Different forms of trauma have been a leading cause of death as seen in the Accident and Emergency specially in the age group of 1-50 years. Most of the usual causes outlined in the published literature include road traffic accidents, stab wounds, falls from height and gunshot wounds.
The abdomen is traumatized in about 10-15% of cases; this wouldbe attributed to its large surface area compared with other parts of the body. This prospective study was carried out over a period of one year starting January 2015 till December 2015, involving 500 cases with isolated abdominal injuries in some of the Gulf states and Iraq major hospitals. Wehighlight the incidence, gender distribution, available modalities of investigation and methods of improving management and prognosis of abdominal trauma in these variable hospitals. There were 500 purely abdominal trauma patients involved in the review over this one-year period. Penetrating injuries were seen in 66 patients (13.2%) and nonpenetrating in 434 patients (86.8%). Gunshot injuries and fall from heights were (2.02%) and (3.05%) of the injuries respectively. The overall ratio of non-penetrating to penetrating injuries was approximately 6:1.
Wound sepsis was the most common complication of patients that underwent surgical exploration; mortality rate was (10%). The major cause of death was irreversible hypovolemic shock due to severe blood loss either prior to arrival in hospital or uncontrollable hemorrhage in the operating room and extreme coagulopathy in the immediate post-operative period.
We advocate rapid transportation and prompt resuscitative measures, availability of modern technological investigations as well as surgical and intensive therapy skills in improving the outcome for victims of abdominal trauma regardless of the etiology. Spreading more awareness of the major factors in the causation of vehicular accidents and health education for drivers and road users, conspicuous display of speed limits as well as identification ofthe known accident black spots where road traffic accidents have historically been concentrated will be of significance in the prevention of future accidents and complications.
Keywords: Abdominal Trauma; Occurrence; Outcome
Trauma remains one of the leading cause of death in the age 1-50 year . It is of importance to address the issuesrelated to the presentation and management of these cases in our catchment area in which majority of the population is young adults usually involved in penetrating and blunt trauma due to Road Traffic Accident.
The abdomen is traumatized in about 10-15% of cases; this would be attributed to its large surface area compared with other parts of the body , therefore bearing major injuries contributing to the severity of visceral damage found in presenting patients; This tends to escalate with increased frequency of high speed travel and possibly the rise in social violence as we have noticed in other cases such as stabbing and other forms of penetrating traumas. According to the World Health Organization (WHO) Global Burden of Disease Project 2002, it was estimated that the Road Traffic Accident (RTA) mortality rate (per 100,000 populations) in the Middle East ranged from 19.1 to 28.3 (WHO, 2004). This stresses upon the enormity that RTAs play insubsequent economic drain to the national economy.
Other causes of abdominal trauma include fall from heights, gunshot wounds, stabbing etc. Blunt abdominal trauma poses a great difficulty in diagnosis and accounts for its higher mortality, so it is of utmost importance for medical personnel to be well versed with the assessment, resuscitation and surgical management of these victims .
Abdominal injuries should never be under estimated. Starting with appropriate initial assessment which includes(FAST) performed by a skilled operatorand followed by repeated re-evaluation with adequate investigations; This specially aids in detecting intra-abdominal damage to viscera like spleen, liver, mesenteryand bowel whichare of immediate threat due to the nature of its vascularity .Intra-abdominal injuries carry high morbidity and mortality rate because usually they are not detected as soon as possible usually due totheir severity being under-estimated in the non-penetrating varieties with few or no external signs  or the approach to detecting it in which many factors contribute to delay the its detection such as operator dependent skills in Focused Assessment with Sonography (FAST) for example.
Prompt pre-hospital transportation, initial assessmentthorough resuscitative measures and correct diagnosis are of paramount importance for subsequent good outcome. The policy of prioritization (proper triage) requires a regimented approach , identifying the victims who require immediate and precise care according to the principles of Advanced Trauma Life Support (ATLS).
