Abdominal trauma

Closed abdominal trauma occurs as a result of exposure to a blast wave, falling from a height, blows to the abdomen, compression of the torso by heavy objects. The severity of the injury depends on the degree of excess pressure of the shock wave or the impact force on the abdomen by a moving object.

Minor injuries are accompanied by isolated damage to the abdominal wall and are manifested by skin abrasions and bruises, limited pain, swelling, and tension in the abdominal muscles.

ICD-10 code

S30-S39 Injuries of abdomen, lower back, lumbar spine and pelvis.

Epidemiology of abdominal trauma

There are closed and open abdominal injuries, which make up 6-7% of the sanitary losses in military conflicts of recent years. In peaceful conditions, injuries to the abdominal organs caused by road traffic accidents (RTA) predominate. It should be noted that the true frequency of abdominal injuries is unknown, perhaps because specialized medical centers (for the treatment of trauma) publish information about the patients they treat, while other medical hospitals (not traumatology) do not provide their data.

Thus, according to the National Pediatric Trauma Registry by Cooper (USA), abdominal trauma accounts for 8% of all injuries in children (25 thousand in total), with 83% of them having a closed injury. Abdominal injuries associated with car accidents accounted for 59% of other types of traumatic injuries.

Similar reviews of adult medical databases show that blunt abdominal trauma is the leading cause of intra-abdominal injuries, with road traffic accidents considered the leading mechanism.

Hollow organ trauma is most often associated with damage to parenchymatous organs, especially the pancreas. Approximately 2/3 of patients with hollow organ trauma suffer them as a result of road traffic accidents.

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International data

WHO data indicate that road traffic accidents are the most common cause of this type of injury.

Generalized data from Southeast Asia define trauma as the leading cause of mortality in the 1-44 age group. Road accidents, blunt force trauma, and falls from height are considered the leading etiologic causes of abdominal trauma. According to their data, closed trauma accounts for 79% of all victims with abdominal trauma.

Morbidity and mortality

Closed abdominal trauma occurs in 85% of cases as a result of a traffic accident. The mortality rate is 6%.

Floor

According to international data, the male/female ratio for abdominal trauma is 60/40.

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Age

Most studies indicate that abdominal trauma occurs in people aged 14-30 years.

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The influence of mechanisms of abdominal trauma

Full information about the mechanism of injury helps to diagnose more correctly and quickly. Thus, in case of injuries to the lower half of the chest, blunt abdominal trauma is suspected in the upper floor and vice versa. In case of an accident, a seat belt injury is possible ("belt" injury), in which there is a high probability of damage to the spleen and liver, which must be taken into account when diagnosing the cause of the critical condition (shock, hypotension).

In case of gunshot wounds, the nature of the wound depends on the caliber and speed of the projectile, as well as the trajectory of its movement in the victim’s body.

In severe and extremely severe injuries to the abdominal organs and retroperitoneal space, the integrity of the liver, spleen, kidneys, and intestines is most often damaged.

Abdominal compartment syndrome

Abdominal compartment syndrome (ACS) occurs when the internal organs of the abdominal cavity are compressed within the cavity itself. The exact clinical conditions that lead to the development of the syndrome are controversial and uncertain. Dysfunction of organs associated with intra-abdominal hypertension is associated with the development of ACS. Such dysfunction is predetermined by secondary hypoxia due to impaired blood flow and decreased urine production caused by impaired renal blood flow. The syndrome was first described in the 19th century (Mareu and Bert). At the beginning of the 20th century, the relationship between ACS and intra-abdominal hypertension was first described, when it became possible to measure intra-abdominal pressure.

The following are distinguished:

• primary ACS - with the development of intra-abdominal pathology directly responsible for the development of hypertension,
• secondary - when there is no visible damage, but there is fluid accumulation due to extra-organ damage to the abdomen,
• chronic - occurs with liver cirrhosis and ascites in later stages of the disease, not typical for abdominal injuries.

