GENERAL METHOD FOR ABDOMINAL INJURIES

This extends Section 51.3 on the care of a severely injured patient. It is mainly concerned with blunt injuries. For penetrating ones goto Section 66.2.

HISTORY Most abdominal injuries are the results of car accidents, but some follow falls from a height, especially in children.

What object struck the patient’s abdomen? Where did it strike him? For example, an injury to his spleen is much more likely after a blow to his left lower chest. How much force was used?

PAIN after an abdominal injury is always important. It is usually present, but a patient may not complain of it if he has even more painful injuries elsewhere.

Where is the pain? What kind of pain is it? Is it getting better or worse? If pain is getting worse after an abdominal injury, it probably means continued bleeding, or a leaking gut.

Has the patient got pain at the tips of either of his shoulders? (make sure that this is not caused by an injured shoulder). Shoulder tip pain is caused by irritation of his diaphragm, usually by blood. It is a particularly useful sign of injury to the liver (right shoulder) or the spleen (left shoulder), especially if tilting the patient’s head down makes it worse.

CAUTION! Almost all patients with abdominal lesions after a blunt injury have persistant pain, and vomit. So these are very important signs. To begin with they may be almost the only ones.

THE EXAMINATION OF AN ABDOMINAL INJURY

If the patient is bleeding, he is likely to be pale, anxious, and still, with cold extremities. Completely uncover his chest and abdomen and sit beside him.

How is he breathing? Shallow, irregular, or grunting respiration is typical of an abdominal injury.

Look for bruises and abrasions. They will show you where he was hit.

Feel for tenderness. This is less marked with a haemoperitoneum than it is with septic peritonitis. Its position may guide you as to which organ has been injured. Increasing tenderness usually requires a laparotomy.

Rebound tendernesss is unreliable and is easily confused with muscle bruising. Pain on coughing and on percussion with your finger tips is much more reliable.

Feel for guarding and rigidity. Guarding progressing to rigidity is a reliable sign of peritonitis. Percuss the patient’s flanks for the dullness that may indicate a haemoperitoneum. Test for shifting dullness.

CAUTION! Even minimal tenderness and guarding are significant.

Listen for bowel sounds for 2 minutes. If you hear them, they mean nothing. When you first examine a patient, his abdomen will probably not have had time to become silent. However, an abdomen which is silent, or becomes silent later, is a useful sign of peritonitis.

Has the patient any signs of fractured ribs (65.1)? If his lower left ribs are fractured, suspect a ruptured spleen. Thoraco–abdominal injuries are common. Cyanosis is a dangerous sign.

Examine him rectally. If the patient is a woman, examine hervaginally while she is lying on her back, then examine her rectally. Look also for blood on your glove. Fullness or tenderness in the recto–vaginal pouch in a woman or the recto–vesical pouch in a man may indicate a haemoperitoneum. Look for wounds of the perineum or buttocks at the same time.

CAUTION! The rectum is completely out of sight at laparotomy. To begin with its injuries may cause no symptoms. If necessary, pass a sigmoidoscope.

Aspirate the patient’s stomach and empty his bladder. If you aspirate blood, his stomach may have been injured. Leave the nasogastric tube down. You will want it later when he goes to the theatre.

HAS HE LOST MORE BLOOD THAN CAN BE ACCOUNTED FOR BY HIS KNOWN INJURIES? This is good evidence for abdominal (or thoracic) bleeding. Assess it by the methods in Section 53.2.

SHOULD YOU ADMIT THE PATIENT?

Admit and observe him if you think he might have an abdominal injury. Half the patients you admit will not have one, but you may save the lives of the other half. If his nose is cold (53.2), be sure to admit him.

SPECIAL METHODS FOR ABDOMINAL INJURIES

These are for doubtful or difficult cases only. Where there are signs that indicate the need for a laparotomy, these methods are quite unnecessary. A positive result in any of them is an indication for an abdominal injury.

TEST FOR ORTHOSTATIC HYPOTENSION This may be useful if a patient has no other obvious cause of blood loss.

Take his pulse and blood pressure while he is lying flat. Then take it again when he is sitting up. While he is lying flat, his circulation may seem to be compensated. But sitting him up may produce a sharp fall in blood pressure, and an increase in his pulse rate. This shows that his blood volume is depleted. TEST FOR INCREASING GIRTH Note any initial distension and measure the patient’s abdomen with a tape measure at his umbilicus. An increase in his girth will be a useful sign of the paralytic ileus that follows peritonitis or haemoperitoneum. So take a base line measurement now. An increase of only 2 or 3 cm indicates a large amount of abdominal fluid or gas. This test only works if: (1) You always measure his girth at the same place (mark it on his skin with a pen). (2) He has a nasogastric tube down. Without a nasogastric tube, swallowed air in his stomach can cause a false positive result. It will also prevent acute gastric dilatation, which may mimic a more serious lesion.

DIAGNOSTIC PARACENTESIS (’Four quadrant tap’) This is a useful rapid test. Some surgeons omit it and proceed immediately with peritoneal lavage.

Take a syringe and a 1.4 mm needle. Under local anaesthesia, or no anaesthesia at all, and using an aseptic no–touch technique, tap all four quadrants of the patient’s abdomen as in Fig. 66-3. Push the needle through his abdominal wall until the sudden give shows that you are just inside his peritoneal cavity, then aspirate.

If aspiration is negative, take the needle out, roll him towards the side of the suspected injury, and repeat the test.

If aspiration is still negative, repeat it in an hour or two, or try lavage as described below.

CAUTION! (1) Although the blood from a haemoperitoneum is usually defibrinated and does not clot, there is always a chance that it may do so. A negative result does not exclude an abdominal injury. If necessary, repeat the tap in an hour or two.

This test is useful on other occasions (6.2). You may occasionally aspirate urine (from a ruptured bladder), cloudy or bile stained fluid (from a perforated gut or peptic ulcer), or pus (in primary peritonitis). if you are in doubt, examine a Gram film, and look for bacteria, leucocytes, or food.

PERITONEAL LAVAGE Many surgeons would say that if lavage is necessary, you should explore a patient’s abdomen anyway. An unnecessary lavage wastes time. Lavage is useful if you are in doubt whether a laparotomy is necessary or not, especially if: (1) A patient is unconscious and cannot complain of pain. (2) He has multiple injuries and you want to assess priorities. (3) You have to take him to the theatre to anaesthetize him for some other procedure, and if there is any suspicion that he might have an abdominal injury.

Catheterize his bladder. Prepare and drape his abdomen. Use lignocaine to infiltrate an area in the midline 2.5 cm below his umbilicus down to his peritoneum.

Use a scalpel to make a small nick down to his peritoneum. Using turning movements, push a trocar and cannula into his abdominal wall. You will feel a sudden ’give’ as it goes into his abdomen.

Ideally, push a peritoneal dialysis catheter through the cannula and then withdraw the cannula. Or, use the tubing from an infusion set with a few extra side holes cut near its tip.

If blood flows up through the tube, you have confirmed a haemoperitoneum.

If nothing happens, connect the cannula or tube to a drip set and infuse 500 ml of warm saline into his peritoneal cavity for 10 minutes. While this is going in, tilt him up and down and from side to side to spread the saline round his abdominal cavity.

Lower the infusion bottle to the floor before it is completely empty, so that some saline syphons back. If blood or bile comes back in the fluid, he has an abdominal injury. The test is a little oversensitive: a trace of blood in the saline is unimportant. But, it you cannot read newsprint through the clear plastic tubing, he needs a laparotomy.

CAUTION! A negative result does not exclude an abdominal injury.

CULDOCENTESIS is one of the most useful and accurate ways of confirming intraperitoneal bleeding in a woman (Fig. 16-4). If you aspirate more than 1 or 2 ml of blood which does not clot, she has a haemoperitoneum.

OTHER TESTS IN AN ABDOMINAL INJURY

URINE Examine this for blood from a bruised kidney or a ruptured bladder.

WHITE CELL COUNT A leucocytosis of 15,000 or more is common with a haemoperitoneum. The rupture of a hollow viscus does not usually raise the white count so high. A leucocytosis is more useful than a low haemoglobin or haematocrit. A patient will not become anaemic until there has been time for his blood to dilute.

X–RAYS Take erect films of a patient’s chest and abdomen. If he cannot sit up, take a lateral film while he is lying on his side. Another good X–ray is to turn the patient on his left side and take an AP view of his liver area.

Look for: (1) His stomach and splenic flexure pushed medially. (2) Herniated viscera in his pleural cavities due to rupture of his diaphragm. (3) Fractures of his lower ribs, suggesting a crush injury to his spleen or liver. (4) Gas under his diaphragm, as in Fig. 66-4, indicating rupture of his gut. (5) Peritoneal effusions. (6) Bullets or foreign bodies. (7) Fluid (or fluid and air) in his pleural cavities. These are signs of a thoracic injury. If you suspect he has ruptured his bladder or urethra, X–ray his pelvis. (8) A grey ’ground glass’ appearance between loops of small gut may be the first sign of a haemoperitoneum.

Ruptured spleen

Signs include: (1) A raised left hemidiaphragm. (2) Indentation of his stomach. (3) An opacity in his left hypochondrium. (4) His transverse colon displaced downwards. (5) Displacement of his gastric gas shadow.

Always review X–ray films in the light of what subsequently happened. Next time you will recognize the signs in time.

THE MANAGEMENT OF ABDOMINAL INJURIES

The critical question is, should you do a laparotomy or not? Close observation and repeated examination is the main way to decide this. If you decide to do one, goto Section 66.2 for a penetrating injury, and to 66.3 for a blunt one.

Examine the patient every half hour. Watch for a rising pulse, restlessness, an increase in his girth, and deterioration in his general condition. It may be stable for a long time and then deteriorate rapidly. Don’t wait too long, because the difference between the results of the best and the worst surgery is much less than that between early and late surgery.

CAUTION! (1) If you do decide to operate, do so immediately. Don’t delay longer than is necessary to organize the theatre and cross match more blood. (2) If you are in doubt as to whether to operate or not, be safe—operate.

REFERRAL Either refer the patient immediately, so that he can be operated on in a few hours, or operate yourself.

THE FURTHER MANAGEMENT OF ABDOMINAL INJURIES

Read on for: penetrating abdominal injuries (66.2), laparotomy (66.3), rupture of a patient’s abdominal wall (66.4), rupture of his diaphragm (66.5), rupture of his spleen (66.6), rupture of his liver (66.7), stomach injuries (66.8), small gut injuries (66.9), injuries to his mesentery (66.10), large gut injuries (66.11), injuries of his caecum (66.12), injuries of his right colon (66.13), injuries of his transverse and descending colon (66.14), rectal injuries (66.15), duodenal injuries (66.16), pancreatic injuries (66.17), gall bladder injuries (66.18), other difficulties with an abdominal injury (66.19).

If a patient is unconscious, the diagnosis of abdominal bleeding will be difficult. Look for: abdominal distension, fluid in his abdomen as shown by shifting dullness, absent bowel sounds, a positive test on paracentesis, a fall in blood pressure, an unaccountable loss of blood (53.2), and the development of oliguria. These are all gross signs when well developed, so watch for them in their earliest stages.

If he develops an lieus or acute intestinal obstruction a few days after admission, operate, he may have an intestinal injury and be developing peritonitis.

For more difficulties, goto Section 66.19.

IF YOU ARE IN DOUBT, ADMIT AND OBSERVE HIM, AND EXAMINE HIM REPEATEDLY IF THERE IS ANY SUSPICION OF AN INTRA–ABDOMINAL INJURY, OPERATE