Blunt Injury Abdomen: A case report

Niveda. R

Emergency Medicine Resident, Kauvery Hospital, Alwarpet, Chennai

Case Presentation

A 20-year young gentleman was brought in by an ambulance around 11:20 am on 11-June-23 with alleged history of Road traffic accident (Two- wheeler rider).

  • Exact mechanism of injury unknown, following which  he sustained injury to head and face, and multiple abrasions over both upper and lower limb, also bleeding from nasal bridge
  • LOC, amnesia for events
  • He was complained of lower abdominal pain and pain and swelling over the right foot.
  • No H/O ENT bleed, shortness of breath, seizures, headache, vomiting, nausea, bowel and bladder disturbances, vision disturbance, hematuria and  chest pain
  • Initially taken to nearby hospital – dressing was done , shifted here for further management.

Past medical and surgical history/drug allergy

  • Hypothyroid on T. Thyronorm (50mcg). This was unusual history in a young male!
  • Nil surgeries
  • No drug/food allergy

Assessment in ER (Primary Survey)

Upon arrival at ER, Patient was conscious, oriented, alert and afebrile

Airway and cervical spine immobilization

Airway patent, in line stabilization done for c-spine, c-collar applied, triple immobilization done. No numbness or tingling sensation.

Breathing

B/L air entry present, no added sounds, NVBS.

RR-22/min, Spo2-99% RA. Anterior part of left side chest – abrasion present

Circulation

BP – 90/50mmhg, HR-98/min, CRT- <2secs

CVS: S1, S 2 heard, no murmur

P/A: soft, tenderness over hypogastric+ , left and right iliac region+ and suprapubic region+++, no organomegaly,no brusies, external genitalia normal, pelvic compression test negative, b/l peripheral pulses felt

Disability

GCS- 15/15, CBG- 172mg/dl

B/L pupils reacting to light- 3mm, Moving all 4 limbs

Exposure

Temp – 98°F

  • Dress soiled with mud
  • Forehead laceration- 4×3×1cm with active bleed and bone exposed
  • Nasal bridge tenderness and laceration 2×1×1cm, active bleed
  • Abrasion over the left side anterior chest 3×2 cm
  • Abrasion over the left hand dorsum involving 2, 3, 4 fingers- ROM and sensation- normal
  • Abrasion over both knee varying sizes , active bleed present(rom and sensation normal)
  • Right foot – swelling and tenderness over the 3rd & 4th metatarsal region.

Secondary Survey

Head to toe examination:

Head and neck

Cervical collar applied and with assistance log roll done and cervical tenderness assessed.

Forehead laceration, nasal bridge laceration – dressing done

Thorax

Abrasion over left anterior chest region. Bilateral air entry present. No muffled heart sounds.

Abdomen

Lower abdominal tenderness present (right and left iliac and hypogastric region) and suprapubic tenderness present. Genitals normal, Foleys catherisation done

Extremities

Upper and lower limb multiple abrasion, rom normal, sensation normal

Swelling and tenderness over right foot 3rd and 4th metatarsal.

Management in ER

  • A 2 wide bore cannula secured
  • Intravenous fluids started- Ringer Lactate 500ml bolus f/b 2nd 500ml bolus given repeat BP was 100/60mmHg.
  • Wound thoroughly cleaned and dressing done
  • Tetanus and Tet glob given
  • Antibiotics and pain management done
  • Vitals were monitored.
  • Routine blood investigation and urgent blood grouping and typing done
  • Patient was complaining of persistent lower abdominal pain despite bladder catheterization, pelvic compression test negative / no obvious abdominal distension, ecchymosis, urethral injury/blood in meatus.
  • POCUS: no free fluid in hepatorenal or splenorenal pouch or in bladder.
  • But still persistent pain!!!