In intensive care units (with the development of metabolic acidosis during the study of the acid-base balance) a decrease in the rate of diuresis, signs of cardiac pathology in elderly victims can be diagnosed. In the absence of knowledge of this type of disorder, developing conditions are perceived as other pathological conditions (for example, hypovolemia), in this regard, we will dwell on this type of complication in more detail.

Pathophysiology is related to organ dysfunction as a result of direct exposure to intra-abdominal hypertension. Problems begin in the parenchymatous organs in the form of thrombosis or edema of the intestinal wall, which leads to translocation of bacterial products and toxins, additional accumulation of fluid and increasing hypertension. At the cellular level, oxygen delivery is disrupted, resulting in ischemia and anaerobic metabolism. Vasoactive substances such as histamine increase endothelial loss, which leads to "sweating" of red blood cells and progression of ischemia. Despite the fact that the abdominal cavity is more distensible than the extremities, in an acute situation the pathological processes look no less dramatic and are considered the cause of decompensation in any critical condition in injured patients.

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Frequency

In the USA, according to literature data, the frequency in intensive care units is from 5 to 15% and about 1% in specialized units. International data are not published.

Morbidity and mortality

The severity of ACS is associated with its impact on organs and systems, which is why high mortality is noted.

Mortality is 25-75%. Intra-abdominal pressure of 25 mm Hg and above leads to disruption of the functioning of internal organs.

Survey

Pain (may precede the development of ACS) is directly related to abdominal trauma and post-traumatic pancreatitis.

Fainting or weakness may be a sign of hypovolemia. Patients may not experience pain. Anuria or oliguria may be the first signs of increasing intra-abdominal compression.

Objective clinical symptoms (in the absence of productive contact):

• increase in abdominal circumference,
• breathing discomfort,
• oliguria,
• collapse,
• melena,
• nausea and vomiting,
• clinical picture of pancreatitis, peritonitis.

Physical examination of the ACS usually suggests an increase in abdominal volume. If these changes are acute, the abdomen is distended and painful. However, this sign is difficult in overweight victims. Wheezing in the lungs, cyanosis, and pallor are also observed.

The etiology of ACS occurs when the intra-abdominal pressure is too high, similar to compartment syndrome in limb injuries. When the abdomen is affected, there are two types of ACS, which have different and sometimes combined causes:

• Primary (acute).
• Penetrating injuries.
• Intra-abdominal bleeding.
• Pancreatitis.
• Compression of abdominal organs due to mechanical compression (according to the mechanism of injury).
• Pelvic fracture.
• Rupture of the abdominal aorta.
• Perforation of the ulcer defect.
• Secondary can develop in victims without abdominal trauma, when fluid accumulates in volumes sufficient to cause intra-abdominal hypertension.
• Excessive infusion therapy in hyponatremia.
• Sepsis.
• Long-term dynamic intestinal obstruction.

Differential diagnostics are performed with all injuries and lesions of the abdominal organs: acute coronary syndrome, ARDS, renal failure, ketoacidosis, including alcoholic, anaphylaxis, appendicitis, cholecystitis, constipation, bulimia, Cushing's syndrome, diaphragm injuries, electrical injuries, gastroenteritis, diverticulosis, intestinal gangrene, inferior vena cava syndrome, urinary retention, peritonitis, thrombocytopenic purpura, etc.

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Laboratory diagnostics

• general blood test with blood count calculation,
• prothrombin time, APTT, PTI,
• amylase and lipase,
• myocardial damage marker test,
• urine analysis,
• plasma lactate content,
• arterial blood gases

Instrumental diagnostics

• radiography is not informative,
• CT (determination of the ratio of the anteroposterior and transverse sizes, thickening of the intestinal walls, expansion of the inguinal ring on both sides),
• Ultrasound (difficult due to intestinal flatulence),
• measuring the pressure in the bladder with a special system through a Foley catheter.

