Types of abdominal injuries. Abdominal injuries

Panina Valentina Viktorovna

Actress, Honored Artist of the RSFSR

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I found out about you on the Internet - I urgently need an MRI.

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May everything be as good in your soul as I am now, despite all the problems...

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I found out about you on the Internet - I urgently need an MRI.

And after the performance I’m with you. I really liked your staff. Thank you for your attention, kindness and accuracy.

May everything be as good in your soul as I am now, despite all the problems...

Be!!! We're happy! Your Panina V.V.

I found out about you on the Internet - I urgently need an MRI.

And after the performance I’m with you. I really liked your staff. Thank you for your attention, kindness and accuracy.

May everything be as good in your soul as I am now, despite all the problems...

Be!!! We're happy! Your Panina V.V.

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Sergei Shnurov

Russian rock musician, film actor, TV presenter and artist.

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With or without violation of the integrity of internal organs.

Any abdominal injury is considered a serious injury that requires immediate examination and treatment in a hospital setting, since there is a high risk of bleeding and the development of peritonitis.

Causes

Abdominal injuries can be either closed or open. Open injuries most often occur due to knife wounds, but other causes are also possible (gunshot wound, falling on a sharp object). The cause of a closed abdominal injury is usually a fall from a height, a car accident, an industrial accident, etc.

Symptoms of abdominal injury

An open abdominal injury can be caused by a bladed weapon, a firearm, or a secondary projectile.

Puncture wounds can be inflicted with a bayonet, a thin knife, a narrow stiletto, an awl, scissors, a table fork, etc. Puncture wounds usually bleed slightly and have a thin wound channel. Characterized by a large depth of the wound channel and damage to internal organs.

Slash wounds to the abdomen occur when struck with an axe. Such wounds are quite large with uneven edges, accompanied by profuse bleeding and extensive damage to soft tissues.

Incised wounds are usually inflicted with a knife. They have the shape of a line, are quite long, and have smooth edges. Often such abdominal injuries are accompanied by severe external bleeding as a result of the intersection of a large number of vessels. With extensive damage, eventration (loss) of the abdominal organs from the wound is possible.

Lacerated wounds are formed when damaged by machinery (industrial injury), or attacked by animals. These are the most extensive and severe wounds. Organs and tissues in such cases have multiple injuries with ruptures and crushing. Lacerations are often accompanied by severe tissue contamination.

Gunshot wounds are classified as particularly severe injuries, since they are accompanied by the formation of a wound channel and tissue contusion at a distance 30 times greater than the diameter of the bullet or pellet. As a result of contusion, organs and tissues are compressed, stretched, separated or torn.

When damaged by a secondary projectile (a glass fragment, a metal part, etc.), lacerations and bruises occur. Such abdominal injuries are typical for industrial accidents and car accidents.

Closed abdominal injuries are characterized by damage to the abdominal wall and internal organs.

A bruise of the abdominal wall is usually accompanied by pain and local swelling of the injury area. The pain intensifies when sneezing, defecation, coughing, or changing body position. Hemorrhages and abrasions are possible.

Rupture of the muscles and fascia of the abdominal wall is accompanied by the same symptoms, but the pain in this case is more severe, and dynamic intestinal obstruction may develop as a result of reflex intestinal paresis.

Rupture of the small intestine occurs with a direct blow to the abdominal area. It manifests itself as tension in the muscles of the abdominal wall, spreading, intensifying abdominal pain, increased heart rate, and vomiting. A rupture of the large intestine resembles a rupture of the small intestine, but tension in the abdominal wall and signs of intra-abdominal bleeding are often detected.

Injury to the spleen is a common injury in blunt abdominal trauma. May be primary (signs appear immediately after injury) or secondary (signs appear days or weeks later). With small ruptures, a blood clot forms and the bleeding stops. With large injuries, profuse internal bleeding develops. Blood accumulates in the abdominal cavity - hemoperitoneum. In this case, the patient’s condition is serious, shock develops, blood pressure drops, pulse and breathing increase. The patient is bothered by pain in the left hypochondrium, radiating to the left shoulder.

Liver damage often occurs due to abdominal trauma. Ruptures, subcapsular cracks, and complete separation of individual parts of the liver are possible. Liver injury is often accompanied by internal bleeding. While conscious, the patient complains of pain in the right hypochondrium. The pulse and breathing are rapid, the skin is pale, blood pressure is reduced.

Possible concussion, bruise, rupture of the pancreas. The patient complains of sharp pain in the epigastric region. The abdomen is swollen, the pulse is rapid, the muscles of the anterior abdominal wall are tense, and blood pressure is reduced.

Bladder rupture can be intraperitoneal or extraperitoneal. The cause is blunt trauma to the abdomen with a full bladder. Intraperitoneal rupture is accompanied by pain in the lower abdomen and frequent false urge to urinate. Urine released into the abdominal cavity causes peritonitis. The abdomen is moderately painful on palpation, soft, bloating and weakened intestinal peristalsis are noted. An extraperitoneal rupture is characterized by pain, swelling of the perineum, and a false urge to urinate. You may pass a small amount of bloody urine.

Diagnostics

Suspicion of abdominal injury is an indication for immediate hospitalization of the patient in a hospital for diagnosis and further treatment.

Upon admission, blood and urine tests are required, blood type and Rh factor are determined. Other research methods are selected individually, taking into account the severity of the patient’s condition and clinical manifestations.

To clarify the diagnosis, radiography of the abdominal cavity, ultrasound examination of the abdominal organs (abdominal organs), computed tomography, ascending cystography, and laparoscopy are performed.

Types of disease

Classification of abdominal injuries:

1. Closed abdominal injuries;

2. Open abdominal injuries.

Patient Actions

If you suspect an abdominal injury, you should seek immediate medical attention.

Before the ambulance arrives, the victim should be ensured in a semi-sitting position with bent legs, ensure rest, hunger, and apply cold.

Treatment of abdominal trauma

For superficial wounds that do not penetrate the abdominal cavity, primary surgical treatment is performed with excision of non-viable, heavily contaminated tissue, washing of the wound cavity, and suturing.

Ruptures of muscles, fascia, and bruises of the abdominal wall are treated conservatively.

For large hematomas, puncture or opening is performed, followed by drainage of the hematoma.

Intra-abdominal bleeding, ruptures of hollow and parenchymal organs are indications for emergency surgery. A midline laparotomy is performed. Through a wide incision in the abdominal cavity, the surgeon examines the abdominal organs and repairs damage. After the operation, analgesics and antibacterial drugs are prescribed.

Complications

Intra-abdominal bleeding;

Rupture of an abdominal organ;

Peritonitis;

Death.

Prevention of abdominal injury

Any traumatic situations should be avoided and protective equipment should be used in production.

In the case of non-through damage to the peritoneum, it is not always possible to determine the severity of the harm to health at first glance. With this type of injury there are no visible signs of impairment. In this case, due to blunt trauma to the abdomen, vital organs can be damaged. When they rupture, there is a possibility of infection followed by acute inflammation. If bruises and injuries to other parts of the body are quite easy to diagnose, then in the case of injury to the abdomen, it is not always possible to determine the extent of the violations and the risk of consequences for health and life.

Classification

In medical practice, abdominal injuries are divided into open and closed. The latter make up 85% of all damage. A more detailed classification of possible abdominal injuries involves dividing them into radiation, thermal and chemical. Combined injury involves a combination of several factors.

The most dangerous are considered to be open injuries of the pelvis and abdomen with damage to internal organs. With these types of disorders, the risk of irreversible changes is high. Knife and gunshot wounds provoke trauma to the abdominal organs and cause extensive and rapid blood loss.

Severe bruises can also damage vital organs. With the external integrity of the soft tissues, hidden injuries such as rupture of the liver, spleen, and intestinal mesentery occur. Closed abdominal trauma with damage to the parenchymal organ system is a common occurrence. At the same time, ZTZ is classified into:

uncomplicated– only the area of the anterior abdominal wall is affected. The bruise can be treated conservatively, the risk of complications is minimal;
involving organs– with a closed abdominal injury, the hollow organs – the stomach and intestines – are affected, and the injuries themselves are fraught with the rapid development of inflammation, which is associated with a violation of the sterility of the intra-abdominal space;
with internal bleeding– with closed injuries, the spleen, kidneys, and pancreas often suffer, and their trauma provokes blood loss;
combined– imply damage to both solid and hollow organs.

During pregnancy, any abdominal injury poses a threat to the health of the mother and fetus. Abdominal injuries warrant immediate hospitalization.

Trauma code according to ICD 10

The coding system for ICD 10, the international classification of diseases, assigns abdominal injuries code S39. According to the classification, abdominal tendons (S39.0) and injuries to intra-abdominal organs (S39.6) are also distinguished. Multiple abdominal injuries are coded S39.7.

Causes

Penetrating abdominal injuries are usually the result of road accidents, military operations, or criminal acts. The causes of closed abdominal injuries are natural disasters, extreme sports, and carelessness in everyday life. When falling from a height, traumatic damage to the abdominal organs is often combined with or. Due to accidents and natural disasters, several systems of the human body are involved in the pathological process.

Blows to the chest and abdomen often lead to disorders incompatible with life. With such injuries, retroperitoneal bleeding and the possible development of peritonitis cannot be ruled out. Blunt abdominal injuries in young children are considered less dangerous. Most of them are the result of negligence and do not involve violent actions. You can also get an abdominal bruise in childhood by falling from a bicycle or horizontal bar.

Symptoms

The nature of the damage can be determined using clinical manifestations. When struck, bruises, scratches, and pain appear, which can radiate to other organs and tissues. Severe injury may result in loss of consciousness. The main symptoms of blunt abdominal trauma are:

swelling in the affected area;
blood pressure is reduced;
the abdominal wall muscles are tense;
nausea and vomiting due to rupture of the small intestine;
bloating due to the presence of free gases in the abdominal cavity - characteristic of trauma to the pancreas;
pulse and breathing are rapid.

A victim with blunt abdominal trauma usually complains of pain throughout the abdomen. If the liver is injured, the pain radiates to the supraclavicular region. Rupture of organs is fraught with the development of peritonitis with characteristic symptoms, which include fever, vomiting, and increasing pain.

Abdominal injuries vary in location, and therefore the symptoms have their own characteristics. When the abdominal muscles rupture, intestinal obstruction occurs. Colon rupture provokes. In case of injury to the child's abdomen, the symptoms are intensified. With penetrating wounds, severe bleeding occurs.

First aid

In case of abdominal trauma, emergency care plays almost a primary role and allows you to save the victim’s life. Medical care for open wounds consists of antiseptic treatment. If the tissue is heavily contaminated, the cavity is washed with chlorhexidine. Prolapsed organs are not set back, but are bandaged with a bandage or gauze bandage, having previously soaked the fabric with an antiseptic.

First aid for closed abdominal injuries involves cooling the injured area. You can place an ice pack on your stomach. This will help stop swelling, hemorrhage and bruises. In case of blunt abdominal trauma, it is recommended to place the victim in a comfortable position, and the position of the body is determined by the nature of the injury. If the blow hits the liver area, it is more comfortable to lie with your legs bent on your left side. If you are vomiting or feeling sick, you should not lie down.

It is recommended to transport a victim with a closed abdominal injury in a reclining position. It is better to entrust transportation to doctors. If the accident occurred far from civilization and doctors cannot quickly reach the victim, you can transport the person yourself, eliminating pressure on the abdominal area. The position in which persons with abdominal injuries are transported depends on the location of the injury. Usually a person lies on his back with his legs bent and his head raised.

The list of first aid supplies includes painkillers. Tablet drugs are prohibited; pain relief is carried out by injection. With an open abdominal injury, the clinical picture is extremely pronounced; the victim may be in post-traumatic shock. In this case, Ketorolac is administered intravenously. All manipulations necessarily require an assessment of the general condition of the victim.

First aid in case of damage to the abdomen and internal organs is aimed at maintaining life support functions. If breathing problems occur, wear an oxygen mask. In case of blood loss, apply a sterile bandage. Is it possible to give a drink to a victim with an abdominal injury?? Since a person may have hidden bleeding, drinking is excluded.

Diagnostics

If an abdominal injury occurs, delay in diagnosis is fraught with dangerous complications. In this case, the nature of the injury itself does not matter, since it is visually impossible to detect organ rupture, internal bleeding, etc. The method of examining patients with abdominal injuries implies:

radiographic examination– is not the main diagnostic method, but allows you to determine the integrity of bones in case of damage to the ribs and pelvis;
Ultrasound– determines the condition of internal organs, reveals hidden bleeding, is considered an informative and reliable research method;
CT– a detailed diagnostic tool that detects minor injuries and hemorrhages that are difficult to detect during ultrasound examination. To diagnose hemoperitoneum (bleeding), tomography of the abdominal and retroperitoneal space is performed.

The chest, pelvis and abdomen require detailed examination. Diagnostic measures are carried out taking into account the clinical picture. If a bladder rupture is suspected, diagnostic catheterization is recommended. Laparoscopy allows you to evaluate the functionality of the internal organs of the abdomen. It can be both diagnostic and therapeutic. In the second case, it is possible not only to examine the organs, but also to remove excess blood from internal bleeding.

Treatment

Treatment for open and closed abdominal injuries will vary. If there are open wounds, they are sanitized and antibiotic therapy is administered. Conservative methods are suitable for the treatment of blunt, uncomplicated abdominal trauma. Bed rest is prescribed. Cold is used to prevent extensive hematomas. In traumatology, minimally invasive methods of hematoma drainage are practiced. Opening the cavity is necessary if it is impossible to resolve the hemorrhage area on its own.

Further treatment of the injury consists of controlling intra-abdominal pressure and normalizing metabolic processes at the tissue level. To do this, it is enough to provide adequate nutrition; the emphasis in therapy is on physiotherapy, taking analgesics and anxiolytics.

Both intraperitoneal and extraperitoneal complications occur due to bladder rupture. If urine enters the sterile space of the peritoneum, peritonitis develops, requiring surgical intervention. For mild bladder injuries with acute urinary retention, catheterization is performed. The method is not used for injuries of the urethra and bleeding.

Surgical treatment

Complicated abdominal injuries with damage to solid and hollow organs are treated surgically. If the bladder and ureters, intestines, liver and kidneys are damaged, the use of conservative methods is inappropriate. The surgeon prescribes emergency surgery for internal bleeding and suspected peritonitis.

Injuries with rupture of hollow organs - stomach, intestines - almost always require surgical intervention. Operations are prescribed for knife and gunshot wounds of the abdomen, as well as in case of rupture of the bladder and peritoneal organs. In general surgery, abdominal injuries are treated through a midline laparotomy.

Revolutionary treatments for abdominal injuries include regenerative medicine. It stimulates recovery processes and returns lost organ functions. It is a transplantation of healthy cells. Currently not widespread, but has great prospects.

Rehabilitation

If the abdominal injury was detected and treated in time, then you will not have to adhere to a special diet after leaving the hospital. Severely ill patients are prescribed enteral nutrition until their condition stabilizes. After surgical treatment, attention is paid to the prevention of intestinal obstruction. It usually occurs due to trauma to the intestine, but can be the result of unsuccessful surgery. In this case, the doctor prescribes drugs that stimulate peristalsis and facilitate the digestion process.

Limit physical activity. They are gradually returning to their normal lifestyle. The recovery period may be delayed due to severe internal disorders. Rehabilitation measures include vitamin therapy, therapeutic exercises, and physiotherapy.

Complications and consequences

If abdominal injuries are detected in time, the risk of complications is minimal, with the exception of penetrating wounds. Blunt abdominal trauma with damage to internal organs can lead to the development of failure of some of them. The most common consequences are:

inflammation of the peritoneum– Medically known as peritonitis. Under the influence of microorganisms entering the abdominal cavity from a damaged intestine or stomach, an acute inflammatory process develops. Delay in treatment can be fatal;
sepsis or septic shock– is a consequence of an acute reaction to an infection that enters the body due to rupture of internal organs. When generalized, the process leads to death;
enteral insufficiency– pathology of the small intestine, which prevents the absorption of nutrients during food processing;
internal bleeding– massive blood loss causes death. Timely detection of the bleeding area can save the victim’s life.

Damage to the peritoneum is always difficult to tolerate, especially if there is damage to internal organs. Their insufficiency subsequently leads to a deterioration in the quality of life and requires maintenance therapy.

Dear readers of the 1MedHelp website, if you still have questions on this topic, we will be happy to answer them. Leave your reviews, comments, share stories of how you experienced a similar trauma and successfully dealt with the consequences! Your life experience may be useful to other readers.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2014

Other and unspecified injuries to the abdomen, lower back and pelvis (S39), Crush and traumatic amputation of part of the abdomen, lower back and pelvis (S38), Trauma to blood vessels at the level of the abdomen, lower back and pelvis (S35), Trauma to the abdominal organs cavities (S36), Pelvic organ trauma (S37)

Traumatology and orthopedics, Surgery

general information

Short description

Expert Council of the Republican State Enterprise at the Republican Exhibition Center "Republican Center for Healthcare Development"

Ministry of Health and Social Development of the Republic of Kazakhstan

Abdominal or abdominal trauma is a violation of the anatomical integrity or functional state of the tissues or organs of the abdominal cavity, retroperitoneal space and pelvis, caused by external influences.

I. INTRODUCTORY PART.

Protocol name: Blunt abdominal trauma, open abdominal injuries.

Protocol code:

ICD 10 code:

S35 Injury to blood vessels in the abdomen, lower back and pelvis

S36 Abdominal trauma

S37 Trauma to the pelvic organs

S38 Crushing and traumatic amputation of part of the abdomen, lower back and pelvis

S39 Other and unspecified injuries of the abdomen, lower back and pelvis

Abbreviations used in the protocol:

ALT - alanine aminotransferase

AST - aspartate aminotransferase

AT - abdominal injury

APTT - activated partial thromboplastin time

BP - abdominal cavity

DIC - disseminated intravascular coagulation

Duodenum - duodenum.

DPL - diagnostic peritoneal lavage

IVL - artificial lung ventilation

CT - computed tomography

ABC - acid-base state

BCC - circulating blood volume

TBI - blunt abdominal trauma

Ultrasound - ultrasound examination

ECG-electrocardiography

ERCP - endoscopic retrograde cholangiopancreatography

Date of development of the protocol: year 2014.

Protocol users: surgeons, obstetricians-gynecologists, urologists, traumatologists, anesthesiologists-resuscitators, general practitioners, emergency doctors/paramedics.

Note: The following grades of recommendation and levels of evidence are used in this protocol:

Level I - Evidence obtained from a prospective, randomized, double-blind study.

Level II - Evidence obtained from a prospective, randomized, non-blinded study.

Level III - Evidence obtained from a retrospective analysis or meta-analysis.

Classification

Clinical classification

According to the classification of abdominal injuries (Savelyev V.S.) there are:

By the nature of the damaging agent:

Mechanical injury;

Thermal injury;

Chemical injury;

Radiation injury;

Combined - a combination of two or more types of energies.

According to the prevalence (scale) of injury:

Isolated abdominal injury;

Combined injury: in combination with injury to the head, spine, spinal cord, neck, chest, musculoskeletal system.

According to the nature of the injury:

Open injury(wounds): punctures, cuts, chopped, torn, bruised and their combinations, gunshots (bullet, fragmentation, mine-explosive)

Does not penetrate the abdominal cavity:

Penetrating into the abdominal cavity:

No damage to PD organs;

With organ damage PD (single or multiple): damage to hollow organs, damage to parenchymal organs, damage to blood vessels.

Closed (blunt) trauma:

Abdominal wall;

Abdominal organs: damage to hollow organs, damage to parenchymal organs, damage to blood vessels;

Retroperitoneal space: damage to hollow organs, damage to parenchymal organs, damage to blood vessels.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic (mandatory) diagnostic examinations performed on an outpatient basis:

Collection of complaints and anamnesis.

Physical examination (according to the “ABCDE” principle) in accordance with Appendix 1.

Additional diagnostic examinations performed on an outpatient basis:

General blood analysis;

General urine analysis;

Determination of blood group;

Determination of Rh factor;

Precipitation microreaction;

Ultrasound of the abdominal organs;

X-ray of the abdominal cavity;

Chest X-ray.

The minimum list of examinations that must be carried out when referred for planned hospitalization: not carried out.

Basic (mandatory) diagnostic examinations carried out at the hospital level

General blood analysis

General urine analysis

Blood group determination

Determination of Rh factor

Biochemical blood test (determination of blood glucose, bilirubin and fractions, AST, ALT, thymol test, creatinine, urea, alkaline phosphatase, blood amylase);

Coagulogram (prothrombin index, clotting time, bleeding time, fibrinogen, APTT);

ECG.

Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations not performed at the outpatient level are carried out):

Ultrasound of the abdominal cavity and pleural cavity

Survey radiography of the abdominal organs with capture of the diaphragm;

Plain radiography of the chest organs

X-ray of the skull in 2 projections

X-ray of the pelvic bones

X-ray of the spine

X-ray of limb bones

Excretory urography

Vulnerography (wound contrast)

Computed tomography of the abdominal organs

Magnetic resonance imaging of the brain and spinal cord

Laparocentesis with a “fumbling catheter” (diagnostic peritoneal lavage) with laboratory testing of the resulting fluid

Fibrogastroduodenography

Endoscopic retrograde cholangiopancreatography

Diagnostic laparoscopy

Diagnostic laparotomy

Diagnostic measures carried out at the stage of emergency care:

Physical examination (according to the “ABCDE” principle) in accordance with Appendix 1:

Diagnostic criteria

Complaints and anamnesis:

Complaints:

Pain in the wound and (or) in the abdomen of varying localization, intensity and irradiation. If the liver is damaged, the pain radiates to the shoulder girdle on the right, if the spleen is injured - on the left;

For dry tongue, nausea, vomiting, gas retention, lack of stool, difficulty urinating;

Dizziness and darkening of the eyes are signs of acute anemia.

Anamnesis: Indication of injury.

To identify blunt trauma, the height from which the fall occurred or the speed of the vehicle at which the accident occurred is of great importance.

For penetrating wounds, the distance from which the shot was fired, the type of weapon and bullet, and the length of the knife are important.

In an unconscious state, anamnesis should be obtained from accompanying persons, if possible.

Physical examination

General inspection:

Paleness of the skin and visible mucous membranes;

Cold sweat;

Frequent shallow breathing;

Frequent (more than 100 beats per minute) pulse of weak filling;

Low (less than 100 mm Hg) blood pressure;

Dry tongue is a common symptom of trauma to hollow organs;

Gross hematuria is a sign of bleeding caused by kidney injury;

Bloating:

With a penetrating injury to the abdomen, it may mean damage to the liver, spleen or great vessel;

In case of blunt trauma, abdominal distension can be caused by paralytic intestinal obstruction, which occurs when the retroperitoneal organs (especially the pancreas) and the spinal cord are damaged;

Sharp swelling that occurs in the first 2 hours after injury is characteristic of a retroperitoneal hematoma;

Gray Turner's sign (cyanosis of the lateral abdominal surface) and Cullen's sign (cyanosis of the umbilical region) indicate a retroperitoneal hematoma;

Direct signs of injury are wounds, abrasions, bruises, hemorrhages. At the same time, their absence on the abdominal wall does not exclude the presence of severe trauma to the internal organs! In case of penetrating wounds, the entrance and exit holes are found, and they are marked with paper clips before radiography.

In the presence of a wound, loss of internal organs and tissues from the wound (usually strands of the greater omentum, less often loops of the small intestine), leakage of intestinal contents, bile, urine from the wound with corresponding staining of the dressing (underwear) and odor are direct signs of a penetrating wound.

Indirect signs of penetrating injury: symptoms of general blood loss, intoxication and peritonitis, as well as pneumoperitoneum (disappearance of hepatic dullness upon percussion), hydroperitoneum (dullness in sloping areas), which are revealed by percussion of the abdomen.

Palpation and percussion of the abdomen:

When palpating the abdomen, space-occupying formations, pain, muscle tension in the anterior abdominal wall, and crepitus over the pelvic bones and lower ribs are noted;

Diffuse tension in the muscles of the anterior abdominal wall and its pain upon palpation are signs of damage to internal organs, but the same symptom is also characteristic of an isolated injury to the rectus muscles of the anterior abdominal wall;

A positive Shchetkin-Blumberg symptom indicates the development of peritonitis, but may be absent in the first hours after injury;

Positive Kulenkampf's symptom - pain and positive symptoms of irritation of the peritoneum in the absence of tension in the anterior abdominal wall are characteristic of hemoperitoneum;

Shortening of the percussion sound in the lateral sections of the abdomen indicates the accumulation of free fluid in the abdominal cavity (blood, exudate, transudate, intestinal contents, pus, urine, etc.);

Joyce's symptom: shortening of the percussion sound, the boundaries of which do not change when the body position changes (turning to one side) - a characteristic sign of retroperitoneal hematoma;

The disappearance of “liver dullness” (an area of shortening of percussion sound over the liver area) indicates a rupture of a hollow organ in the abdominal cavity, when free gas accumulates under the right dome of the diaphragm. The absence of this sign does not exclude rupture of a hollow organ.

Auscultation of the abdomen:

The absence of peristaltic sounds with the simultaneous absence of sharp swelling indicates injury to internal organs. Bloating and absence of peristaltic sounds can be observed with retroperitoneal hematoma and in the late stages of peritonitis. The absence of bowel sounds within 5 minutes is an indication for diagnostic laparotomy, especially for penetrating wounds.

Rectal examination: If blood is released from the anus or remains on the glove during digital examination, sigmoidoscopy is performed to identify damage to the rectum.

Nasogastric tube and urinary catheter are required for all patients with suspected abdominal trauma. The presence of blood in the resulting fluid is a sign of damage to the upper gastrointestinal tract or urinary tract.

It should be remembered:

Impaired consciousness (concomitant traumatic brain or spinal cord injury), alcohol and drug intoxication significantly alter pain sensitivity and complicate examination;

Analgesics (narcotic and non-narcotic) are not prescribed until a final diagnosis is made.

Laboratory research:

Indicators of hemoglobin and hematocrit immediately upon admission are not very informative for assessing the patient’s condition and the amount of blood loss, however, if bleeding continues, the data obtained serve as a starting point for dynamic monitoring;

Leukocytosis over 20x109/l in the absence of signs of infection indicates significant blood loss or rupture of the spleen (an early sign);

Increased serum amylase activity is a sign of pancreatic damage or intestinal rupture;

Increased activity of serum aminotransferases is characteristic of liver damage;

Hematuria in 75-90% of patients with kidney injuries. microhematuria is typical for small injuries; microhematuria in combination with shock and macrohematuria - for severe kidney damage. however, this rule is not always observed; in 24-34% of patients with injuries to the renal pedicle and in 28% of patients with gunshot and stab wounds of the kidney, hematuria is completely absent;

Study of the lavage fluid during diagnostic peritoneal lavage (laparocentesis with a “groping” catheter): the content of erythrocytes in the lavage water, over 108/l, or leukocytes, over 5x105/l, is regarded as a positive test for hemoperitoneum. DPL does not indicate the depth of damage; in 1%-2% of cases complications of the method are possible, requiring laparotomy (level of evidence - 2); This method is mainly intended for the rapid and effective determination of hemoperitoneum and has limited capabilities for diagnosing injuries to the intestine and diaphragm, and is virtually useless for diagnosing injuries to retroperitoneal organs. .

Instrumental studies:
Primary surgical treatment with wound revision- the main and most informative diagnostic method for open abdominal injuries. Allows you to establish the penetrating nature of the wound and determine the tactics of patient management. The presence of a peritoneal defect is usually an indication for a wide midline laparotomy.

Vulnerography- contrast radiography of the wound channel. With a penetrating wound, the contrast agent enters the abdominal cavity, spreading between the loops of intestine and causing pain. With a non-penetrating wound, contrast in the form of a lake accumulates in the soft tissues. Negative vulnerography data do not allow us to completely exclude the penetrating nature of the injury. However, the general direction and length of the wound channel becomes known, which facilitates the initial surgical treatment (if indicated).

Ultrasound- signs of free fluid in the abdominal cavity indicate organ damage. Subcapsular and central hematomas of parenchymal organs are visualized. It is also used for dynamic observation and resolving the issue of management tactics (tendency to break into the abdominal cavity).
Ultrasound should be considered as the primary method for TTG to exclude hemoperitoneum, with a negative or indeterminate result, DPL and CT are complementary methods (level of evidence - I, strength of recommendation - A). Contraindication - unstable hemodynamics of the patient.

CT- diagnosis of damage to parenchymal organs, the aorta, foci of hemorrhage in the abdominal cavity and retroperitoneal space. The use of radiopaque contrast agents (IV or orally) expands the capabilities of CT and allows simultaneous visualization of parenchymal and hollow organs of the abdominal cavity. Renal injuries and retroperitoneal hematomas are detected using a CT scan of the abdomen, which should be performed in every patient with hematuria and stable hemodynamics (Level of recommendation - C). The need for mechanical ventilation in a patient is not a contraindication to CT. Contraindication - unstable hemodynamics of the patient. When there is a suspicion of damage to the liver/spleen, CT can exclude injuries requiring emergency surgical intervention (Level of recommendation - B). CT is recommended in hemodynamically stable patients with equivocal physical examination findings, concomitant neurological injury, or multiple extra-abdominal trauma. If the CT result is negative, the patient is hospitalized for follow-up (level of evidence - I). CT allows the choice of conservative management tactics in patients with a solid nature of damage to internal organs (level of evidence - I). In hemodynamically stable patients, DPL and CT are complementary diagnostic methods (level of evidence - I). CT cannot be used as the only diagnostic method to exclude injuries to the intestine, diaphragm, and pancreas (Level of recommendation - B). CT scan of BP reliably identifies hemoperitoneum in patients with TTG (Level of recommendation - B). Oral administration of CT contrast is mandatory for the diagnosis of TTG (Level of recommendation - B).

X-ray of the abdominal cavity with capture of the diaphragm- allows you to establish a rupture of a hollow organ (free gas), fluid in the abdominal cavity, fractures of the pelvic bones, spine, damage to the diaphragm. Free gas is best detected when the victim is positioned on the left side and the x-rays are directed horizontally (laterography). Free fluid in the abdominal cavity is detected in the form of parietal ribbon-like shadows in the lateral canals and widening of the interloop spaces, especially clearly visible against the background of intestinal pneumatosis. Also signs of injury are: displacement of the gas bubble of the stomach, altered location of intestinal loops, foreign bodies. With fractures of the lower ribs, damage to the liver, spleen, and kidneys is possible.

Excretory urography- mandatory for unstable hemodynamics. One image 5-10 minutes after the introduction of a radiocontrast substance is enough. Contrast can be added to infused solutions. If the patient's condition allows, continue the study every 5 minutes until the kidneys, ureters and bladder are completely visualized. If concomitant traumatic brain injury is suspected, excretory urography should be postponed until a CT scan of the head is performed so as not to distort its results.

Contrast cystography- in case of pelvic fractures, it is necessary to exclude intraperitoneal and extraperitoneal ruptures of the bladder.

Urethrography- for diagnosing damage to the urethra.

Angiography- for diagnosing damage to large vessels. The study is also carried out if an arteriovenous fistula or false aneurysm of the arteries is suspected.

Laparocentesis with a fumbling catheter or diagnostic peritoneal lavage- a fast and effective method. Allows you to detect hemoperitoneum, the contents of hollow organs that leak into the abdominal cavity when they are damaged (intestinal contents, bile, urine). For a positive result of this test, it is enough to obtain 5-10 ml of apparent blood. If no fluid is obtained, 1 liter of warm saline is injected into the abdominal cavity, followed by microscopic examination of the washing fluid (see paragraph 12.3). When using DPL, making a tactical decision is based on data from aspiration of the contents and microscopic analysis of the wash water (level of evidence - II). Contraindicated in case of severe bloating, multiple postoperative scars of the anterior abdominal wall. In the absence of experience, it can lead to complications (injury to organs, blood vessels) or a false conclusion.

Diagnostic laparoscopy allows you to visually examine the abdominal cavity and assess the degree of damage and thereby finally decide on the need for laparotomy. Contraindications: severe bloating of the abdomen, the presence of multiple scars on the anterior abdominal wall, extremely serious condition caused by shock, damage to the chest, brain, as well as

Suspicion of rupture of the diaphragm (due to the need to create pneumoperitoneum).

Dynamic observation(repeat ultrasound, or CT or DPL) is justified in hemodynamically stable patients with an indeterminate ultrasound result (level of evidence - II).

Indications for consultations with specialists:

Consultation with a gynecologist: if an injury to a woman’s external or internal genitalia is detected or suspected;

Consultation with a urologist: if injury to the urinary system is established or suspected;

Consultation with an angiosurgeon: if injury to the great vessels is detected or suspected;

Consultation with a traumatologist: if an injury to the osteoarticular system is detected or suspected;

Consultation with a neurosurgeon: if a brain or spinal cord injury is suspected or detected;

Consultation with a thoracic surgeon: if a thoracic injury is suspected or detected;

Consultation with an otorhinolaryngologist: if injury to the ENT organs is suspected or detected;

Consultation with a resuscitator: to determine indications for treating a patient in an intensive care unit;

Consultation with an anesthesiologist: to determine the type of anesthesia for surgery, as well as coordination of tactics for managing the preoperative period;

Consultation with a therapist: in the presence of concomitant pathology.

Differential diagnosis

Differential diagnosis

Table 1. Differential diagnosis for abdominal trauma

Damaged organ	Characteristic syndromes orsymptoms	Differentiation test
Abdominal wall	Pain on palpation, tension in the muscles of the anterior abdominal wall, and a palpable mass formation can be caused by a hematoma of the rectus abdominis sheath.	In order to distinguish such a hematoma from an intra-abdominal mass formation, the patient lying on his back is asked to raise his head. At the same time, the abdominal muscles tense, and the intra-abdominal formation is not palpable or is difficult to palpate. An intramural hematoma is palpable equally well in any position.
Spleen	History of blunt trauma is more common than injury, pain in the upper left quadrant, or pain referred to the left shoulder. Often combined with a rib fracture on the left. Symptoms of hypovolemia. Tenderness in the left upper quadrant. There are no specific tests on physical examination to detect splenic injury. Sudden abdominal pain and symptoms of intra-abdominal bleeding sometimes appear several days after the injury. In this case, a two-stage splenic rupture should be suspected.	CT with IV contrast: splenic rupture, intra-abdominal bleeding or active bleeding from the spleen. DPL - detect blood.
Liver	Hypovolemia, abdominal enlargement. Physical data is not reliable.	CT with IV contrast: liver rupture, intra-abdominal bleeding or active bleeding from the spleen. The tests revealed anemia, decreased hematocrit. Ultrasound shows subcapsular or intra-abdominal hematoma DPL - detect blood. Angiography - intrahepatic arterial ERCP: signs of damage to the biliary tract.
Kidneys	There is a history of blunt or open trauma to the lateral surface of the abdomen, gross hematuria, pain and tenderness in the side and lower back, which intensifies with inspiration. Fractures of the 11th or 12th ribs. Unstable hemodynamics.	In the urine there is marogematuria. CT of the PD or pelvis with IV contrast: slow contrast of the kidneys and bladder, hematoma, rupture of the liver, destruction of the urogenital tree.
Pancreas	Indication of a wound or local blunt trauma of the epimesogastrium. Symptoms appear delayed due to the retroperitoneal location. Diffuse abdominal pain radiating to the back. After a few hours, muscle tension and peritoneal symptoms may appear.	CT scan with intravenous contrast: inflammatory changes around the pancreas. Significant increase in the activity of serum amylase and lipase.
Stomach	Indication of a wound or local blunt trauma, especially of the epigastrium, often an injury against the background of a full stomach. Nonspecific abdominal pain. Sometimes dagger pain and board-like muscle tension.	P-graphography with diaphragm capture: free gas under the diaphragm. Discharge of blood through a nasogastric tube.
Small intestine	More often indications of wounds than blunt trauma. Often in the early period without signs of peritonitis, then a board-shaped abdomen with diffuse tenderness.	CT: free fluid without signs of damage to parenchymal organs. Thickening of the intestinal wall. DPL - positive test for hemoperitoneum, the presence of bacteria, bile or food particles.
Colon	More often indications of wounds than blunt trauma. Pay attention to the possibility of damage to the colon and rectum during pelvic fractures. Diffuse tenderness with a tense abdomen, blood on rectal examination, often in the early period without signs of peritonitis, then a board-shaped abdomen with diffuse tenderness. Blood on rectal examination.	P-graphography with diaphragm capture: free gas under the diaphragm. CT: free gas or mesenteric hematoma, contrast extravasation.
Diaphragm	High-altitude and high-velocity blunt abdominal trauma or thoracoabdominal injuries. Chest pain, nonspecific abdominal pain. Feeling short of air. Auscultation - decreased breathing or bowel sounds in the chest. Hemodynamic instability, shortness of breath, tachycardia, pain in the shoulder girdle, tension in the abdominal muscles.	X-ray of the chest: hemopneumothorax, high position of the diaphragm, stomach and intestines in the chest cavity. CT scan: hemopneumothorax, high position of the diaphragm, stomach and intestine in the chest cavity. Laparoscopy: direct visualization of diaphragmatic injury.
Bladder	Indications of blunt trauma or wound, association with pelvic fracture, dysuria and gross hematuria, pain in the lower sections.	CT scan with intravenous contrast: free fluid. Increased urea and creatinine in the blood. Cystography: leakage of contrast into the abdominal cavity or retroperitoneal space.
Abdominal vessels	Indications of injuries to the abdomen or pelvis more often than blunt trauma. Abdominal bloating, tachycardia, hemodynamic instability, hypotension, loss of pulse in the lower extremities.	Ultrasound: free fluid. CT scan with intravenous contrast: free fluid, contrast extravasation.

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Treatment

Treatment goals:

Elimination of life-threatening injuries to the abdominal organs;

Preventing the development of possible complications.

Treatment tactics: Correction of vital functions (breathing, blood circulation), carrying out anti-shock measures. When a diagnosis of AT is established or if there is reasonable suspicion of AT, immediate hospitalization in a surgical hospital. Tactics for abdominal and TJ wounds are different.

For abdominal injuries(Appendix 2) the safest management tactic is to carry out primary surgical treatment with revision of the wound under local anesthesia and, if a penetrating wound is detected, proceed to diagnostic laparotomy under general anesthesia.

Diagnostic laparotomy: indicated in the vast majority of cases for penetrating wounds (bullet, knife, shot wounds, etc.). Exploratory laparotomy is performed immediately if there is shock, evisceration, peritonitis, or abdominal distension. In other cases, it is advisable to first conduct instrumental diagnostics to identify possible associated injuries.

Expectant conservative therapy is possible only in hemodynamically stable patients in the absence of symptoms of damage to the abdominal organs and retroperitoneal space, small wounds of the anterior abdominal wall, when damage to the peritoneum is unlikely. If any symptoms of peritoneal irritation appear during follow-up and if bowel sounds disappear, surgery is necessary.

For blunt trauma(Appendix 3) treatment tactics are determined by the clinical picture and the results of diagnostic studies. If the examination data is questionable, the issue is resolved in favor of surgical intervention.

Emergency diagnostic laparotomy for TTG, it is indicated for patients with a positive DPL result (level of evidence - I), as well as with a positive ultrasound result in hemodynamically unstable patients.

Indications for emergency diagnostic laparotomy for blunt abdominal trauma:

. Systolic blood pressure< 90 mm Hg + положительные тесты при УЗИ БП или ДПЛ ;

Active extravasation of contrast on CT;

Physiological exhaustion (failure of compensation);

Deterioration in dynamics during examination of the abdomen;

Severe damage to parenchymal organs;

High need for transfusion or its increase;

Unsuccessful attempt at vascular embolization;

Multiple intra-abdominal injuries;

Unexplained fever or leukocytosis;

Signs of damage to hollow organs on CT.

With stable hemodynamics and a positive ultrasound, follow-up CT may justify the choice of conservative tactics for some types of injuries (level of evidence - II).

Non-drug treatment- according to the ATLS protocol, events are carried out according to the “ABCDE” principle (Appendix 4).

Drug treatment:

Preoperative antibiotic prophylaxis in the form of 1 dose of broad-spectrum antibiotics against aerobic and anaerobic flora should be performed in all patients with open abdominal trauma (level of evidence - I). Prophylactic antibiotics should be prescribed for no more than 24 hours in case of damage to hollow organs with open abdominal trauma ( level of evidence - I) No evidence of damage to hollow organs, does not require further administration of antibiotics (level of evidence - I).

In case of unstable hemodynamics, in parallel with diagnostic procedures and preparation for surgery, intensive therapy is carried out aimed at replenishing the volume of blood volume, maintaining perfusion pressure, correcting acid-base balance and the hemostatic system.

Transfusion of blood components, under the control of blood tests and taking into account the volume of blood loss.

In the case of the development of severe coagulopathy (DIC syndrome), the administration of blood coagulation factors (fresh frozen plasma, platelet mass, cryoprecipitate, eptacogalpha (VIIa factor)) is indicated.

The ineffectiveness of resuscitation measures for hypovolemic shock in combination with a suspected abdominal injury is an indication for urgent surgical intervention to stop bleeding. Unfortunately, multiple fractures and extensive soft tissue injuries often distract the doctor’s attention and force him to waste time on unsuccessful infusion therapy instead of immediately assuming profuse intra-abdominal bleeding and taking appropriate measures.