In view of the importance attached to this type of trauma resulting in high morbidity and mortality if not detected early and managed aggressively alongside with its subsequent severe socio-economic impact on the society, healthcare institutions and the government. This is why we found a need to carry out this retrospective study.
Materials and Methods
Data collection was by patients’ medical record, number, sex, age, clinical presentation, type of trauma inflicted on the abdomen, information also gathered include ancillary investigations such as Diagnostic Peritoneal Lavage (DPL), abdominal ultrasound and abdominal Computerized Tomography (CT) scan carriedout on the patients.
Data was initially documented on a special datacollection form then transferred into a software form to be analyzed. The files were reviewed in regards of the history ofpresentation. The usual diagnostic pathway of takinghistory, physical examination and special investigationswere not followed in some cases because of the urgencyof presentation.
Causes of the trauma such as road traffic accidentswith or without seat belts, stabs, fall from heights, andblunt trauma with heavy objects falling on the abdomenwith pure abdominal injuries were also included from the files. The findings on the abdomen and lower chest wall,anterior or posterior, regarding evidence of bruises,lacerations, impressions of seat belts or vehicle wheels,penetrating wounds, entry and exit wounds were also allrecorded.The presence of abdominal rigidity, percussion orcough tenderness as indicators of visceral injury was alsorecorded from the files.
Bowel sounds auscultation did not show much initially, but digital rectal examination was found useful specially to ascertain the integrity of the rectal wall orthe presence of blood denoting large bowel injury ororgan damage within the pelvis.
Clinical presentations in this study are as outlined in Graph 1 of which haemo-peritoneum resulting in agonizingabdominal pain was the most common mode ofpresentation.
Careful evaluation of the clinical signs of peritonealirritation is frequently rewarding,however analysis ofthese figures has shown a call forcaution since the most constant signs and symptomsmay be absent.
The investigations that were done includebaseline Complete Blood Count (CBC), biochemistry, blood grouping andcross matching and subsequently the valueswere compared with the base-line values.
Other ancillary mode of investigations were plain radiographs of cervical spine, chest, and pelvis X-ray.Urgent abdominal ultrasound in the emergency roomand Diagnostic Peritoneal Lavage (DPL) were indicated in some cases but not all.Plain X-ray in many cases did not provide much helpin the diagnosis of abdominal trauma. However,ten (10)of our patients had evidence of pneumoperitoneumon radiograph with air under the diaphragm as seen on erect plain films.
Abdominal imaging such as ultra-sonography andcomputed tomography are not usually available forroutine diagnosis in some emergency departments, butthese are readily available in the hospitals involved in the study. Theabdominal ultrasound in the series had a reliability of
about 90% especially in detecting splenic trauma cases.
Ultrasound in the form of Focused Assessment withSonography for trauma (FAST) was also performedimmediately after the primary survey of the patient.Extended FAST (eFAST) was carried out in someof the highly unstable patients and this allows for theexamination of both lungs. Helping in detection ofa pneumothorax and possible tension pneumothorax; adeadly complication if not treated immediately at thebedside.Computed tomography was used routinely for all stable cases that did not need immediate laparotomyand in the diagnosis of suspected pancreatic and otherretroperitoneal injuries. Diagnostic Peritoneal Lavage (DPL) was carried out in 30 cases that had equivocal signs, or cases with coexisting closed head injury.Five cases had diagnostic laparoscopy needed in which the ultrasound operator could not completely rule out the presence of haemo-peritoneum.
The total number of abdominal trauma cases reviewed from the period January 2015 till December 2015 were 500 cases out of which 424 (84.8%) were non-penetrating and 76 (15.2%) were penetrating with a ratio of almost 6:1. (Graph 2)
It is immediately obvious that abdominal injuries and possibly multiple injuries for that matter arepredominantly an affliction of the young males and femalesreaching the peak in 21 – 30 age group and extending to 31- 50 in both.
This can be considered the productive age in which thesociety strongly needs these men and women to be active and accomplishing instead of them being wasted injuries and traumas thatif not tackled well, a huge burden and a great drain is put upon the society and the national economy.
