Abdominal trauma: keys to success (Proceedings)


Abdominal trauma: keys to success (Proceedings)

Nov 01, 2010

Table 1
Abdominal trauma may result in specific injury of the peritoneal or retroperitoneal structures, diaphragm, or body wall constituents. Pain referred from other sites (especially spine) is also frequently mistaken for abdominal pain. Historical examination and physical examination should allow the clinician to recognize the likelihood that a given patient has sustained trauma. Trauma associated acute abdomen is a unique situation and should prompt an already narrowed list of differential diagnoses. (Table 1) It is critical to recognize that trauma is most often a whole body problem (polytrauma) involving multiple body systems. Similarly, it is also not uncommon for trauma-associated acute abdomen to result from multiple injuries, for example, concurrent uroperitoneum and hemoperitoneum.

Stabilization & Resuscitation:

Stabilization of the patient with abdominal trauma should initially be focused on restoring abnormalities identified on major body systems assessment to normal thus maximizing the delivery of oxygen to the tissues. Perfusion abnormalities such as hypovolemic shock as well as oxygenation abnormalities due to concurrent pulmonary and / or pleural space injuries are commonly identified in animals with abdominal trauma. Shock is defined as the failure of oxygen delivery (DO2) to the tissues and can result from significant compromise to the cardiovascular, respiratory, central nervous systems, or a combination thereof. Immediately after trauma, we will most often by faced with traumatic / hypovolemic shock. In order to better understand the possible causes of the shock states, we must first consider the factors that will influence delivery of oxygen (DO2) to the tissues:

After significant trauma, DO2 may be compromised via a variety of mechanisms including alterations in both cardiac output (CO) and blood oxygen content (CaO2). We can then utilize knowledge of the determinants of DO2 to help guide resuscitation efforts.

Example: A young (2yr old) intact male mixed breed dog is hit by a car and is presented to your veterinary hospital for immediate care. Upon triage, you note pale mucous membranes, a CRT of 4 seconds, a pulse rate of 220, extremely weak pulse quality, dramatically increased respiratory rate (60bpm) and effort. The dog also has a severely depressed level of consciousness. A gaping wound in the left thorax is noted. You immediately transport the patient to the treatment area for resuscitation efforts. This animal is obviously showing signs of shock (decreased DO2). Applying our knowledge as to possible causes in this patient, you may deduce that CO is depleted due to decreased preload from blood loss. In addition, CaO2 is also likely significantly decreased because of decreased hemoglobin concentration (blood loss), decreased SpO2 (open pneumothorax and pulmonary contusion), and decreased PaO2 (open pneumothorax and pulmonary contusion). You can now consider "attacking" the low DO2 via a number of different routes including provision of oxygen support to maximize SpO2 and PaO2 and thus CaO2, volume resuscitation to improve preload and thus CO, and possibly sanguineous blood product administration also to improve hemoglobin concentration and thus CaO2 and CO. In addition, the wound will need to be sealed with concurrent chest tube placement for decompression of the pneumothorax. Antibiotic therapy should be initiated immediately. Once stable, the patient will require aggressive surgical debridement and exploration of the wound and chest (within hours).

In a serious trauma situation, each member of the team should have specific responsibilities. Resuscitation efforts will proceed optimally when doctors are doing "doctor things", technicians are doing "technician things", and other support staff is performing

Table 2: Characteristics of common causes of abdominal effusion after abdominal trauma
Table 2 illustrates fluid characteristics resulting from various injuries to the abdomen after trauma.