Any patient who has sustained injury to the torso (nipple to perineum) from a direct blow, deceleration, blast, or penetrating injury should be considered to have an abdominal visceral, vascular, or pelvic injury until proven otherwise. Significant blood loss can be present in the abdominal cavity without dramatic external changes or signs of peritoneal irritation.

Basic Abdominal Anatomy

• The anterior abdomen: between the costal margins, the inguinal ligaments and symphysis pubis, and the anterior axillary lines. Injury to this region provides risk to injury of most of the hollow viscera.
• The thoracoabdomen comprises the area between the nipple line/infrascapular line and superior to the costal margins. Potential damage to the diaphragm, spleen, stomach.
• The flank is the area between the anterior and posterior axillary lines from the 6th ICS to the iliac crest.
• The pelvic cavity is the area surrounded by the pelvic bones, containing the lower retroperitoneal and the intraperitoneal spaces. Includes the rectum, bladder, iliac vessels, female internal reproductive organs.

Mechanisms of Abdominopelvic Injury

• Blunt trauma can cause deformations of solid and hollow organs, cause rupture with secondary hemorrhage and peritonitis. The most common injuries are spleen (40-55%), liver (35-45%), and small bowel (5-10%), and retroperitoneal (15%) hematomas.
• Shear injuries can lead to liver and splenic lacerations, bucket-handle small bowel injuries.
• Penetrating injuries cause high-energy injuries (lacerations, tearing, temporary cavitation. ?Stab wounds, GSW.
• Blast injuries cause damage via direct penetrating injury, blunt injury, and shock/overpressure injuries.

In assessing the patient, gather the following information:

1. Type and mechanism of injury
2. Speed of collisions?
3. Restraining devices involved?
4. Distance thrown or fallen?
5. Other involved patients?
6. Types of weapons, muzzle velocity, calibre, number of GSW or stab wounds, amount of external bleeding?

Examination of Abdominopelvic Injury

Standard IPPA assessment. In particular,

• Urethral rupture is suggested by urethral meatal blood or scrotal/perineal hematoma, or gross hematuria. Do not insert a Foley until such injury is ruled out.
  • A retrograde urethrogram is mandatory when the patient is unable to void, requires a pelvic binder, or examination suggests urethral injury.
• Rectal examination to assess sphincter tone and rectal mucosal integrity.
• Consider vaginal examination for suspected injuries and remove any tampons/menstrual devices
• Limb length comparison and rotational deformities?
• Manual pelvic distraction is NOT recommended during the early assessment as this may worsen or cause recurrent pelvic bleeding (?clot disruption). Just gently palpate for now.
• Early pelvic stabilization/binding if the clinical suspicion for a significant bleed is there. Centre it over the GTs rather than the iliac crests.

Adjuncts

1. NGT
2. Urethral catheter
3. eFAST/DPL
4. Abdominal/pelvic/chest XR

Laparotomy

Surgical wisdom is required. Indications for laparotomy might include: