Injury of the abdomen

Closed abdominal trauma occurs as a result of the impact of an explosive wave, when falling from a height, blows in the stomach, and squeezing the trunk with heavy objects. The severity of the damage depends on the degree of excess pressure of the shock wave or shock force in the stomach by the moving object.

Light injuries are accompanied by isolated injuries of the abdominal wall and are manifested by abrasions of the skin and bruises, limited by soreness, swelling, tension of the abdominal muscles.

ICD-10 code

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

Epidemiology of abdominal trauma

There are closed and open abdominal injuries, accounting for 6-7% of the structure of sanitary losses in military conflicts of recent years. In a peaceful environment, the damage to the abdominal cavity organs is the result of a traffic accident (road accident). It should be noted that the true incidence of abdominal injuries is unknown, perhaps due to the fact that specialized medical centers (for the treatment of trauma) publish information about patients who are in their care, while other medical hospitals (not trauma profile) do not represent their data.

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

Similar surveys of medical databases of adult victims show that closed abdominal trauma is the leading cause of intra-abdominal injuries, and the leading mechanism for its reception is an accident.

Injury of hollow organs is more often associated with damage to the parenchymal organs, especially the pancreas. Approximately 2/3 of patients with trauma to the hollow organs receive them due to an accident.

[1], [2], [3]

International data

WHO data indicate that an accident is the most common cause of this type of injury.

Generalized data from South-East Asia define trauma as the leading cause of mortality at the age of 1-44 years. Road accidents, trauma with a blunt object and falls from a height are considered to be leading in the etiological structure of abdominal injuries. Closed injury is, according to their data, 79% of all victims with a trauma to the abdomen.

Morbidity and mortality

Closed abdominal injury in 85% of cases occurs due to an accident. The lethality in this case is 6%.

Floor

According to international data, the ratio of men / women with a stomach injury is 60/40.

[4], [5], [6], [7]

Age

Most of the studies indicate that people who are 14-30 years old receive abdominal trauma.

[8], [9], [10], [11], [12]

Influence of mechanisms of reception of a trauma of a stomach

Full information on the mechanism of injury helps more correct and quick diagnosis. So, with injuries of the lower half of the breast, they suspect a blunt stomach injury in the upper floor and vice versa. In case of an accident, a seat belt injury ("injury" injury) is possible, in which the probability of damage to the spleen and liver is high, which must be taken into account when diagnosing the cause of a critical condition (shock, hypotension).

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

In severe and extremely serious injuries of the abdominal cavity and retroperitoneal space, the integrity of the liver, spleen, kidneys, and intestines is most often disturbed.

Abdominal compartment syndrome

Abdominal compartment syndrome (AKS) 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 infringement of inflow-outflow of blood, reduction of production of urine, caused by violation of renal blood flow. For the first time the syndrome is described in the XIX century (Mageu and Bert). At the beginning of the XX century, the relationship between ACS and intra-abdominal hypertension was first described when the possibility of measuring intra-abdominal pressure appeared.

Allocate:

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

In the intensive care units, a decrease in the rate of diuresis, signs of cardiac pathology in elderly patients can be diagnosed (with the development of metabolic acidosis in the study of CBS). In the absence of knowledge of this type of disorder, developing states are perceived for other pathological conditions (eg, hypovolemia), in this connection we will dwell on this type of complication in more detail.

Pathophysiology is associated with organ dysfunction as a result of direct exposure to intraperitoneal hypertension. Problems arise in the parenchymal 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 the increase of hypertension. At the cellular level, oxygen delivery is impaired, resulting in ischemia and anaerobic metabolism. Vasoactive substances such as histamine increase the endothelial loss, which leads to "sweating" of red blood cells and the progression of ischemia. Although the abdominal cavity is more extensible than the limbs, in an acute situation, pathological processes look no less dramatic and are considered the cause of decompensation in any critical condition in traumatized patients.

[13], [14], [15], [16], [17]

Frequency

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

Morbidity and mortality

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

Mortality is 25-75%. The level of intra-abdominal pressure is 25 mm. Gt; Art. And higher leads to disruption of the internal organs.