Drug treatment provided on an outpatient basis

Morphine hydrochloride 1%; 2% 1 ml, solution for intravenous and intramuscular injection (for traumatic shock);

Drug treatment provided at the inpatient level:

List of essential medicines(having a 100% probability of application):

Sodium chloride, solution for infusion 0.9%, 200 ml bottle; 400 ml; 500 ml;

Ringer's lactate, solution for infusion, bottle, 400 ml;

Dextrose, solution for infusion, bottle, 5% - 400 ml;

Hydroxyethyl starch solution for infusion 6%; bottle 500 ml;

Tramadol solution for injection 5%-2 ml in ampoules;

Ceftriaxone, powder for the preparation of solution for intravenous and intramuscular administration 1000 mg, bottle;

Etamsylate, solution for injection 250 mg/2 ml.

List of additional medicines(less than 100% chance of application):

Amino acids for parenteral nutrition, solution for infusion, bottle 10% - 500 ml;

Albumin, solution for infusion, 10%;

Red blood cell mass, washed red blood cells;

Thrombomass;

Cryoprecipitate;

Fresh frozen plasma;

Dopamine, concentrate for the preparation of solution for infusion 0.5%; 4%; . Adrenaline hydrotartrate, solution for injection 0.18%, ampoule 1 ml;

Aminophylline, solution for intravenous administration 24 mg/ml; ampoule 5 ml;

Furosemide, solution for intravenous and intramuscular administration 10 mg/ml, ampoule 2 ml;

Platyphylline hydrotartrate, solution for injection 0.2%, ampoule 1 ml;

Drotaverine, solution for injection 40 mg/2 ml;

Prednisolone, solution for injection 30 mg/ml, ampoule 1 ml;

Ertapenem, lyophilisate for the preparation of solution for injection 1000 mg in 20 ml glass bottles; . Amoxicillin + clavulanic acid (Amoxiclav), powder for solution for intravenous administration 500 mg + 100 mg;

Ampicillin sodium, sulbactam sodium, powder for solution for injection 1500 mg;

Ceftazidime, powder for solution for injection and infusion 1000 mg;

Gentamicin sulfate, solution, ampoule 80 mg/ml-2 ml;

Metronidazole, solution, bottle 500 mg-100 ml; . Procaine, solution, bottle 0.25% - 200 ml;

Nadroparin calcium, solution, syringe ampoule, 0.3; 0.4; 0.6 ml;

Ketoprofen solution for intravenous and intramuscular injection. 50 mg/ml, amp. dark glass, 2 ml;

Trimeperidine 2% -1 ml in solution for intravenous and intramuscular injection;

Morphine hydrochloride 2% 1 ml, solution for intravenous and intramuscular injection;

Neostigmine methyl sulfate 0.5 mg/1 ml solution for injection;

Eptacog alfa (activated), lyophilisate for the preparation of solution for intravenous administration 1 mg (50 KU); 2 mg (100 KU);

Fibrinogen, Thrombin, absorbent hemostatic agent, Tachocomb sponge;

Iohexol (Omnipak) injection solution 300 mg iodine/ml, bottle 20 ml, 50 ml;

Aminocaproic acid, solution for infusion 5%;

Ethyl alcohol, solution, bottle, 95% - 100 ml;

Chlorhexidine bigluconate, solution, bottle, 0.02% - 400 ml.

Drug treatment provided at the emergency stage: anti-shock, infusion-transfusion therapy.

Morphine hydrochloride 2% 1 ml, solution for intravenous and intramuscular injection (for traumatic shock);

Sodium chloride, solution for infusion 0.9%, 200 ml bottle; 400 ml; 500 ml.

Other treatments

Other types of treatment provided on an outpatient basis: not provided.

Other types of services provided at the stationary level:

X-ray endovascular embolization of BP vessels - in some cases allows to achieve hemostasis without the use of laparotomy.

For pelvic fractures accompanied by profuse bleeding, infusion therapy is often ineffective. In this case, a pneumatic anti-shock suit is used. If a patient with a suspected abdominal injury is admitted in a shock suit, the abdominal chamber should be deflated to allow peritoneal lavage or ultrasound.

Physiotherapy is carried out for inflammation and infiltration in the area of the postoperative wound:

Magnetotherapy;

Electrophoresis.

Other types of treatment provided at the emergency stage: providing support for vital functions, whenever possible, in compliance with the “ABCDE” principle (Appendix 4).

Surgical intervention

Surgical intervention provided on an outpatient basis: if possible, treat the wound, temporarily or permanently stop bleeding.

Surgical intervention provided in an inpatient setting

Preparing for surgery. In addition to the measures required when preparing patients for operations, the following are carried out before diagnostic laparotomy:

Installation of a nasogastric tube;

Installation of a permanent urinary catheter;

Installation of peripheral or central vascular access;

Parenteral administration of antibiotics (if there is suspected injury to the stomach or intestines, severe shock, extensive damage);

Drainage of the pleural cavity (for penetrating wounds and blunt chest trauma with signs of pneumothorax or hemothorax).

Surgical access: midline laparotomy. The incision should be long, allowing a quick inspection of the entire abdominal cavity.

Main stage:

Quick examination of the abdominal cavity to detect sources of bleeding;

Temporary stop of bleeding: tamponade - in case of damage to parenchymal organs; application of clamps - in case of damage to the main arteries; pressing with a finger - when large veins are damaged.

Reimbursement of blood volume begins after temporary cessation of bleeding. It is impossible to continue an operation that may lead to further blood loss without this;

Damaged loops of intestine are wrapped in a napkin and brought out onto the abdominal wall; this measure prevents further contamination of the abdominal cavity with intestinal contents. It is advisable to open large or growing retroperitoneal hematomas, determine the source and stop the bleeding;

Final stop of bleeding: application of vascular sutures, ligation of blood vessels; suturing wounds, liver resection, resection or removal of the kidney, spleen. In extreme cases, the source of bleeding is packed and subsequently relaparotomy is performed; in case of extreme severity of the condition, unstable hemodynamics against the background of anti-shock therapy and the presence of hypothermia, a 2-3 moment intervention is used according to the damage control protocol;

Suturing wounds or resection of the stomach and intestines;

Rinsing the abdominal cavity with a large amount of saline if it has been contaminated with intestinal contents;

Inspection of the abdominal cavity, including opening of the omental bursa and examination of the pancreas. If hemorrhage or swelling is detected, mobilization and complete examination of the pancreas is indicated. To examine the posterior wall of the duodenum, it is mobilized along the Kocher;

Repeated examination of all damaged organs and sutures; toilet of the abdominal cavity, installation of drainages (if necessary), layer-by-layer suturing of the abdominal wall wound;

If the abdominal cavity has been contaminated with intestinal contents, primary delayed sutures are placed on the skin and subcutaneous tissue or the wound is left open.

Surgical treatment of open and closed injuries of individual organs:

Spleen.
If a splenic rupture is discovered during exploratory laparotomy, suturing of the wound or resection of the spleen can be resorted to. Organ-saving operations are performed only in stable hemodynamics, in the absence of multiple associated injuries and massive bleeding. Otherwise, splenectomy is indicated; After surgery, a pneumococcal vaccine is administered.

Liver.
If damage to other organs is excluded, minor liver injuries can be treated conservatively.

1. Minor damage. Stab and cut wounds, penetrating gunshot wounds inflicted by a projectile with low kinetic energy, if they are located away from large vessels of the liver and do not bleed during diagnostic laparotomy, can be left without treatment and limited to drainage of the damaged area. Capsular wounds are not sutured. Bleeding wounds are examined by carefully spreading the edges; ligate damaged vessels, install drainages; the capsule is not sutured. It is extremely undesirable to leave foreign hemostatic materials in the wound.

2. Major damage. Complete mobilization of the liver is indicated with examination of all major blood vessels:

The falciform ligament of the liver is separated from the anterior abdominal wall and diaphragm up to the anterior surface of the suprahepatic part of the inferior vena cava;

The left triangular ligament of the liver is dissected in the direction from the left edge of the ligament to the suprahepatic part of the inferior vena cava;

The right lobe of the liver is pushed toward the center and the right triangular ligament is dissected to examine the lateral surface of the hepatic portion of the inferior vena cava;

The suprahepatic and subhepatic parts of the inferior vena cava adjacent to the liver are released. It is usually not necessary to cut the diaphragm;

The hepatoduodenal ligament, together with the structures passing through it at the porta hepatis, is wrapped with a gauze strip (Pringle maneuver);

The extent of damage is assessed and the extent of the operation is determined. It must be borne in mind that resection very often can significantly reduce the area of the bleeding surface of the liver (for example, with extensive deep wounds). Areas of the liver with impaired blood supply are subject to mandatory resection;

You should not stop the bleeding by applying wide mattress sutures: this leads to the formation of foci of necrosis and the formation of abscesses;

After resection, drains are installed and the absence of bleeding is ensured. The bile ducts are usually not drained;

Conventional methods of stopping bleeding are often ineffective, especially after multiple blood transfusions. In this case, resort to tamponade. Bleeding liver wounds are packed with large napkins, which are removed after 2-4 days during relaparotomy. A viable strand of pedunculated omentum can be used for packing;

When performing complete mobilization of the liver, it is usually not necessary to extend the midline incision into the chest. However, if the view is insufficient and bleeding continues, the incision is extended without hesitation;

Profuse bleeding and damage to the liver parenchyma can lead to coagulation disorders. In this case, fresh blood, fresh frozen plasma, platelet mass, and coagulation factor concentrates are transfused.

