الفهرس 
Pathophysiology of Blunt Abdominal TraumaOnly 14 pages are availabe for public view
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Abstract
B
lunt abdominal trauma continues to be the most common cause of injury to the abdomen, the failure to manage abdominal injuries successfully accounts for the majority of preventable deaths following multiple injuries, failure to recognize intra-abdominal hemorrhage and to successfully control bleeding from intra-abdominal organs leads to significant morbidity, there are many mechanisms that account for abdominal injuries, the recognition of it is of great importance for treatment and diagnostic work-up.
The liver and spleen seem the most frequently injured organs, although reports vary, small and large intestines are the next most injured organs, respectively. Recent studies show an increased number of hepatic injuries, perhaps reflecting increased use of CT scanning and concomitant identification of more injuries.
Initial management of patients with blunt abdominal trauma i.e. resuscitation and dearly care of traumatized patients aims to identify and correct any immediate life threatening condition, priorities include airway, cervical spine contour, breathing, and circulation, and hemorrhage control, dysfunction of the central nervous system and exposure of the patient, diagnosis can be done by one or more of the following modalities:
1. Clinical examination.
2. Laboratory investigation.
3. Plain x rays.
4. Abdominal ultrasound.
5. Computed Tomography (CT).
6. Diagnostic Peritoneal Lavage (DPL).
7. Diagnostic Laparoscopy.
Physical examination of patients with blunt abdominal trauma must be done for every part of body in the same time, head, neck, and chest abdomen, extremities, back and neurological system to exclude any other injured organs, physical examination in the alert patient remains the most reliable predictor of injury, yet this will be misleading as either a false-positive or false negative examination 10 to 20 percent of patients.
Laboratory tests of value in the evaluation of a patient with abdominal trauma include haematocrit, urine analysis and serum amylase, serum amylase can be elevated in patients without significant visceral injury.
The focused assessment with sonography for trauma (FAST) is a rapid and used to identify the presence of free intraperitoneal fluid, it has the advantage of being rapid, cheap, non-invasive, dose not require radiation, can be repeated over time, and can be performed in parallel to the initial assessment in the resuscitation room.
CT remains an important diagnostic tool because of its specificity for hepatic, splenic and renal injuries, CT is indicated primarily for hemodynamically stable patients who are candidates for non-operative therapy, it is non-invasive and repeatable; however, it is expensive and time consuming, requiring transfer of the patient to the radiology department.
The peritoneal lavage can be used in blunt abdominal injury, to detect the presence of intraperitoneal blood; it cannot identify the source of hemorrhage, it is a safe, rapid and accurate method for determining the presence of intraperitoneal blood in victims of blunt abdominal trauma, it is more accurate than CT for the early diagnosis of hollow visceral and mesenteric injuries, but it does not reliably exclude significant injuries to retroperitoneal structures.
Laparoscopy has been applied safely and effectively as a screening tool in stable patients with blunt abdominal trauma, it decrease hospital stays and significantly decreases morbidity, therefore had decreased hospital costs and were noted to have decreased pain, better cosmetic results, earlier ambulation, and faster return to their activities, it cannot be used in hemodynamically unstable patients; there is risk of developing tension pneumothorax in diaphragmatic injuries, gas embolism with intraperitoneal venous injuries, missed injuries especially small bowel perforations and retroperitoneal injuries.
Nonoperative management is attractive because it avoids the morbidity and potential mortality of an unnecessary laparotomy, unnecessary operations include those in which the surgeon fails to find any injury in the peritoneal, pelvic, or retroperitoneal cavities (negative laparotomy) or finds only minor injuries that do not need surgical repair, such as a non-bleeding liver laceration (non therapeutic laparotomy), the morbidity of an unnecessary laparotomy has been reported to be as high as 41.3%, when problems such as atelectasis, prolonged ileus, and urinary tract infections are included and to as low as 2.5% when only major complications such as subsequent small bowel obstruction are considered, in addition, an unnecessary laparotomy increases the hospital length of stay and significantly increases the cost of care.
Non operative management need:
1. Hemodynamicaily stable patients without sign of
peritonitis.
2. Repeated examinations, when the patient will be
unable to have reliable examinations because of
head injury, spinal cord injury, sedation or other
factors, non-operative management are impossible.
Nonoperative management for blunt injuries of solid organs is now the rule rather than the exception, up to 90% of children and 50% of adults are treated in this manner.
Indications for exploration of the abdomen are peritonitis, unexplained hypovolemia, and evisceration of a viscous, deterioration of findings during routine follows up, emergency abdominal exploration should be considered for patients with profound hypovolemic shock and a normal chest x-ray unless extra-abdominal blood loss is sufficient to account for the hypovolemia.
By the use of recent diagnostic tools, non-operative management of blunt abdominal trauma is feasible and safe in a selected group of patients provided that the patient is hemodynamically stable no concomitants other severe abdominal injuries that require laparotomy and follow up with repeated abdominal ultrasonography and CT scanning is available, other wise laparotomy is mandatory.