Treatment

• The underlying disease is treated. Various surgical techniques are used for prevention, which helps reduce the likelihood of developing ACS syndrome. Balanced infusion therapy is performed, crystalloids are not administered. It is important to remember that undiagnosed ACS is considered fatal in almost 100% of cases due to the development of acute renal failure, acute liver failure, ARDS, and intestinal necrosis.
• When making a diagnosis, it is necessary, first of all, to free the abdomen from any pressing bandages, clothing. Pharmacotherapy is prescribed to reduce IAP. Furosemide and other diuretics are used, which are less effective than surgical intervention.
• Percutaneous drainage of fluid (puncture). Multiple data prove its effectiveness in ACS. Decompressive laparotomy can be performed.
• Laparoscopic decompression.

Abdominal sepsis. Infectious complications

Abdominal surgical trauma is often accompanied by infectious complications. The use of antibacterial therapy without sanitizing the infectious focus is ineffective.

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Enteral failure

Enteral insufficiency (maldigestion syndrome, malabsorption, intestinal paresis, etc.) is a condition that accompanies patients with damage to the abdominal organs (intestines, liver, gallbladder, pancreas, in the presence of retroperitoneal hematoma). The frequency of the syndrome is up to 40% of cases. With the development of intestinal pathology, enteral nutrition becomes impossible (with persistent intestinal paresis, the absorption process is disrupted). In this regard, against the background of impaired vascularization of the mucosa, the phenomenon of microorganism translocation has been determined. Its significance in the development of infectious complications continues to be studied. Enterosorption is performed in the absence of contraindications.

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Classification of abdominal injuries

Classification by B. V. Petrovsky (1972)

By the nature of damage:

• open,
• closed.

By the nature of damage to other organs and the damaging factor:

• isolated and combined (in combination with damage to other organs),
• combined - when the body is exposed to two or more damaging factors.

By type of wounding weapon:

• stab-and-cut,
• gunshots.

By the nature of the wound channel:

• through,
• tangents,
• blind.

In addition, abdominal wounds can be penetrating or non-penetrating, with or without damage to internal organs, with or without intraperitoneal bleeding.

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Complications of abdominal trauma

The given complex of treatment and diagnostic measures is aimed not only at diagnosing the underlying disease, clarifying the nature of the damage, but also at timely detection of complications of abdominal trauma. The most specific ones are:

• massive blood loss and hemorrhagic shock,
• DIC syndrome and MODS,
• post-traumatic pancreatitis,
• abdominal compartment syndrome (abdominal hypertension syndrome),
• abdominal sepsis, septic shock,
• enteral insufficiency.

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Massive blood loss and hemorrhagic shock

Massive blood loss is the loss of one BCC within 24 hours or 0.5 BCC volume within 3 hours. In trauma, massive blood loss leads to death in 30-40%. In the description of this section, we will focus on the factors that contribute to early diagnosis and methods of correction of anemia and hypovolemia in this category of victims, using the Management of bleeding following major trauma a European guideline, 2007 protocol. When performing resuscitation measures in victims with an undetected source of bleeding, rapid diagnosis of the source is necessary to eliminate it, restore perfusion and achieve hemodynamic stability.

