If the return of fluids shows RBC > 100,000 per cubic millimeter, WBC > 100 per cubic millimeter, food, or bile, then the patient should undergo exploratory laparotomy. If less than ten milliliters of blood are obtained upon initial aspiration, then one liter of warm saline is poured into the abdomen. Although the FAST examination is a helpful adjunct, it has poor sensitivity for bowel injury.ĭiagnostic peritoneal lavage (DPL)- DPL can be a useful tool in determining which patients would benefit from an exploratory laparotomy. Radiographs are also useful in penetrating injuries to evaluate for the type of foreign body and the trajectory of the foreign body.įocused assessment of ultrasonography in trauma (FAST)- Fluid in the hepatorenal space, in the splenorenal space, and/or on the suprapubic view indicates there may be intraabdominal bleeding or intestinal injury. Air under the diaphragm indicates intestinal perforation. Radiographs- Typically a chest and pelvis radiograph are obtained to evaluate for the presence of an abnormal mediastinal profile, hemothorax or pneumothorax, air under or abnormality of the diaphragm, and fractures, particularly unstable pelvic fractures. In addition to the initial history and physical exam, chest and pelvis radiographs, focused assessment of ultrasonography in trauma (FAST), diagnostic peritoneal lavage (DPL), computed tomography (CT) and diagnostic laparoscopy (DL) can be used to provide further information. ![]() Additionally, if time allows and the patient is lucid, information regarding medical, surgical, social, allergy and family history should be obtained. Understanding the mechanism of injury can provide important information about what type of injury the patient sustained. In penetrating trauma, the number and location of wounds help determine possible penetration and injuries.Ĭoncurrent with the physical exam, clinicians should monitor vital signs and gather information regarding the mechanism. In blunt abdominal trauma, the presence of a seatbelt sign was associated with a 4.7-fold increase of relative risk for small bowel perforation. During the secondary survey, the patient’s abdomen is assessed for visual signs of trauma and the presence of pain in a neurologically intact patient. Following the primary survey, the team should search for other signs of injury during the secondary survey, while utilizing adjuncts as clinically indicated. Īll trauma patients should be evaluated in a standard format beginning with the primary survey. Thus, guidelines recommend the early use of red blood cells, plasma, and platelets in an equal ratio in part to limit the extensive fluid shifts that occur with large volume crystalloid resuscitation. Additionally, high-volume crystalloid resuscitation classically administered to trauma patients results in decreased oncotic pressure and increased hydrostatic pressure that causes further extravasation of fluid and bowel edema. found elevated circulating intestinal fatty acid binding protein (I-FABP) released as a result of intestinal injury in trauma patients which correlated well with triage scoring systems for trauma including the shock index, Abbreviated Injury Score (AIS), as well as the overall Injury Severity Score (ISS).Īcute phase reactants activated as a result of bowel injury leads to an increase in the permeability of the capillaries. Blunt injury can ultimately lead to devascularization of the affected segment of bowel, leading to intestinal necrosis.Īnother mechanism for indirect intestinal injury involves a low perfusion state and global hypotension from hemorrhagic shock or direct vascular trauma. In patients with prior abdominal surgery, acceleration/deceleration injuries can be precipitated by underlying adhesions leading to an unpredictable pattern of traction injuries. ![]() The duodenum-jejunum junction is a common site for this type of shear injury due to the stabilization of the duodenum by the ligament of Treitz. Indirect injuries in blunt trauma can also occur from acceleration/deceleration injuries when one part of the bowel is tethered in place and the other part is mobile. Penetrating trauma invariably also results in other associated injuries of the abdomen.īlunt intestinal injury is usually caused by the intestine being crushed between external objects (e.g., car door, handlebars, etc.) and internal structures (e.g., vertebrae, pelvis, etc.). The severity of injury depends on the penetrating object, its velocity, and the site and trajectory of the path. Penetrating trauma causes trauma to the intestines by direct laceration of the tissue from the penetrating object. ![]() Mechanical injury can be direct or indirect. ![]() The pathophysiology of intestinal trauma is multifaceted including mechanical, ischemia/reperfusion, and signaling mediated mechanisms.
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