Pancreas.
In case of bruises of the gland without damage to the ducts, drainage is performed. For severe damage to the body and tail of the pancreas, resection is indicated. Damage to the area of the pancreas located to the right of the superior mesenteric vessels is often accompanied by rupture of the ducts. In this case, pancreatojejunostomy with simultaneous application of a Y-shaped Roux-en-Y enterojejunostomy is indicated. In case of severe damage to the head of the pancreas, especially in combination with injury to the duodenum, pancreaticoduodenectomy may be required.

Gallbladder and bile ducts.
Biliary tract injuries typically occur with penetrating injuries; With blunt trauma, rupture of the gallbladder artery is possible. The damaged gallbladder must be removed. Damage to the extrahepatic parts of the biliary tract is usually detected only during laparotomy - by bile staining of the surrounding tissues. The damaged duct should be sutured. If this is not possible, a choledochojejunostomy is performed.

Stomach.
The omental bursa is opened and the stomach is completely mobilized and examined. Particular attention should be paid to the lesser curvature, since damage to this area often goes unnoticed. The gastric wound is sutured after wide excision of its edges.

Duodenum. The type of operation depends on the size of the defect in the duodenal wall after excision of the wound edges. Minor injuries are sutured along the wound. Extensive defects are closed by placing a jejunal wall over the damaged area or suturing a pedunculated section of jejunum. With combined injuries of the pancreas and duodenum, suture failure often occurs. Therefore, after the operation, the duodenum is unloaded. To do this, probes are inserted from both sides, through the stomach and jejunum (jejunostomy), to suction out the contents. The abdominal cavity and retroperitoneal tissue are also drained. Internal and external drainages are installed for at least 10 days. With extensive damage to the duodenum and pancreas, pancreaticoduodenectomy may be required.

Small intestine.
Nonviable tissue is excised and primary sutures are applied. For multiple intestinal wounds located close to each other, resection of the entire damaged area is indicated. It is necessary to carefully examine the entire small intestine, paying special attention to its mesenteric edge.

Colon.
Primary suturing of the wound is permissible if the following conditions are met: the wound is small, there are no associated injuries, the contamination of the abdominal cavity is insignificant, and little time has passed since the injury. Resection is a safer method, especially in cases of extensive damage to the colon, severe contamination of the abdominal cavity with feces, the presence of concomitant injuries and when treatment was started late. After resection, the ends of the colon are brought out onto the abdominal wall,

Forming a colostomy or unnatural anus. Intestinal continuity is restored during the next operation. However, recently, many surgeons have successfully used primary anastomosis. The operation is completed by washing the abdominal cavity with a large amount of saline solution. Prevention of sepsis, which often complicates colon injuries, is necessary.

Female genital organs.
Hysterectomy or removal of damaged uterine appendages may be required. The question of whether to continue pregnancy is decided depending on its duration and the degree of damage to the fetus.

Preventive actions(prevention of complications, primary prevention for the primary care level, indicating risk factors).

Primary prevention of AT is the prevention of injuries in everyday life, at work and in transport.

Further management(postoperative care, clinical examinations indicating the frequency of visits to primary care doctors and specialists, primary rehabilitation carried out at the hospital level)

Early activation after stabilization of hemodynamics and spontaneous breathing.

Parenteral nutrition - until peristalsis is restored. Tube enteral nutrition is possible. Usually drinking from 1-3 days (depending on the damaged organs), liquid food - with the appearance of intestinal peristalsis and the release of gases.

Removal of the nasogastric tube - usually on the day of surgery, but during operations on the stomach, duodenum, small intestine - the tube can remain in place for several days.

According to indications - carrying out infusion therapy, antibacterial therapy, treatment of concomitant diseases.

Prevention of thromboembolic complications and microcirculation disorders with low molecular weight heparins.

Removal of control drainage (in cases of installation) on days 3-5 in the absence of discharge.

Removal of sutures from the surgical wound after 7-8 days.

Discharge in case of uncomplicated postoperative period is made 7-10 days after laparotomy.

After the operation, the patient must be observed for at least 2 weeks after discharge from the hospital, during which time he is exempt from work and attending educational institutions. Pay attention to the appearance of symptoms - fever, nausea, vomiting, abdominal pain, loss of appetite. Inspect the wound for inflammation. Control blood and urine tests.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:

Elimination of manifestations of AT itself and its complications;

Healing of the surgical wound by primary intention, absence of signs of inflammation of the postoperative wound in the early postoperative period and hernia in the late period;

Absence of fever, pain and other symptoms indicating a complicated course of injury or postoperative period.

Drugs (active ingredients) used in treatment

Hemostatic sponge
Albumin human
Aminocaproic acid
Aminophylline
Amoxicillin
Ampicillin
Gentamicin
Hydroxyethyl starch
Dextrose
Dopamine
Drotaverine (Drotaverinum)
Iohexol
Potassium chloride (Potassium chloride)
Calcium chloride
Ketoprofen
Clavulanic acid
Complex of amino acids for parenteral nutrition
Platelet concentrate (CT)
Cryoprecipitate
Metronidazole
Morphine
Nadroparin calcium
Sodium lactate
Sodium chloride
Neostigmine methylsulfate
Fresh frozen plasma
Platifillin
Prednisolone
Procaine
Sulbactam
Tramadol
Trimeperidine
Thrombinum
Fibrinogen
Furosemide
Chlorhexidine
Ceftazidime
Ceftriaxone
Epinephrine
Eptacog alfa (activated)
Red blood cell mass
Ertapenem
Etamsylate
Ethanol

Definition

abdominal injury injury

Abdominal injury- closed or open injury to the abdominal area, both with and without violation of the integrity of internal organs.

Classification of abdominal injuries

In domestic traumatology, the following classification of abdominal injuries is used.

Closed abdominal injuries:

· Without damage to internal organs - bruises of the abdominal wall.
· With damage to internal organs outside the abdominal cavity. In this case, the bladder, kidneys and some parts of the large intestine are more often damaged.
· With damage to the abdominal organs.
· With intra-abdominal bleeding. Occurs due to injury to the intestinal mesentery, omental vessels, spleen and liver.
· With the threat of rapid development of peritonitis. This includes abdominal injuries with rupture of hollow organs - the stomach and intestines.
· With combined injuries of parenchymal and hollow organs.

Open abdominal injuries:

· Non-penetrating.
· Penetrating without damaging internal organs.
· Penetrating with damage to internal organs.

Clinic

They may be accompanied by severe muscle ruptures and hemorrhage into the subcutaneous and retroperitoneal tissue. If the superior and inferior epigastric arteries are damaged, hemorrhages can become life-threatening for victims. With injuries to the abdominal wall without rupture of the arteries, increased heart rate, breathing, and vomiting are rare. Abdominal pain and tenderness of the abdominal wall are usually observed. The most alarming symptom is protective tension in the abdominal muscles. It can be pronounced, but in such cases it is most often limited to the area of application of force. Unlike damage to internal organs, this is a local tension of the abdominal wall, which is not accompanied by the Shchetkin-Blumberg symptom.

When a hematoma forms in the thickness of the abdominal wall, it is not always easy to distinguish it from the infiltrate located in the abdominal cavity. The diagnostic task is resolved by examining the abdominal wall during its active tension at the moment the patient independently rises in bed. An intra-abdominal formation ceases to be detected under a tense abdominal wall, while an intra-abdominal formation does not disappear and is quite clearly contoured in the thickness of the abdominal wall.

Distinguishing between damage to the abdominal wall and damage to the abdominal organs is not always easy. An error in diagnosis can lead to dangerous consequences, especially if the patient leaves the surgeon’s care. Therefore, after an abdominal injury, in the presence of pain of any nature, the patient should be hospitalized.