• Reducing the time from injury to surgery improves the prognosis (level A).
• Casualties with hemorrhagic shock and an identified source of bleeding should undergo immediate surgical intervention to definitively stop the bleeding (Level B).
• Patients with hemorrhagic shock and an undetected source of bleeding undergo further urgent diagnostic work-up (level B).
• Victims with significant accumulation of fluid in the free abdominal cavity (according to ultrasound data) and unstable hemodynamics undergo emergency surgery (level C).
• In hemodynamically stable patients with a combined injury pattern and/or abdominal bleeding, CT scanning is required (level C).
• The use of hematocrit values as the sole laboratory marker of the degree of blood loss is not recommended (Level B).
• The use of dynamic plasma lactate determination as a diagnostic test in cases of massive blood loss and/or hemorrhagic shock is recommended (level B).
• Determine the lack of grounds for additional diagnostics of the consequences of massive blood loss (level C).
• Systolic pressure levels should be maintained within 80-100 mm Hg (in victims without brain injury) until surgical stopping of bleeding in the acute period of injury (level E).
• The use of crystalloids for infusion therapy in victims with ongoing bleeding is suggested. The administration of colloids is performed individually (level E).
• Warming patients to achieve normothermia is recommended (Level C).
• The required hemoglobin content is 70-90 g/l (level C).
• Fresh frozen plasma is prescribed to patients with massive blood loss complicated by coagulopathy (APTT is higher or PTI is 1.5 times lower than normal). The initial plasma dose is 10-15 ml/kg, with subsequent correction possible (level C).
• Maintaining platelet levels above 50x10 ⁹ /l (level C).
• Fibrinogen concentrate or cryoprecipitate is recommended if severe blood loss is accompanied by a decrease in serum fibrinogen levels below 1 g/L. The initial dose of fibrinogen concentrate is 3-4 g or 50 mg/kg cryoprecipitate, equivalent to 15-20 units in a 70 kg adult. Repeat dosing is based on laboratory data (grade C).
• The administration of antifibrinolytic drugs is prescribed only until the final surgical stop of bleeding (level E).
• The use of recombinant activated factor VII is recommended for effective hemostatic therapy in blunt trauma (level C).
• Antithrombin III is not used in intensive care of trauma victims (level C).

Coagulopathy and DIC syndrome

The description and development of DIC syndrome are described in more detail in other chapters of the manual. There is no evidence that the degree of blood loss or the level of systolic blood pressure determine the subsequent development of coagulopathic disorders. Adequate intensive care, focused on the required volume status, balanced infusion therapy reduce the risk of developing DIC syndrome. The prognosis of victims with coagulopathy is worse than that of victims with the same pathology, but without coagulopathy.

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Posttraumatic pancreatitis

In the structure of acute pancreatitis, posttraumatic pancreatitis accounts for 5-10%. The peculiarity of its course is a high (more than 30%) frequency of necrosis development (in acute pancreatitis of other genesis - no more than 15%) and a high (up to 80%) frequency of infection. The issues of the clinical picture, therapy of complications are described in the relevant chapters of the manual. The development of pancreatitis worsens the prognosis of the course of traumatic disease in abdominal injuries. In 15-20% of cases, it is considered the direct cause of death.

Recommendations for the diagnosis of victims with abdominal trauma

• Abdominal injuries should be excluded in every patient who has suffered a road traffic, industrial or sports injury. Even minor trauma can be accompanied by severe damage to the abdominal organs.
• Diagnosis of closed abdominal injuries is difficult. Symptoms sometimes do not appear immediately, and when several organs or systems are damaged, some signs may be masked by others.
• The clinical picture is often distorted by concomitant damage to other anatomical areas. Impaired consciousness and spinal cord injury make examination extremely difficult.
• If no abdominal damage is detected during the initial examination, a repeat examination is required after a certain period of time.
• Rupture of a hollow organ is usually accompanied by symptoms of peritoneal irritation and absence of intestinal sounds. These signs may be absent during the initial examination. Thus, with damage to the small intestine and bladder, early symptoms are sometimes scanty, so frequent follow-up examinations are necessary.
• When a parenchymatous organ (liver, spleen, kidneys) is damaged, bleeding usually occurs. In case of shock of unclear etiology that occurs after trauma, damage to the abdominal organs is primarily assumed. This is primarily due to the anatomical features of the parenchymatous organs, namely their pronounced vascularization.
• In case of abdominal trauma, the overfilled bladder and pregnant uterus are especially sensitive to damage.

Diagnosis of abdominal trauma

In some cases, the diagnosis of "abdominal trauma" is beyond doubt (wound channel in the abdominal projection, hematomas, eventration of abdominal organs). To exclude damage to internal organs, objective (physical), instrumental and laboratory examinations are performed.

The examination and/or initial assessment of the casualty's severity should be performed simultaneously with the immediate intensive care measures. The condition is not assessed in detail until all life-threatening disorders have been identified. Anamnestic data from accompanying personnel or witnesses, as well as the results of gastric intubation and bladder catheterization are very useful.