Examination

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

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

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

• an increase in the circumference of the abdomen,
• respiratory discomfort,
• oliguria,
• collapse,
• melena,
• nausea and vomiting,
• clinical picture of pancreatitis, peritonitis.

Physical examination of ACS usually involves an increase in the volume of the abdomen. If these changes are acute, the abdomen is swollen and painful. However, this symptom is more difficult for victims with excessive weight. Also observed rales in the lungs, cyanosis, pallor.

The etiology of ACS occurs when intra-abdominal pressure is too high, like the compression syndrome in limb injuries. When the abdomen is affected, two types of ACS are distinguished, with different and sometimes combined causes:

• Primary (acute).
• Penetrating trauma.
• Intraperitoneal hemorrhage.
• Pancreatitis.
• Compression of the abdominal cavity organs by mechanical compression (by the mechanism of trauma).
• Fracture of the pelvis.
• Rupture of the abdominal aorta.
• Perforation of a ulcerative defect.
• Secondary can develop in the victims without injury to the stomach, when there is accumulation of fluid in volumes sufficient to cause intra-abdominal hypertension.
• Excessive infusion therapy for hyponatremia.
• Sepsis.
• Prolonged dynamic intestinal obstruction.

Differential diagnosis is performed with all the injuries and lesions of the abdominal cavity organs with acute coronary syndrome, ARDS, kidney failure, ketoacidosis, including alcoholic, anaphylaxis, appendicitis, cholecystitis, constipation, bulimia, Cushing syndrome, diaphragm damage, electric trauma, gastroenteritis, diverticulosis, gangrene intestine, inferior vena cava syndrome, urinary retention, peritonitis, thrombocytopenic purpura, etc.

[18]

Laboratory diagnostics

• a general blood test with the calculation of the blood formula,
• prothrombin time, APTT, PTI,
• amylase and lipase,
• test for markers of myocardial damage,
• Analysis of urine,
• blood plasma lactate content,
• arterial blood gases

Instrumental diagnostics

• radiography is not informative,
• CT (determination of the ratio of anteroposterior and transverse size, thickening of the intestinal walls, widening of the inguinal ring from both sides),
• Ultrasound (difficult with intestinal flatulence),
• measurement of pressure in the bladder by a special system through the Foley catheter.

Treatment

• Perform treatment of the underlying disease. For the prevention use of various surgical techniques, thanks to which it is possible to reduce the likelihood of development of the syndrome of ACS. Conduct a balanced infusion therapy, crystalloids do not inject. It is necessary to remember undiagnosed ACS in almost 100% considered fatal as a result of development of acute renal failure, acute liver failure, ARDS, and bowel necrosis.
• When making a diagnosis, it is necessary, first of all, to release the stomach from any pressure bandages, clothes. Pharmacotherapy is prescribed to reduce the WBD. Use furosemide and other diuretics, which are less effective than the surgical manual.
• Percutaneous drainage of fluid (puncture). Multiple data prove its effectiveness in the ACS. It is possible to perform decompressive laparotomy.
• Laparoscopic decompression.

Abdominal sepsis. Infectious complications

Abdominal surgical trauma is often accompanied by infectious complications. The use of antibiotic therapy without sanation of an infectious focus is ineffective.

[19], [20], [21], [22], [23]

Enteral insufficiency

Enteral insufficiency (maldigestia syndrome, malabsorption, intestinal paresis, etc.) is a condition accompanying patients with damage to the abdominal organs (intestine, liver, gallbladder, pancreas, with retroperitoneal hematoma). The incidence of the syndrome is up to 40% of cases. With the development of intestinal pathology, enteral nutrition becomes impossible (with a persistent paresis of the intestine, the absorption process is disrupted). In this regard, against the background of a violation of the vascularization of the mucosa, the phenomenon of translocation of microorganisms is determined. Its importance in the development of infectious complications continues to be studied. In the absence of contraindications enterosorption is carried out.

[24], [25], [26], [27], [28], [29]

Classification of abdominal injuries

Classification of BV Petrovsky (1972)

By the nature of the damage:

• open,
• closed.

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

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

By the type of wounding weapon:

• chopped-cut,
• firearms.

By the nature of the wound channel:

• cross-cutting,
• tangential,
• the blind.