The other notable feature is the overall incidence of male cases (424) 84.8% to female cases (76) 15.2% with a ratio of about 6:1, This shows a reflection that the males are more vulnerable to trauma and accidents since culturally and traditionallyin this region society is male dominant.
Splenic rupture in 242 cases (48.4%) topped the list of specific organ damage as shown in Graph 3, meanwhile delayed rupture of the spleen was not seen in this review. Hepatic injuries in 86 cases account for (17.2%) of the lesions. A combination of both splenic and hepatic injuries was seen in 10 cases (2%), out of which twodied on the operative table due to severe uncontrollable bleeding but the other patients survived. Retroperitoneal hematoma and injuries to the small bowel and stomach were seen in 61 (12.2%), 50 (10%) and 10 (2%) cases respectively. There were 50 deaths in this study (10%) out of which 40were males and 10 were females.
Some of these deaths are caused due to a delay in getting help for early transportation to the hospital and most probably bled at the accident site and might also had associated severe chest and head injuries.With regards to management, three principles emerged regarding these cases, early transportation to the hospital, prompt resuscitation and early laparotomy. Early blood transfusion has not been a problem although most emergency departments rely heavily on the use of colloids and crystalloids. Auto transfusion has not been found to be a suitable alternative in abdominal trauma but has succeeded in few cases of splenic trauma.
The decision to operate was based on the clinical evaluation, signs of peritoneal irritation, unexplained shock despite adequate fluid resuscitation, rigid silent abdomen, evisceration, Findings from abdominal ultrasound, Diagnostic Peritoneal Lavage (DPL)in selected cases and abdominal paracentesis.Delaying operation beyond 24 hours of presentation contributed significantly to the mortality rate.Postoperative complications seen in this study are as shown in Graph4.Wound sepsis was seen in (15.2%). This is probably related to wound contamination at the time of injury; the same goes for wound dehiscence (5.1%). Incidence of paralytic ileus was (5.1%).
Abdominal trauma carries a high morbidity and mortalityespecially if not detected early or if its severity isunderestimated [9,10].Intra-abdominal bleeding should be suspected if thereare fractures of the fifth to eleventh ribs, which lie overthe liver and spleen [6,11], or if there are marks caused by seat beltsor vehicular wheels over the abdomen.
Measurement of pulse and blood pressure wereparticularly unreliable as indices of serious intraabdominalbleeding. Initial hemoglobin measurementhad no relevance to severity of injury. Urinalysis seemedto be a reasonable indication of lower urinary tract injurysince most cases of renal trauma showed hematuria orblood at the urethral meatus.The presence or absence of bowel sounds was alsomisleading.
The role of the plain radiograph is not so significant inassessing abdominal trauma except when there isrupture of the diaphragm and missiles that lodged in theabdomen.Ultrasound used to be the ideal initial imaging modalitybecause it can be performed simultaneously with other resuscitative cares, providing vital information without the time delay caused by radiographs or computed tomography Although ultrasound is not 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy and for diagnosing cardiac injuries from penetrating trauma [12,13].
This supremacy has been taken over by FAST which has been used in the evaluation of traumapatients in Europe and United States for more than 20 years. It has now became the initial imaging modality of choice for trauma and it is part of the Advanced Trauma Life Support (ATLS) protocol developed by the American College of Surgeons.
The FAST exam, per ATLS protocol, is performed immediately after the primary survey of the patient. The concept behind the FAST examination is that many life-threatening injuries cause internal bleeding which should be detected by FAST.
The four classic areas examined during FAST for free fluid are the perihepatic space also called Morison’s pouch or the hepatorenal recess, peri splenic space, pericardium, and the pelvis.
With this technique, it is possible to identify the presence of intraperitoneal or pericardial free fluid. In the context of traumatic injury, this fluid will usually be due to bleeding.
FAST’s diagnostic accuracy generally is equal to that of diagnostic peritoneal lavage (DPL).Recently, research studies have shown that bedside ultrasound is equivalent to, or better than, chest radiography for identifying a hemothorax or pneumothorax in trauma patients.