Physical examination is not considered the diagnostic minimum for abdominal trauma. Diagnostic peritoneal lavage, CT and/or ultrasound are recommended. Diagnostic algorithms have been established that allow the most adequate use of each method. The choice is influenced by:

• type of hospital (specialized for trauma treatment or not),
• technical equipment,
• the experience of the physician performing the treatment in a particular case.

It is important to remember that any diagnostic tactics must be flexible and dynamic.

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History and physical examination

The main goal of the initial examination is to immediately identify life-threatening conditions. The exception is hemodynamically unstable victims. The dominant significance in examining this category of victims is determining the degree of impairment of vital functions and, as a result, the volume of intensive care.

When collecting anamnesis, it is necessary to take into account allergies, previous surgeries, chronic pathology, time of the last meal, and circumstances of the injury.

The following matters:

• anatomical location of the wound and type of projectile, time of impact (additional data regarding trajectory, body position),
• the distance from which the blow was delivered (height of fall, etc.). In case of gunshot wounds, it is necessary to remember that a close shot transfers a greater amount of kinetic energy,
• pre-hospital assessment of the amount of blood loss by accompanying personnel,
• initial level of consciousness (according to the Glasgow Coma Scale). During transportation from the pre-hospital stage, it is necessary to determine the scope of assistance and the victim's response to the therapy being administered.

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Additional continuous monitoring

• Blood pressure and heart rate levels in dynamics.
• Body temperature, rectal temperature.
• Pulse oximetry (S _p O ₂ ).
• Assessment of the level of consciousness.

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Additional diagnostics

• Chest and abdominal x-ray, standing if possible.
• Ultrasound of the abdominal cavity and pelvic cavity.
• Gas analysis of arterial and venous blood (pO2, SaO2, PvO2, SvO2, pO2/FiO2), acid-base balance indicators.
• Plasma lactate content, base deficit as criteria of tissue hypoperfusion.
• Coagulogram (APTT, PTI).
• Glycemic level.
• Content of creatinine and residual nitrogen.
• Determination of blood group.
• Calcium and magnesium in blood serum.

Interventions and additional studies (performed when the victim is hemodynamically stable)

• laparocentesis (diagnostic peritoneal lavage),
• laparotomy

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Detailed inspection

A more detailed examination and complete laboratory testing aimed at identifying all injuries and planning further diagnostics and treatment measures are, in some situations, carried out in conjunction with resuscitation measures.

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Physical examination

• Physical examination is the primary tool for diagnosing abdominal trauma. With proper organization of the examination and certain skills, physical examination takes about 5 minutes. To optimize time costs, from the point of view of importance for the clinical condition of the victim, it is recommended to conduct the examination sequentially.
• Respiratory tract. Determine patency, preservation of protective reflexes, absence of foreign bodies in the oral cavity, secretion, damage to the respiratory tract.
• Breathing. Presence or absence of spontaneous breathing. Determine the respiratory rate, subjective assessment of the depth and effort of inhalation.
• Circulation. The examination of circulation begins with an assessment of the skin, the mental status of the victim, dermal temperature and the fullness of the veins of the extremities. In victims in a state of hemorrhagic shock, changes in mental status from anxiety to coma are possible. Traditional indicators of blood pressure, heart rate, and respiratory rate are of great importance, but are not considered very sensitive for determining the degree of hemorrhagic shock (data on oxygen transport, acid-base balance, and blood plasma lactate are required).
• Neurological status (neurological deficit). It is necessary to objectively assess the degree of neurological deficit (as early as possible before the administration of sedatives or analgesics).
• Skin (visible mucous membranes). It is very important to examine everything - from the back of the head to the tips of the toes, since wounds can be secondary and tertiary and determine the further course of the disease and the prognosis of traumatic injury.

Classic physical examination findings

After the initial examination, a physical examination is performed as an integral part of a detailed examination, including laboratory and instrumental methods. A detailed examination may be postponed for the period of surgical intervention, which is performed for the final elimination of life-threatening damage.