In addition, the injured stomach is penetrating and non-penetrating, with damage and without damage to the internal organs, with intraperitoneal bleeding and without it.

[30], [31], [32]

Complications of abdominal injuries

The above complex of medical and diagnostic measures is aimed not only at diagnosis of the underlying disease, clarification of the nature of injuries, but also on the timely detection of complications of abdominal trauma. The most specific:

• massive hemorrhage and hemorrhagic shock,
• DIC-syndrome and PON,
• posttraumatic pancreatitis,
• abdominal compartment syndrome (syndrome of abdominal hypertension),
• abdominal sepsis, septic shock,
• enteral insufficiency.

[33], [34], [35], [36]

Massive hemorrhage and hemorrhagic shock

Massive blood loss is the loss of one BCC within 24 hours or 0.5 volume of BCC for 3 hours. At a trauma of 30-40% massive blood loss leads to fatal outcomes. In the description of this section, let us dwell on the factors contributing to early diagnosis and methods of correction of anemia and hypovolemia in this category of victims using the protocol Management of bleeding, the following major trauma a European guideline, 2007. In carrying out resuscitation activities in victims with an undetected source of bleeding, a rapid diagnosis of the source for its elimination, restoration of perfusion and achievement of hemodynamic stability.

• Reducing the time from injury to surgery improves the prognosis (level A).
• Victims with hemorrhagic shock and established source of bleeding should be subjected to urgent surgical intervention in order to definitively stop bleeding (level B).
• Patients with hemorrhagic shock and an undetected source of bleeding conduct further emergency diagnosis (level B).
• Victims with a significant accumulation of fluid in the free abdominal cavity (according to ultrasound) and unstable hemodynamics perform urgent surgical intervention (level C).
• Hemodynamically stable patients with a combined injury and / or abdominal hemorrhage need to perform CT (level C).
• Do not recommend the use of hematocrit indicators as the only laboratory marker of the degree of blood loss (level B).
• It is recommended to use the determination of plasma lactate level in dynamics as a diagnostic test for massive blood loss and / or hemorrhagic shock (level B).
• Define a deficit of grounds for additional diagnosis of the consequences of massive blood loss (level C).
• The level of systolic pressure should be maintained within 80-100 mm. Gt; Art. (for victims without brain injury) to surgical stopping of bleeding in the acute period of the trauma (level E).
• Offer the use of crystalloids for infusion therapy in patients with continued bleeding. The introduction of colloids is carried out individually (level E).
• It is recommended that patients warm up before reaching normothermia (level C).
• The required hemoglobin content is 70-90 g / l (level C).
• Freshly frozen plasma is prescribed for patients with massive blood loss, complicated by coagulopathy (APTT is higher or PTI is 1.5 times lower than normal). The initial dose of plasma is 10-15 ml / kg, its subsequent correction (level C) is possible.
• Maintenance of platelet levels is more than 50х10 ⁹ / l (level C).
• It is recommended to use a fibrinogen concentrate or cryoprecipitate if severe blood loss is accompanied by a decrease in the serum fibrinogen content below 1 g / l. The initial dose of fibrinogen concentrate is 3-4 g or 50 mg / kg cryoprecipitate, which is equivalent to 15-20 units in an adult weighing 70 kg. Repeated dose administration is performed according to the results of laboratory data (level C).
• The introduction of antifibrinolytic drugs is prescribed only until the final surgical stop of bleeding (level E).
• It is recommended to use recombinant activated VII factor for the purpose of effective haemostatic therapy with closed trauma (level C).
• Antithrombin III in the intensive care of victims with trauma is not used (level C).

Coagulopathy and DIC-Syndrome

Description and development of DIC syndrome is described in more detail in other chapters of the manual. Evidence that the degree of blood loss, the level of systolic blood pressure is determined in the subsequent development of coagulopathic disorders, no. Adequate intensive therapy, focused on the necessary vollemic status, balanced infusion therapy reduces the risk of developing DIC syndrome. In patients with coagulopathy, the prognosis is worse than for those with the same pathology, but without coagulopathy.

[37], [38], [39], [40], [41], [42], [43]

Post-traumatic pancreatitis

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

Recommendations for the diagnosis of victims with abdominal trauma

• Damage to the abdomen should be excluded from every patient who has received a road, industrial or sports injury. Even a minor injury can be accompanied by severe injuries to the abdominal organs.
• The diagnosis of closed abdominal injuries is complicated. Symptoms sometimes do not appear immediately, if several organs or systems are damaged, some signs can be veiled by others.
• The clinical picture is often distorted by concomitant damage to other anatomical areas. Disturbance of consciousness and a trauma of a spinal cord extremely complicate inspection.
• If during the initial examination of damage to the abdomen are not identified, be sure to conduct a second examination after a certain period of time.
• The rupture of the hollow organ is usually accompanied by symptoms of irritation of the peritoneum and absence of intestinal noises. At a primary examination, these symptoms may be absent. Thus, with lesions of the small intestine and bladder, early symptoms are sometimes meager, therefore frequent repeated examinations are necessary.
• If the parenchymal organ (liver, spleen, kidneys) is damaged, bleeding usually occurs. In the shock of the unclear etiology that has arisen after the trauma, in the first place, damage to the abdominal organs is assumed. First of all, this is due to the anatomical features of the parenchymal organs, namely, to their pronounced vascularization.
• When a stomach injury is particularly sensitive to damage, a full bladder and a pregnant uterus.

Diagnosis of abdominal trauma

In some cases, the diagnosis of "stomach injury" is unquestionable (wound channel in the projection of the abdomen, hematoma, ablation of the abdominal cavity organs). To exclude damage to internal organs, objective (physical), instrumental and laboratory examinations are performed.

Execution of the examination and / or initial assessment of the severity of the victim should be carried out simultaneously with emergency intensive care interventions. In detail, the condition is not evaluated until all life-threatening disorders have been identified. Very useful are anamnestic data from accompanying personnel or witnesses, as well as the results of sensing the stomach and catheterization of the bladder.

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

• type of medical hospital (specialized for trauma treatment or not),
• technical equipment,
• The experience of a doctor who is treating in a particular case.

It should be remembered that any diagnostic tactics should be flexible and dynamic.

[44], [45], [46]

Anamnesis and physical examination

The primary purpose of a primary examination is to immediately identify life-threatening conditions. The exception is hemodynamically unstable victims. The dominant role in the examination of this category of victims is to determine the extent of violations of vital functions and, as a consequence, the volume of intensive care.

When collecting anamnesis, it is necessary to take into account allergies, surgical interventions, chronic pathology, the time of the last meal, the circumstances of the trauma.

They matter:

• the anatomical location of the wound and the type of wounding projectile, the time to strike (additional data on the trajectory, position of the body),
• The distance from which the impact was struck (height at fall, etc.). With gunshot lesions, it must be remembered that when a close shot is transmitted a greater amount of kinetic energy,
• prehospital assessment of the magnitude of blood loss by accompanying personnel,
• the initial level of consciousness (on the Glasgow coma scale). When transporting from the prehospital stage, it is necessary to determine the amount of care and response of the victim to the therapy.

[47], [48], [49], [50]

Additional continuous monitoring

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

[51], [52], [53], [54]

Additional diagnostics

• Radiography of the chest and abdominal cavity, if possible standing.
• Ultrasound of the abdominal cavity and cavity of the small pelvis.
• Gas analysis of arterial and venous blood (pO2, Sa2, PvO2, SvO2, pO2 / FiO2), indicators of acid-base balance.
• Blood plasma lactate content, deficiency of bases as criteria for tissue hypoperfusion.
• Coagulogram (APTTV, PTI).
• The level of glycemia.
• Creatinine and residual nitrogen content.
• Determination of the blood group.
• Calcium and magnesium in blood serum.

Interventions and additional studies (performed with hemodynamic stability of the victim)

• laparocentesis (diagnostic peritoneal lavage),
• laparotomy

[55], [56], [57], [58], [59], [60],

Detailed inspection

A more detailed examination and a complete laboratory study aimed at identifying all lesions and planning further diagnostics and treatment activities, in some situations, are conducted in conjunction with resuscitation.

[61]

Physical examination

• Physical examination is the primary tool for the diagnosis of abdominal trauma. With the proper organization of the examination and certain skills, a physical examination takes about 5 minutes. To optimize time costs, from the point of view of the importance for the patient's clinical condition, it is recommended that the examination be performed sequentially.
• Airways. Determine the patency, safety of protective reflexes, the absence of foreign bodies in the oral cavity, secretion, respiratory tract damage.
• Breath. Presence or absence of independent breathing. Determine the frequency of breathing, a subjective evaluation of the depth and effort of inspiration.
• Circulation. The study of blood circulation begins with assessing the skin, the mental status of the affected, dermal temperature and the fullness of the veins of the extremities. In patients with hemorrhagic shock in mental status, changes from anxiety to coma are possible. Traditional indices of blood pressure, heart rate, NRF are of great importance, but are not considered very sensitive for determining the degree of hemorrhagic shock (oxygen, CBS, lactate of blood plasma data are needed).
• Neurological status (neurological deficit). It is necessary to assess objectively the degree of neurological deficit (as early as possible before the administration of sedatives or analgesics).
• Skin covers (visible mucous membranes). It is very important to examine everything from the neck to the tips of the toes, as the wounds can be secondary and tertiary and determine later the course of the disease and the forecast of traumatic injury.

Data of classical physical examination

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

[62], [63], [64], [65]

Laboratory research

Measurement of hemoglobin and hematocrit in order to assess the condition of the victim and the volume of blood loss immediately upon admission is of little informative, however, with continued hemorrhage, the data obtained are very important for dynamic observation.

Leukocytosis (more than 20x10 ⁹ / L) in the absence of signs of infection indicates significant blood loss or rupture of the spleen (early sign).

An increase in serum amylase activity (specific test - pancreatic amylase) is a sign of pancreatic damage or gut rupture, an increase in serum aminotransferase activity is characteristic for liver damage.

Instrumental research

• Survey radiography. In parallel with the infusion therapy, an overview radiograph of the abdominal cavity and chest is performed. Pay attention to the following signs free gas in the abdominal cavity and retroperitoneal space (especially near the duodenum), high standing of the dome of the diaphragm, absence of the shadow of the lumbar muscle, displacement of the gastric gas bubble, altered location of the intestinal loops, foreign bodies. At fractures of the lower ribs, damage to the liver, spleen, kidneys is possible.
• CT. The use of radiocontrast substances (intravenous or oral) expands the possibilities of the method and allows simultaneous visualization of the parenchymal and hollow organs of the abdominal cavity. Concerning the advantages of CT in the face of peritoneal lavage, there is still no consensus that CT finds a damaged organ (a possible source of bleeding), and peritoneal lavage - blood in the abdominal cavity.
• Radiocontrast studies of the urinary tract. Urethrorrhagia, abnormal position of the prostate or its mobility in digital rectal examination, hematuria - signs of damage to the urinary tract or genitals. Urethrography is performed to diagnose damage to the urethra. The intraperitoneal and extraperitoneal rupture of the bladder can be detected with the help of cystography, the radiopaque substance is injected through the Foley catheter. Renal damage and retroperitoneal hematomas are diagnosed with CT scans of the abdomen, which is performed for each patient with hematuria and stable hemodynamics. With penetrating wounds of the abdomen, excretory urography is prescribed, with the help of which the condition of the kidneys and ureters is evaluated. If there is a suspicion of concomitant TBI, excretory urography should be postponed until CT scan of the head.
• Angiography. Carried out hemodynamically stable victims for the diagnosis of additional damage (for example, trauma of the thoracic and abdominal aorta).

Other studies

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

Ultrasound is a more informative method for diagnosing intraabdominal bleeding compared to peritoneal lavage.

If blood is released from the anus or remains on the glove with digital rectal examination, then rheumatoscopy is performed to diagnose damage to the rectum.

All patients with suspected abdominal trauma should be placed nasogastric tube and urinary catheter (with a combined injury with a fracture of the base of the skull probe installed through the mouth). Blood in the resulting fluid is a sign of damage to the upper parts of the digestive system or urinary tract.

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

A Level I

• Diagnostic laparotomy is performed by all victims with positive peritoneal lavage.
• CT is recommended for evaluation of hemodynamically stable victims with questionable data obtained during physical examination, especially with the combined nature of injury and CNS trauma. Under these circumstances, patients with negative CT data are subject to dynamic observation.
• CT is a diagnostic tool of choice for victims with an isolated trauma of internal organs, who undergo conservative therapy.
• In hemodynamically stable patients, diagnostic peritoneal lavage and CT are additional diagnostic methods.

In Level II

• Ultrasound is designated as an initial diagnostic tool to exclude hemoperitoneum. With a negative or uncertain ultrasound result, diagnostic peritoneal lavage and CT are prescribed as additional methods.
• When diagnostic peritoneal lavage is used, the clinical solution should be based on the presence of blood (10 ml) or microscopic analysis of the aspirate.
• In hemodynamically stable victims with positive diagnostic peritoneal lavage, the next step should be CT, especially with a pelvic fracture or suspected damage to the genito-urinary organs, diaphragm or pancreas.
• Diagnostic laparotomy is prescribed to victims with unstable hemodynamics, in stable patients ultrasound is used. To hemodynamically stable patients with a positive response from ultrasound, CT is performed, which helps in the selection of further tactics.
• Studies (diagnostic peritoneal lavage, CT, repeated ultrasound) in hemodynamically stable patients depend on the initial results of ultrasound.

C Level III

• Objective diagnostic studies (ultrasound, diagnostic peritoneal lavage, CT) are performed by victims with encephalopathy, questionable data obtained during physical examination, combined trauma or hematuria.
• Victims with a "belt" injury need diagnostic supervision and a thorough physical examination. When intraperitoneal fluid is detected (by ultrasound or CT), further tactics - either diagnostic peritoneal lavage or laparotomy - are determined.
• CT is performed by all victims with suspected renal damage.
• With negative ultrasound, a CT scan should be performed for patients at high risk of intraperitoneal damage (for example, a complex limb injury, severe chest injury, and negative neurological symptoms).
• Angiography of the internal organs is performed to diagnose additional injuries (trauma of the thoracic and / or peritoneal aorta).

Indications for hospitalization

For all injuries of the abdominal organs, including superficial injuries, care must be taken. Later treatment leads to an increase in disability.

Indications for consultation of other specialists

For successful therapeutic and diagnostic tactics, the joint work of the teams of resuscitation, thoracic and abdominal surgery departments, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopic surgeries) is necessary.

[66], [67], [68], [69]

Treatment of abdominal trauma

Penetrating abdominal injuries (bullet, knife, shot injuries, etc.) - an indication for laparotomy and revision of the abdominal cavity. To the diagnostic laparotomy start immediately, if there is shock or bloating. In other cases, it is advisable to first carry out the studies listed above.

Expectant conservative therapy is possible only with small wounds of the anterior abdominal wall, when peritoneal damage is unlikely. When there are any symptoms of irritation of the peritoneum (soreness in palpation, muscle tension in the anterior abdominal wall) and with the disappearance of intestinal noises, surgery is necessary. The safest tactic of conducting - revision of the wound under local anesthesia, when a penetrating wound is detected, go to a diagnostic laparotomy under general anesthesia. However, in most cases, if the symptoms of irritation of the peritoneum are absent, even with puncture wounds of the anterior abdominal wall, we can confine ourselves to observation.

The tactics of treatment for blunt abdominal trauma depends on the clinical picture and the results of diagnostic studies. If the symptoms are minor, and the suspicions of serious damage to the abdominal organs are confirmed, the patient is hospitalized, observed and repeated radiography of the abdominal cavity. Frequent repeated examinations should be carried out by the same doctor.

Indications for diagnostic laparotomy with closed abdominal injury:

• persistent tension in the muscles of the anterior abdominal wall or soreness in palpation,
• any unexplained symptoms, diagnosed with each study of the abdomen,
• signs of shock and blood loss,
• pathological changes on the chest x-ray and laboratory data.

With pelvic fractures, accompanied by profuse bleeding, infusion therapy is often ineffective. In this case, a pneumatic anti-shock suit is used. If a patient with a suspected abdominal trauma has acted in an anti-shock suit, it is necessary to release air from the camera located on the abdomen for peritoneal lavage or ultrasound.

Medication

The main components of therapy for victims with an abdominal trauma:

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

Recommendations for antibiotic therapy in victims with penetrating wounds of the abdominal cavity (The EAST Practice Management Guidelines Work Group)

A Level I

According to available evidence (class I and II data), pre-operative prophylaxis with antibacterial drugs with a broad spectrum of action (for aerobes and anaerobes) is recommended as standard for victims with penetrating injuries.

In the absence of damage to the internal organs, further administration of the drugs is stopped.

In Level II

According to the available evidence (Class I and II data), it is recommended to prophylactic administration of antibacterial drugs for various injuries of the internal organs within 24 hours.

C Level III

There are insufficient informative clinical studies to develop principles on the reduction of infectious risk in patients with hemorrhagic shock. Because of the vasospasm, the normal distribution of antibiotics changes, which reduces their penetration into the tissues. To solve this problem, it is suggested to increase the dose of an antibiotic 2-3 times before stopping the bleeding. When hemodynamic stability is reached, antimicrobial agents with high activity for facultative anaerobic bacteria are prescribed for a certain period, which depends on the degree of contamination of the wound. For this purpose aminoglycosides are used, which showed suboptimal activity in victims with severe trauma, which is associated with altered pharmacokinetics.

Miorelaxants are used in situations where relaxation is necessary during sedation to ensure adequate ventilation (among medications, muscle relaxants are recommended non-depolarizing action).

Immunoprophylaxis. In addition to sera, with the penetrating nature of the wound of the abdominal cavity, the use of polyvalent immunoglobulins is recommended to improve the long-term results of treatment.

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 research.

[70], [71]

Anesthetic care

Anesthetic management is performed according to all the rules of anesthesiology, with safety and effectiveness criteria. Thus it is necessary to consider that from intraoperative introduction of nitrous oxide it is better to abstain because of a possible stretching of the intestine.

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

[72], [73], [74], [75], [76], [77], [78]

Surgical treatment of abdominal trauma

Emergency diagnostic laparotomy

In addition to the activities that are mandatory in the preparation of patients for routine operations, diagnostic laparotomy is performed:

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

Operative access is median laparotomy. The incision should be long, ensuring a quick examination of the entire abdominal cavity.

[79], [80], [81], [82], [83], [84], [85], [86], [87]

Methodology

• Quick examination of the abdominal cavity to detect sources of bleeding.
• Temporary stopping of tamponade bleeding - if parenchymatous organs are damaged, clamps are applied - in case of damage to the main arteries, pressing with a finger - if large veins are damaged.
• Compensation BCC begin after a temporary stop of bleeding. Continue the operation, which can lead to further blood loss, without this it is impossible.
• Damaged hinge loops are wrapped with a napkin and removed to the abdominal wall to prevent further infection of the abdominal cavity with intestinal contents. Large or increasing retroperitoneal hematomas must be opened, a source is identified and bleeding stopped.
• The final stop of bleeding is the imposition of vascular sutures, vasoconstriction, wound suturing, liver resection, resection or removal of the kidney, spleen. In extreme cases, the source of bleeding is swabbed and relaparotomy is performed.
• Sewing of wounds or resection of the stomach and intestines.
• Washing of the abdominal cavity with a large amount of isotonic sodium chloride solution if it was contaminated with the contents of the intestine.
• Revision of the abdominal cavity, including opening of the gland bag and examination of the pancreas. If hemorrhages or swelling are detected, mobilization and a complete examination of the pancreas are performed. To examine the back wall of the duodenum, it is mobilized according to Kocher.
• Re-examination of all damaged organs, seams, etc., toilet of the abdominal cavity, installation of drains (if necessary), layer-by-layer suturing of the wound of the abdominal wall.
• If the abdominal cavity was contaminated with the contents of the intestine, the skin and subcutaneous tissue are not sutured.

[88], [89], [90], [91], [92], [93], [94], [95], [96], [97]

Forecast abdominal trauma

According to the world data, the level of scores on the TRISS scale is considered as prognostic. At the same time, the prognosis for penetrating and closed lesions is separately taken into account.

[98], [99], [100]