drainage and subsequent definitive repair.

DIAPHRAGM

Diaphragmatic injury occurs in fewer than 5% of cases of blunt injury, is left-sided in 80% of cases, and is commonly associated with injuries to abdominal organs. It should also be suspected in penetrating trauma below the fifth rib. Diagnosis can be difficult, especially in the presence of positive-pressure ventilation, and may become evident only after ventilatory support is discontinued.

• Chest X-rays are commonly abnormal but often with non-specific findings
• DPL is insensitive for isolated diaphragmatic injuries
• Laparoscopy and thoracoscopy provide good views of the diaphragm

Spontaneous healing does not occur, and all defects should be repaired. The risk of associated injuries in acute cases mandates an abdominal approach.38

BONY PELVIS AND PERINEUM

Pelvic fractures are primarily caused by vehicular trauma or falls. Associated injuries to the bladder, urethra and intra-abdominal organs are common. Injuries may be life-threatening initially from major haemorrhage, or later from sepsis. Significant morbidity can result from damage to pelvic nerves, urethra or the structural integrity of the pelvis. Pelvic injury is suggested by pain on movement, structural instability, gross haematuria or peri-pelvic ecchymosis. Rectal examination is mandatory to identify rectal injury and prostatic position.

Radiography can confirm bony injury, but CT is required to identify associated intra-abdominal injuries (in the haemodynamically stable) and can assist in planning operative stabilisation. FAST has a significant false-negative rate with major pelvic fractures.39

Patients with haemodynamic instability and pelvic fractures must have intra-abdominal haemorrhage excluded. Early open supraumbilical DPL or FAST are the investigations of choice. If grossly positive, laparotomy should precede external fixation or angiography. If DPL is positive by cell count alone or FAST negative, the risk of life-threatening intra-abdominal haemorrhage is relativelylow, and achieving haemostasis for pelvic bleeding becomes the priority; CT and/or laparotomy should follow if the patient is still unstable.

• Emergency measures to improve tamponade by reducing pelvic volume (pelvic binding or C-clamp) and prompt angiography and selective embolisation can significantly reduce mortality40
• External fixation of the pelvis can control venous and small arteriolar bleeding near fracture sites, and will also reduce the volume of an open pelvis
• Bleeding from large vessels such as the aorta, common and external iliac arteries, and common femoral artery requires surgical control

Pelvic fractures range from simple fractures of individual bones requiring bed rest alone to complex fractures. Early operative stabilisation of complex pelvic fractures is preferred in the intensive care unit (ICU), as it facilitates respiratory care, pain control and early mobilisation. Compound pelvic fractures involving the perineum, rectum or vagina require aggressive surgery (including diversion of the faecal stream) to avoid high mortality.

RETROPERITONEAL HAEMATOMA

Retroperitoneal haematoma is frequent following blunt trauma, and is commonly caused by injury to the lumbar spine, bony pelvis, bladder or kidney or, less commonly, to the pancreas, duodenum or major vascular structures. Diagnosis may be inferred by excluding other sites of major blood loss, or presumed by signs of underlying organ injury.

CT is the most useful investigation in the stable patient.

A central haematoma should be explored with proximal vascular control, because of the risk of pancreatic, duodenal or major vascular injury. A lateral or pelvic haematoma should not be explored, unless there is evidence of major arterial injury, intraperitoneal bladder rupture or colonic injury.41

TRAUMA IN PREGNANCY

Women injured during pregnancy pose problems of altered physiology, risk to the gravid uterus and fetus, and conflict of priorities between mother and fetus.

• High-flow oxygen must be given until maternal hypoxaemia, hypovolaemia and fetal distress have been excluded
• Reduced respiratory reserve demands earlier intervention
• Maternal compensation for blood loss is at the expense of uteroplacental blood flow
• Mothers should be positioned to avoid aortocaval compression
• Secondary survey must include a vaginal examination
• Intravenous access should be in the upper limbs
• Transfusions should be Rhesus compatible
• All Rhesus-negative mothers should receive immune globulin, because of the immunological risk of even minor fetomaternal haemorrhage42

Only X-rays that may significantly alter therapy should be taken (with appropriate shielding), especially if under 20 weeks’ gestation.

Ultrasound is the preferred investigation as it is safe and can accurately detect free intra-abdominal fluid, confirm gestation and fetal well-being, and identify placental abnormalities. DPL is safe if performed by the open method above the fundus. CT may miss injuries due to abdominal crowding.

Retroperitoneal haemorrhage is more common in pregnant patients. Placental abruption may conceal significant blood loss. Treatment may be expectant or by caesarean section, depending on the condition of the mother and fetus. Uterine rupture is unusual and will often require hysterectomy. Rarely, perimortem caesarean section may be indicated in a dead or dying mother, to attempt to save the fetus.

Placental abruption, fetal distress and fetal loss are rare following blunt injury, but premature uterine contractions are common.

Continuous cardiotocography (indicated at viable gestations) is the most sensitive test to detect obstetric complications, but is required for only 4 hours unless abnormalities are noted.42 Kleihauer–Betke tests to identify fetomaternal haemorrhage are not predictive of fetal or maternal morbidity.

HAEMORRHAGE

Patients with haemorrhage from abdominal and pelvic injuries can suffer the same complications of shock and massive transfusion as any patient with severe haemorrhage. Dilutional coagulopathy is common following resuscitation with fluids deficient in haemostatic factors. Patients resuscitated with crystalloids, colloids and red cells often require platelet and fresh frozen plasma transfusions. Disseminated intravascular coagulation occurs infrequently in trauma, usually when shock has been prolonged.

SEPSIS

Intra-abdominal sepsis remains an important preventable cause of death after trauma. Predisposing factors include:

• peritoneal contamination from GIT injury
• external wounds
• invasive procedures
• delayed diagnosis of hollow viscus injuries
• splenectomy
• devitalised tissue

Early diagnosis and effective lavage and drainage procedures may reduce the incidence of intra-abdominal sepsis.

Prophylactic antibiotics for 24 hours are satisfactory for penetrating injuries. Intra-abdominal sepsis should be excluded if unexplained fever and/or neutrophil leukocytosis or multiple organ failure develops. Septic shock may represent a second shock insult to the trauma patient, leading to multiorgan dysfunction.

GASTROINTESTINAL FAILURE

GIT failure in various forms, ranging from stress ulceration and delayed gastric emptying to paralytic ileus, is a frequent occurrence. Prophylaxis against stress ulceration may be indicated. Enteral nutrition is associated with a lower incidence of sepsis following trauma.43 Feeding through a jejunostomy tube placed during surgery or radiologically in the ICU is usually feasible. Parenteral nutrition may be necessary in patients with severe bowel or retroperitoneal injuries.

RAISED INTRA-ABDOMINAL PRESSURE

Abdominal distension with raised intra-abdominal pressure may be seen in the critically injured as a consequence of haemorrhage, bowel oedema, ileus or surgical packs. This can have severe adverse effects on respiratory, cardiovascular and renal function.44 Alleviation is by abdominal decompression using interposed synthetic mesh45 or by leaving the abdomen open, with or without visceral packing. The abdomen is subsequently closed by staged repair as the distension resolves.

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