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Laboratory research

Measuring hemoglobin and hematocrit to assess the condition of the victim and the volume of blood loss immediately upon admission is of little information, but if bleeding continues, the data obtained is very important for dynamic monitoring.

Leukocytosis (over 20x10 ⁹ /l) in the absence of signs of infection indicates significant blood loss or rupture of the spleen (an early sign).

An increase in the activity of serum amylase (specific test - pancreatic amylase) is a sign of damage to the pancreas or intestinal rupture, an increase in the activity of serum aminotransferases is characteristic of liver damage.

Instrumental research

• Survey radiography. In parallel with infusion therapy, survey radiography of the abdominal cavity and chest is performed. The following signs are noted: free gas in the abdominal cavity and retroperitoneal space (especially near the duodenum), high position of the diaphragm dome, absence of the shadow of the lumbar muscle, displacement of the gastric gas bubble, altered location of intestinal loops, foreign bodies. In case of fractures of the lower ribs, damage to the liver, spleen, and kidneys is possible.
• CT. The use of radiopaque substances (intravenously or orally) expands the capabilities of the method and allows for simultaneous visualization of parenchymatous and hollow organs of the abdominal cavity. There is still no consensus regarding the advantages of CT over peritoneal lavage: CT detects the damaged organ (a possible source of bleeding), while peritoneal lavage detects blood in the abdominal cavity.
• X-ray contrast studies of the urinary tract. Urethrorrhagia, abnormal position of the prostate or its mobility during digital rectal examination, hematuria are signs of damage to the urinary tract or genitals. Urethrography is used to diagnose damage to the urethra. Intraperitoneal and extraperitoneal rupture of the bladder can be detected using cystography, a radiopaque substance is introduced through a Foley catheter. Kidney damage and retroperitoneal hematomas are diagnosed using abdominal CT, which is performed on every patient with hematuria and stable hemodynamics. In case of penetrating abdominal wounds, excretory urography is prescribed, which is used to assess the condition of the kidneys and ureters. If concomitant TBI is suspected, excretory urography should be postponed until CT of the head is performed.
• Angiography. Conducted on hemodynamically stable victims to diagnose additional injuries (for example, injuries to the thoracic and abdominal aorta).

Other studies

Diagnostic peritoneal lavage with laboratory examination of aspirate Blood in the aspirate is a sign of intra-abdominal bleeding, which may be the cause of arterial hypotension. The content of erythrocytes in the washing waters, equal to 100,000 in 1 ml, corresponds to 20 ml of blood per 1 liter of fluid and indicates intra-abdominal bleeding.

Ultrasound is a more informative method for diagnosing intra-abdominal bleeding compared to peritoneal lavage.

If blood is released from the anus or remains on the glove during a digital rectal examination, a rectoscopy is performed to diagnose damage to the rectum.

All patients with suspected abdominal trauma must have a nasogastric tube and urinary catheter inserted (in case of combined trauma with a basal skull fracture, the tube is inserted through the mouth). Blood in the resulting fluid is a sign of damage to the upper gastrointestinal tract or urinary tract.

According to the protocol for the diagnosis and treatment of blunt abdominal trauma (EAST Practice Management Guidelines Work Group, 2001),

A Level I

• Diagnostic laparotomy is performed in all victims with positive peritoneal lavage.
• CT is recommended for evaluation of hemodynamically stable patients with equivocal physical examination findings, particularly in cases of combined injury and CNS trauma. In these circumstances, patients with negative CT findings should be followed up.
• CT is the diagnostic tool of choice for patients with isolated internal organ trauma who are receiving conservative therapy.
• In hemodynamically stable patients, diagnostic peritoneal lavage and CT are additional diagnostic methods.

In Level II

• Ultrasound is prescribed as an initial diagnostic tool to exclude hemoperitoneum. If the ultrasound result is negative or inconclusive, diagnostic peritoneal lavage and CT are prescribed as additional methods.
• When diagnostic peritoneal lavage is used, clinical decision should be based on the presence of blood (10 mL) or microscopic examination of the aspirate.
• In hemodynamically stable patients with a positive diagnostic peritoneal lavage, the next step should be CT, especially if there is a pelvic fracture or suspected injury to the genitourinary organs, diaphragm, or pancreas.
• Diagnostic laparotomy is prescribed to victims with unstable hemodynamics; ultrasound is used in stable patients. Hemodynamically stable patients with a positive ultrasound response undergo CT, which helps in choosing further tactics.
• Investigations (diagnostic peritoneal lavage, CT, repeat ultrasound) in hemodynamically stable patients depend on the initial ultrasound results.

C Level III

• Objective diagnostic studies (ultrasound, diagnostic peritoneal lavage, CT) are performed on victims with encephalopathy, questionable data obtained during physical examination, combined trauma or hematuria.
• Victims with a "belt" injury require diagnostic observation and a thorough physical examination. If intraperitoneal fluid is detected (by ultrasound or CT), further tactics are determined - either diagnostic peritoneal lavage or laparotomy.
• CT is performed on all victims with suspected kidney damage.
• If the ultrasound examination is negative, CT scanning should be performed for patients at high risk of intra-abdominal injury (eg, complex extremity trauma, severe chest trauma, and negative neurologic signs).
• Angiography of internal organs is performed to diagnose additional injuries (trauma to the thoracic and/or abdominal aorta).

Indications for hospitalization

All abdominal injuries, including superficial ones, require medical attention. Late treatment leads to increased disability.

Indications for consultation with other specialists

For successful treatment and diagnostic tactics, joint work of teams from intensive care, thoracic and abdominal surgery departments, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopy rooms) is necessary.

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Treatment of abdominal trauma

Penetrating abdominal trauma (bullet, knife, shotgun pellets, etc.) is an indication for laparotomy and abdominal cavity revision. Diagnostic laparotomy is started immediately if there is shock or abdominal distension. In other cases, it is advisable to first conduct the studies listed above.

Expectant conservative therapy is possible only for small wounds of the anterior abdominal wall, when damage to the peritoneum is unlikely. If any symptoms of peritoneal irritation appear (pain on palpation, tension of the muscles of the anterior abdominal wall) and intestinal sounds disappear, surgery is necessary. The safest management tactic is wound revision under local anesthesia; if a penetrating wound is detected, diagnostic laparotomy under general anesthesia is performed. However, in most cases, if there are no symptoms of peritoneal irritation, even with stab wounds of the anterior abdominal wall, observation may suffice.

Treatment tactics for blunt abdominal trauma depend on the clinical picture and diagnostic test results. If the symptoms are minor and suspicions of serious damage to the abdominal organs are confirmed, the patient is hospitalized, monitored, and undergoes repeated abdominal X-rays. Frequent follow-up examinations should be performed by the same physician.

Indications for diagnostic laparotomy in case of closed abdominal trauma:

• persistent tension in the muscles of the anterior abdominal wall or pain upon palpation,
• any unexplained symptoms diagnosed with each abdominal examination,
• signs of shock and blood loss,
• pathological changes on abdominal X-ray and laboratory data.

In pelvic fractures with profuse bleeding, infusion therapy is often ineffective. In this case, a pneumatic anti-shock suit is used. If a patient with suspected abdominal trauma is admitted in an anti-shock suit, the air must be released from the chamber located on the abdomen to perform peritoneal lavage or ultrasound.

Drug treatment

The main components of therapy for victims with abdominal trauma:

• analgesics (morphine, fentanyl). For adequate analgesia (if there are no contraindications), epidural analgesia is recommended,
• anxiolytics (benzodiazepines, haloperidol),
• antibacterial drugs,
• infusion and transfusion therapy.

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Recommendations for antibacterial therapy in victims with penetrating abdominal wounds (The EAST Practice Management Guidelines Work Group)

A Level I

Based on available evidence (class I and II data), preoperative prophylaxis with broad-spectrum antibacterial agents (against aerobes and anaerobes) is recommended as standard for patients with penetrating injuries.