For this reason, some trauma centers have begun performing an extended FAST examination (EFAST) evaluating for pneumothorax and hemothorax in addition to intraperitoneal injuries. It can also detect tension pneumothorax which is a deadly complication if nottreated immediately at the bedside without the need to shift the unstable patient to a radiology suite.
CT scan of the abdomen with and without contrast as the case may be increased the diagnostic work-up of trauma patients with suspected abdominal injuries. A wide range of intra-peritoneal and retroperitoneal organ injuries can be quickly and accurately diagnosed with CT scan of the abdomen .
It should be noted that only hemodynamically stable patients should be transported to the CT scanner and while performing CT scan, close monitoring of the vital signs for clinical evidence of decompensation should be carried out.
The drawbacks of CT scanning are the need to transport the patient from the trauma resuscitation area and the additional time required to perform CT scanning as compared to FAST, EFAST or DPL. The best CT imageryrequires both oral and intravenous (IV) contrast.
However, helical CT technology permits evenfaster examinations with its technological advancement lately, with improved intravenous contrastopacification of parenchymal organs and vascularstructures and reduced CT artifacts caused by patientmotion, respiration, and arterial pulsation.Severely injured and potentially unstable patients, whomight not have been able to tolerate the long CTexaminations in the past, may be quickly evaluated todaywith helical CTParacentesis abdominis was reported in some serieswith a sensitivity of 96.6%. Diagnostic peritoneal lavagewas done only in six (6) patients (6.1%) in our series[8,15,16].
Laparoscopy is still awaiting a true delineation of utility.It will probably be most useful in cases of penetratingtrauma where significant intra-abdominal injury cannot beexcluded, but appears clinically doubtful [17,18].
Laparoscopy gives complete visualization of theperitoneal cavity but retroperitoneal structures are noteasy to visualize. Even a small amount of blood in theperitoneal cavity precludes adequate visualization andtherefore mandates laparotomy.The effect of laparoscopy upon intracranial pressure incases of concomitant head trauma has not beencompletely delineated.The significant factors affecting prognosis or finaloutcome noticed in this study include how rapidly thepatient was transported to the hospital [19,20].This could be broken down to the injury admissioninterval and injury operation interval. Prompt evacuationof the injured and early evaluation and treatment arerequired to reduce mortality. Secondly the presence of other associated injuries inaddition to abdominal trauma also determine finalprognosis. The combination of head and chest injurieswith abdominal trauma is particularly undesirable , while patients with orthopedic injury have amore favorable course.
The nature of the associated injury may decideoutcome but as far as the abdominal lesion itself isconcerned early recognition and prompt surgical actionare the essential features of successful management.The lesions liable to be over-looked in patients withmultiple injuries who are not subjected to immediatelaparotomy are diaphragmatic tear with subsequenthernia, intestinal rupture and sub capsularhematoma ofthe hollow viscera and these should be especiallyconsidered [22-24].
we recommend that prompt evacuationof the injured patient to the hospital, adequate resuscitation, diagnostic Focused Abdominal Sonogram for Trauma (FAST) as well as EFAST, Peritoneal Lavage (DPL) and other diagnostic modalities, constant monitoring with re-assessment and finally timely surgical intervention all play a key role in the successful outcomeof such patients.Adherence to local highway laws and education of road traffic accident prevention should be encouraged and enforced [19,25]. The concept of teamwork in the management of the critically traumatized patient cannot be over-emphasized and has to be promoted, practiced and established in order to improve clinical outcome.
- Ghulam NL, Ghulam QP, Khursheed AW, Abdul MB, Naar AW, et al. (2001) An experience with abdominal trauma in adults in Kashmir. JK-Practitioner 8: 225-230.
- Ponifasio P, Poki HO, Watters DA (2001) Abdominal trauma in urban Papua New Guinea. P N G Med J 44: 36-42.
- Bates T (1973) Abdominal trauma- a report of 129 cases. Postgrad Med J 49: 285-292.