CT Brain Image

Whole Spine

CT Abdomen

CT Chest

X-Ray Pelvis, with both hips

X-Ray Right Foot

CT whole body trauma protocol

  • Brain: undisplaced fracture of left nasal bone, scalp hematoma in left frontal region, no bleed
  • Chest: patchy ground glass opacities seen in bilateral lung apex no
  • Pneumothorax/hemothorax, no fractures
  • Whole Spine: normal
  • Abdomen: Pneumoperitoneum with minimal free fluid in peritoneal cavity
  • X-ray right foot: displaced 3rd metatarsal fracture

Patient was complaining of severe abdomen pain. Planned for surgical exploration. So urgent referral was obtained.

Plan

  • General surgery opinion- planned for diagnostic laproscopy f/b laparotomy
  • Orthopedic– plan k –wire fixation
  • Plastic team- soft tissue repair
  • Anesthetist informed

Diagnosis

Hollow viscus perforation – Jejunal transection

Management

  • Diagnostic laproscopy f/b laparotomy done
  • Proximal jejunal complete transection
  • Minimal fecal spillage
  • Minimal hemoperitoneum
  • Side to side jejuno- jejunal anastomosis done
  • Ortho : K- wire fixation done
  • Plastic Team– soft tissue repair of nasal bridge laceration

Fig: K- wire fixation

Course in ICU

Post operatively, he was shifted to ICU. Treated with antibiotics, analgesic, PPI.

Regular wound assessment and dressings were applied.

He improved symptomatically and clinically stable, hence was discharged on POD -6 (16/6/23)

Discussion

  1. Blunt Abdominal Trauma
  • In blunt trauma , all abdominal structures are at risk
  • Compressive , shearing or stretching and acceleration force cause impact to abdominal cavity leading to solid or hollow viscus injury
  • Most common mechanism- RTA , 2nd – falls
  1. Common symptoms/signs

Abdominal pain, abdominal distension, vomiting, nausea, bruises in abdomen

Tachycardia, tachypnea, hypotension, urine output<30ml/hr.

Inspect abdomen for abrasion, laceration, contusion, seatbelt marks.

Palpate for tenderness, guarding, rigidity

Any blunt abdominal trauma patient with diffuse peritonitis or who is hemodynamically unstable- take for emergency laparotomy

Blunt trauma causes a combination of blood loss and peritoneal contamination.

  1. Abdominal injuries that need expanded evaluation
  • Abdominal pain, tenderness, distension or external signs of trauma
  • Mechanism of injury
  • Suspicious of pelvic/chest injury
  • Altered consciousness/sensorium
  • Patients who are elderly, on anticoagulant.
  1. Diagnosis

USG: FAST (Focused Assessment with Sonography for Trauma) is the rapid identification of free intraperitoneal fluid in hypotensive patient

  • Disadvantage: inability to identify the source of free peritoneal fluid, operator dependant, difficult in interpreting images

CECT – non-invasive gold standard

X-Ray erect and left lateral – can detect but can miss small pneumoperitoneum

Treatment

Laparotomy: All patients with persistent hypotension, abdominal wall disruption or peritonitis need surgical exploration

Indication for Laparotomy

Absolute:

  • Anterior abdominal injury with hypotension
  • Peritonitis
  • Free air under diaphragm on chest radiograph
  • Positive FAST in unstable pt
  • CT- diagnosed injury

Relative:

  • Positive FAST in stable patient
  • Solid visceral injury in stable patient
  • Hemoperitoneum on CT without clear source

Non-operative Management of blunt trauma

  • In-patient in whom vascular injury diagnosed percutaneous trans catheter embolization with stainless steel coil or gelfoam to arrest bleed
  • Tranexamic acid
  • If the patient is on warfarin – vitamin-k and fresh frozen plasma, and if the patient is on Dabigatran – Idarucizumab can be given as an antidote.

Pneumoperitoneum

  • In this case pneumoperitoneum due to hollow viscus perforation
  • Free air within the peritoneal cavity
  • Diagnosis: ideal is CECT – which can visualize quantities as small as 5cm of air

Conclusion

  • Airway is of primary importance
  • ABC is the priority
  • Resuscitation goes hand in hand with primary assessment
  • Secondary assessment after completion of primary

Acknowledgement

Dr. Aslesha Vijaay sheth (Head of emergency Department)

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