If there is no damage to internal organs, further administration of the drugs is stopped.

In Level II

Based on available evidence (class I and II data), prophylactic administration of antibacterial drugs for various internal organ injuries is recommended for 24 hours.

C Level III

There are insufficient clinical studies to develop guidelines for reducing the risk of infection in patients with hemorrhagic shock. Vasospasm alters the normal distribution of antibiotics, reducing their penetration into tissues. To solve this problem, it is suggested to increase the antibiotic dose by 2-3 times until bleeding stops. When hemodynamic stability is achieved, antibacterial agents with high activity against facultative anaerobic bacteria are prescribed for a certain period, which depends on the degree of wound contamination. For this purpose, aminoglycosides are used, which have shown suboptimal activity in victims with severe trauma, which is associated with altered pharmacokinetics.

Muscle relaxants are used in situations where relaxation is required during sedative therapy to ensure adequate ventilation (non-depolarizing muscle relaxants are recommended among the drugs).

Immunoprophylaxis. In addition to serums, in case of penetrating abdominal wounds, the use of polyvalent immunoglobulins is recommended to improve long-term treatment results.

Other groups of drugs are used for symptomatic therapy. It should be noted that the use of many traditional drugs does not prove its effectiveness in studies.

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Anesthetic support

Anesthesia is performed according to all the rules of anesthesiology, ensuring safety and efficiency criteria. It should be taken into account that it is better to refrain from intraoperative administration of nitrous oxide due to possible intestinal distension.

It is recommended to install an epidural catheter at the required level (depending on the level of damage) for subsequent adequate analgesia in the postoperative period.

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Surgical treatment of abdominal trauma

Emergency diagnostic laparotomy

In addition to the measures required when preparing patients for planned operations, the following are performed before diagnostic laparotomy:

• installation of a nasogastric tube and a permanent urinary catheter,
• parenteral administration of antibiotics (if there is a suspicion of injury to the stomach or intestines, severe shock, extensive damage),
• drainage of the pleural cavity (in case of penetrating wounds and closed chest trauma with signs of pneumothorax or hemothorax),
• ensuring reliable vascular access, including for monitoring hemodynamics in an invasive manner.

The surgical approach is a midline laparotomy. The incision should be long, allowing for a quick inspection of the entire abdominal cavity.

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Methodology

• A quick examination of the abdominal cavity to detect sources of bleeding.
• Temporary stopping of bleeding: tamponade - in case of damage to parenchymatous organs, application of clamps - in case of damage to the main arteries, finger pressure - in case of damage to large veins.
• The replenishment of the BCC begins after the bleeding has temporarily stopped. Without this, it is impossible to continue the operation, which may lead to further blood loss.
• Damaged intestinal loops are wrapped with a napkin and brought out to the abdominal wall to prevent further infection of the abdominal cavity with intestinal contents. Large or growing retroperitoneal hematomas must be opened, the source must be established and the bleeding must be stopped.
• Final stopping of bleeding: application of vascular sutures, ligation of vessels, suturing of wounds, liver resection, resection or removal of the kidney, spleen. In extreme cases, the source of bleeding is tamponed and relaparotomy is performed.
• Suturing wounds or resection of the stomach and intestines.
• Washing the abdominal cavity with a large amount of isotonic sodium chloride solution if it was contaminated with intestinal contents.
• Inspection of the abdominal cavity, including opening of the omental bursa and examination of the pancreas. If hemorrhages or edema are detected, mobilization and full examination of the pancreas are performed. To examine the posterior wall of the duodenum, its mobilization according to Kocher is performed.
• Re-examination of all damaged organs, sutures, etc., toilet of the abdominal cavity, installation of drains (if necessary), layer-by-layer suturing of the abdominal wall wound.
• If the abdominal cavity has been contaminated with intestinal contents, the skin and subcutaneous tissue are not sutured.

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Prognosis of abdominal trauma

According to global data, the prognostic level is considered to be the score on the TRISS scale. In this case, the prognosis for penetrating and closed injuries is taken into account separately.

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