- El-Sadig M, Norman JN, Lloyd OL, Romilly P, Bener A (2002) Road traffic accidents in the United Arab Emirates: trends, morbidity and mortality during 1977-1998. Accid Anal Prev 34: 465-476.
- Ng KS, Hung WT, Wong WG (2002) An algorithm for assessing the risk of traffic accident. J Safety Res 33: 387-410.
- Ohanaka EC, Osime U, Okonkwo CE (2001) A five-year review of splenic injuries in the University of Benin Teaching Hospital, Benin City, Nigeria. West Afr J Med 20: 48-51.
- Edna TH, Bjerkeset T, Myrvold HE (1989) Abdominal injuries. Occurrence and outcome. Tidsskr Nor Laegeforen 109: 2111-2114.
- Maxwell-Armstrong C, Brooks A, Field M, Hammond J, Abercrombie J (2002) Diagnostic peritoneal lavage analysis: should trauma guidelines be revised?.Emerg Med J 19: 524-525.
- Cox EF (1984) Blunt abdominal trauma A 5-year analysis of 870 patients requiring celiotomy. Ann Surg 199: 467-474.
- IsenhourJL, Marx J (2007) Advances in Abdominal Trauma.Emerg Med Clin N Am: 713-733.
- Iribhogbe PE, Okolo CJ (2009) Management of splenic injuries in a University Teaching hospital in Nigeria. West African Journal of Medicine 28: 308-312.
- Rozycki GS, Shackford SR (1996) Ultrasound, what every trauma surgeon should know. J Trauma 40: 1-4.
- Rothlin MA, Naf R, Amgwerd M, Candinas D (1993) Ultrasound in blunt abdominal and thoracic trauma. J Trauma 34: 488-495.
- Udekwu PO, Gurkin B, Oller DW (1996) The use of computed tomography in blunt abdominal injuries. Am Surg 62: 56-59.
- Liu M, Lee CH, P’eng FK (1993) Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma 35: 267-270.
- Cuschieri A, Hennessy TP, Stephens RB, Berci G (1988) Diagnosis of significant abdominal trauma after road traffic accidents: preliminary results of a multicenter clinical trial comparing minilaparoscopy with peritoneal lavage. Ann R Coll SurgEngl 70: 153-155.
- Ahmed N, Whelan J, Brownlee J, Chari V, Chung R (2005) The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am CollSurg 201: 213-216.
- Bokarev MI, Molitvoslov AB, biriukovIuV, Sergeev SV (2004) Laparoscopy in diagnosis of abdominal injuries in patients with combined trauma. Khirurgiia (Mosk): 23-25.
- Berner A, Abu-Zidan FM, Bensiali AK, Al-Mulla AA, Jadaan KS (2003) Strategy to improve road safety in developing countries. Saudi. Med J 24: 447-452.
- Anderson ID, Woodford M, de Dombal T, Irving M (1988) Retrospective study of 1000 deaths from injury in England and Wales. Br Med J 296: 1305-1308.
- Munns J, Richardson M, Hewett P (1995) A review of intestinal injury from blunt abdominal trauma. Aust. N. Z. JSurg 65: 857-860.
- Sayers RD, Bewes PC, Porter KM (1992) Emergency laparotomy for abdominal trauma. Injury 23: 537-541.
- Oyo-Ita A, Ugare UG, Ikpeme IA (2012) Surgical versus non-surgical management of abdominal injury. Cochrane Database Syst Rev 14: 11.
- Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, et al. (2013) AAST Open Abdomen Study Group.; Open abdominal management after damage-control laparotomy for trauma: A prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 74:113-22.
- Mnguni MN, Muckart DJ, Madiba TE (2012) Abdominal trauma in durban, South Africa: factors influencing outcome. IntSurg97:161-168.
Graph 1:*Died (50) (40 males 10 females): Closed abdominal trauma (45) & Penetrating abdominal trauma (5).
Graph 2 A, B:Shows the age and sex distribution of the cases.
Graph 3: Specific Organ Injury.
Graph 4: Postoperative Complications.