Closed injuries to abdominal organs

Damage to hollow and parenchymal organs is distinguished. Injuries to hollow organs are observed in 39.5% of cases, parenchymal ones in 32.8%, damage to the urinary tract in 24.7%, and damage to blood vessels or the diaphragm during operations in 3% of cases. Closed injuries to the internal organs of the abdomen in 25% of cases are characterized by combined organ damage. In addition, collateral damage is not uncommon. Combined damage to internal organs, as well as concomitant injuries, sharply complicate the course of abdominal injuries and significantly influence the outcomes of injuries to the abdominal organs.

Damage to hollow organs

There are bruises, crushes, partial and complete ruptures of the entire thickness of the organ wall. A hollow organ filled with liquid contents or distended with gases ruptures more easily than an empty one. The degree of filling of the organ, especially with liquid contents, determines the intensity of the spread of peritonitis. A tense abdominal wall largely absorbs a blow to the abdomen. Intestinal bruises are characterized by the presence of hematomas. A hematoma of the small intestine is most often formed in the submucosal layer, since its serous layer is closely connected with the muscular layer; hematomas of the large intestine are more often found under the serous layer. Superficial hematomas are not dangerous. Hematomas are dangerous, even small ones, but infiltrating the entire thickness of the bruised intestinal wall. In such cases, necrosis of the wall is very likely and dangerous. It leads, more often on the 3-5th day, to the sudden development of severe perforated peritonitis.

Injuries to the stomach are rare (4.2% of all closed injuries to the abdominal organs). Ruptures are most often localized on the anterior wall, but ruptures in the fundus and posterior wall are possible.

The duodenum is damaged in 2% of cases. There are retroperitoneal and intraperitoneal intestinal injuries. The former are characterized by the development of retroperitoneal phlegmon against the background of severe sepsis and subsequent peritonitis.

The small intestine is damaged in 26.2%, and the integrity of its initial and final sections is more often damaged.

Colon injuries occur in 7.1% of cases. The most dangerous are retroperitoneal ruptures of the colon, because, when viewed, they lead to severe phlegmon of the retroperitoneal tissue.

The rectum is well protected by the bones of the pelvis, but it can be ruptured by a fall, sudden abdominal tension, or a blow to the abdomen, especially in cases where the anus is closed. In pelvic fractures, the intestine is damaged by bone fragments. Rectal ruptures are almost usually observed in the anterior wall.

Bladder injuries due to closed abdominal trauma are divided into intra- and extraperitoneal. The frequency of intraperitoneal injuries to the bladder, isolated and combined, is 8% of all closed injuries to the abdominal organs. In the mechanism of bladder rupture, the degree of its filling is of great importance. Urine pouring into the free abdominal cavity leads to the development of peritonitis.

Damage to parenchymal organs

Injuries to the liver and spleen are almost equally common (16.3-15.4%). Given the massiveness, fragility and good fixation of the liver, the impact force is almost completely transferred to the tissue of the organ. The spleen is equally easily ruptured due to the large blood supply and the tenderness of its tissue. Damage to the liver, as well as the spleen, occurs without violating the integrity of the capsule (subcapsular and central hematomas) and with violating the integrity of the capsule (cracks and tears, avulsions and crushing).

If an organ is damaged without violating the integrity of the capsule, if it is small, the initial symptoms are scant, but subsequently, sometimes after 1-2 weeks, even with a small muscular effort, a rupture of the capsule with massive hemorrhage into the abdominal cavity may occur - the so-called 2-phase rupture occurs organ (spleen, liver).

Damage to the liver with disruption of the integrity of the capsule can be very diverse - from a small crack to extensive ruptures with separation of part of the liver. The clinical course is determined depending on the degree of tissue damage. Small single superficial cracks may hardly appear clinically. Large ruptures, in addition to the danger of fatal bleeding and biliary peritonitis, cause serious impairment of liver function and sometimes severe intoxication due to the absorption of decay products of liver tissue.

Liver damage may be accompanied by ruptures of large bile ducts and the gallbladder. They are not very rare and deserve serious attention. Damage to the biliary tract that is not recognized during surgery leads to the development of general biliary peritonitis. Isolated injuries to the extrahepatic bile ducts and gallbladder are rare.

Damage to the spleen, despite the fact that it is better protected by the ribs and is smaller in size than the liver, is also common. The delicate tissue of the spleen, when it is full of blood and especially when the organ is pathologically enlarged, ruptures easily.

Collapse is a frequent accompaniment of spleen damage. It develops immediately following organ damage and is characteristic of both acute and biphasic rupture. When the spleen is completely separated from the pedicle, death occurs quickly. If such a patient is managed to be taken to the operating room, then the surgeon has a few minutes to immediately open the abdominal cavity, find and clamp the pedicle of the spleen and begin to replace blood loss. When splenic tissue ruptures, in most cases during preoperative preparation, after transfusion of an ampoule of blood, the collapse passes and signs of serious damage to the abdomen, complicated by internal blood loss, are revealed. The clinical picture of splenic rupture is determined by internal bleeding. The severity of symptoms depends on the severity of the injury, the time that has passed since the injury, and the body's compensatory capabilities. Fainting, pale skin, cold sweat, and rapid small pulse develop immediately after the injury. They can be caused by both a general reaction to injury without organ rupture, and internal bleeding. The general reaction will subside in the coming hours. With internal hemorrhage, the symptoms persist, and with continued bleeding they increase. Massive bleeding leads to the rapid development of acute blood loss. The severity of symptoms of acute blood loss to a certain extent depends on the compensatory capabilities of the body. In one patient, the symptoms increase rapidly, while in another, the drop in blood pressure and increased heart rate develop slowly.

For damage to the spleen, in addition to symptoms of internal bleeding, pain in the left hypochondrium is quite typical. Often the pain radiates to the scapula and left shoulder. Quite pathognomonic, but not always encountered, is the “Vanka-Vstanka” symptom. The patient lies on his left side or sits hunched over with his thighs pressed to his stomach. When the patient is removed from this position, he immediately strives to return to the previous position and instinctively creates peace for the damaged area. Respiratory excursions of the left half of the abdominal wall are limited. The abdominal wall is tense. The degree of tension is different, until in the left hypochondrium it is always clearly expressed, and the greatest pain is also determined there. In shock, there is usually no tension in the abdominal wall. The Shchetkin-Blumberg symptom is often detected throughout the abdomen (but in the left hypochondrium it is always distinct , this symptom persists even during shock, but it is revealed only by facial expressions. During percussion, dullness is established in the left hypochondrium. With a large accumulation of blood in the abdominal cavity, with a change in the patient’s body position, the dullness moves with a change in body position.

If the spleen ruptures while the capsule is preserved, the initial symptoms of the injury may quickly subside. The patient comes to a satisfactory condition. Symptoms of subcapsular splenic rupture are scanty. Stretching of the capsule by gushing blood causes pain when breathing, a feeling of fullness in the left hypochondrium. The severity of these signs depends on the amount of blood flowing under the capsule. The pain can be quite intense. In some cases, ruptures, especially small ones, proceed favorably and end in the formation of cysts. In other cases, the capsule suddenly ruptures and a picture of internal bleeding of one degree or another develops. Biphasic ruptures of the spleen have been described at different times, up to 2 weeks or more after the initial injury. Moreover, any repeated injury, and sometimes just a sharp change in body position, can lead to rupture of the capsule.

Due to its deep location, the pancreas is rarely damaged. With severe bruises and compression of the abdomen, it is crushed on the spine. When the gland is located deeply, its injury is most often combined with damage to neighboring organs. Damage to the elements of the solar plexus causes the development of severe shock. Violation of the integrity of the gland parenchyma leads to fat necrosis and vascular thrombosis.

Kidney injuries, isolated and combined, occur in 16.7% of injuries to abdominal organs.

Closed kidney injuries include:

1. Superficial injuries, which include: subcapsular hematoma with minor damage to the renal parenchyma, superficial ruptures of the renal parenchyma with rupture of the fibrous capsule and the formation of a perinephric hematoma.
2. Deep ruptures of the kidney, reaching the calyces and pelvis and accompanied by significant hemorrhage and urinary infiltration. The latter develops very quickly if the ureter becomes clogged with clots.
3. Crushing of the kidney, sometimes with its division into separate parts. Bleeding in this case can be either very strong or moderate due to thrombosis of crushed vessels.
4. Complete or partial separation of the kidney from the renal pedicle.