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186 Abdominal Trauma

Blunt Abdominal Trauma

Abdominal pain or tenderness Suspected solid organ injury
(no haemodynamic instability) Haemodynamic instability
FAST shows haemoperitoneum

Fluid resuscitation
US or CT scan Stable

Unstable
Liver or Splenic injury

Observation Unstable Theatre

Figure 29.3: Algorithm for the management of blunt splenic or liver injury when CT or US is
available. FAST is used for the rapid detection of haemoperitoneum in unstable patients, whereas
detailed US may be used for the evaluation of stable patients.

4. unsure of the nature and extent of intraabdominal injury; • multiple abdominal injuries;
5. evidence of hollow viscera injury; or • haemodynamic instability;
6. lack of appropriate imaging facilities for adequate evaluation and • uncontrollable bleeding; or
monitoring of intraabdominal injury (e.g., CT scan, US).
Operative treatment entails full laparotomy using a midline incision, • lack of experience on the part of the surgeon.
which may be extended. If US or CT is available, we recommend the If splenectomy is performed, place the child on long-term prophylactic
algorithm for the management of solid organ injury illustrated in Figure 29.3. antimalarials using proguanil or pyrimethamine. Give vaccination
(R)
Operative Management against pneumococcal infection (Pnuemovac , if available). Educate
Liver the parents on the susceptibility of the child to infections, and the need
Once the peritoneal cavity is entered, large packs are placed around the to report any infections early. Treat any infection promptly.
liver posteriorly, inferiorly, and superiorly to control initial haemor- Injury to other solid organs
rhage. The packs are removed one by one to assess the extent of injury. Injuries to other solid organs should be handled on their own merit.
If packing is unable to control haemorrhage, the Pringle manoeuvre The management of injuries to the kidneys is discussed in Chapter 31.
(occlusion of the porta between the thumb and forefinger or using a Hollow viscera injury
vascular clamp) is done. Some lacerations may need to be extended to Hollow viscera injuries are less common than solid organ injuries. The
enable proper assessment of the extent of injury. The following inter- most commonly injured hollow viscera are those of the gastrointestinal
ventions could be done, depending on the degree of injury to the liver: tract, and only these are discussed here. The various types of gastroin-
• simple repair; testinal injuries include:
• contusion;
• exploration of expanding haematomas;
• serosal lacerations;
• resectional debridement where there is much devitalised liver
tissue; or • perforation; and
• rarely, lobectomy if hepatic damage is extensive. • transverse mesenteric tear.
Spleen These features may not be obvious at initial assessment. A high index
The guiding principle in the operative management of splenic injury is of suspicion and repeated examination are essential for the diagnosis.
to avoid splenectomy as much as possible to prevent the complication DPL, plain abdominal radiographs, and a CT scan may need
of overwhelming postsplenectomy infection (OPSI). to be repeated after 24 hours to reach a diagnosis. Indicators of
The spleen can be preserved by the following procedures: (1) gastrointestinal injury are listed below:
splenorrhaphy, in which simple repair of lacerations is done, or (2) • fever;
segmental resection if a segment of the spleen is devitalised or the
spleen is wrapped up with the omentum. Haemostatic agents such as • haematemesis or drainage of blood-stained effluent from nasogastric
haemacele could be used to stop bleeding from the spleen. Splenectomy tube;
may be necessary in the following situations: