Abdominal Trauma

Abdominal trauma is injury to the internal organs of the abdomen, either by direct impact or by the action of shock waves. Trauma is divided into open and closed. Open is when an object penetrates the abdominal cavity, like a bullet, and closed is when the trauma occurs from an impact against a person’s body from a collision or from a seat belt, among others. In my country, there is a very high crime rate that has been increasing in the last 20 years. Any street robbery can result in a gunshot or stab wound, because thieves are extremely aggressive. While doing my residency in general surgery, we used to receive gunshot wounds especially on weekends, when the emergency room could be overwhelmed by such patients. I like emergency surgery very much and it is one of the specialties I considered, however in Venezuela the training program was not fully developed until 2012.

a) Open Abdominal Trauma: Penetrating Wounds

Penetrating wounds are those that cause direct damage to the intra-abdominal organs. A gunshot or stab wound can cause a lot of damage to the abdomen, and you’ll know the exact damage in the operating room.

Gunshot

I have more experience with shooting than with any other type of weapon since in my city, many robbers are armed. The type of patients that I have treated are usually from criminal gangs that come directly to my hospital because, being a university hospital, it has a policy of not letting police forces in. The weekends are the busiest days, with five or more wounded in one day. What Should You Do? The wounds are unpredictable. It all depends on the type of weapon, type of projectile, distance from the attacker, and many other aspects. Each injured patient must be evaluated as a surgical patient until proven otherwise. First of all, remember that the most important thing is to stop the bleeding, if there is any. Wherever you see an area of bleeding, compress it tightly with a towel to try to plug the area. At that point, you need to call for help. If you are the injured person, concentrate on calling 911 and stopping the bleeding. If it is someone else you are treating, find a helper who can continue to pack the wound while you proceed with the physical examination for signs of neurological deficits, such as slurred speech, disorientation, loss of consciousness, and other injuries to the rest of the body.

Bobjgalindo, Own work, CC BY-SA 4.0

First, completely undress the injured person. This way you will have visual access to the entire surface of the skin, and it will be easier to locate other entry or exit holes. Not all bullets go out, and contrary to what we are told on TV and in the movies, that is neither good nor bad. The only benefit we get from watching the bullet exit is that we can calculate the direction it went and from there presume which organs may have been injured. This is an absolute life-threatening emergency. Until the ambulance arrives, monitor the injured person’s heart and breathing rate, and talk to him or her to assess the level of consciousness and orientation. With pads or small towels, you can estimate the amount of blood he has lost. A fully soaked pad contains about 100 ml of blood and a surgical compress just over 200 ml. You can make an empirical calculation from this data, but if you want to be more accurate, do the calculation now with the smallest pads you have at home. The calculation is done with one measuring glass or with a syringe. Deposit water until the cloth is soaked and begins to drip. That’s the maximum absorption capacity, and it’s an objective amount that’s very important information for the health care team. Always remember to examine the patient from behind. Both the front and side areas and the back are necessary for the examination to be complete.

Stabbing

The vast majority of times stab wounds are linear, not like the gunshot wound, where the bullet may have made some movements inside the abdomen, but they usually bleed a lot. First of all, it’s important to stop the bleeding. If you have an assistant, one can call 911 while the other continues to compress the bleeding area. As with bullet wounds, be sure to examine the patient thoroughly for other wounds. Don’t forget to check the back and sides. If the knife is still stuck, DO NOT try to pull it out. It is safer to have this procedure done by people who can care for the patient in case of severe bleeding or other complications. Sometimes the knife will cover the internal wound, so it prevents the patient from bleeding more. Always remember that an injured patient is in a life-threatening situation. Don’t feel confident just because he looks good or is talking and walking. That patient should be taken to the emergency room and examined and evaluated by a surgeon. Stab wounds are less frequent, but they do occur. I will never forget the patient who arrived at the emergency room because in the rush hour of the subway with so many people around, she felt that something had punctured her abdomen. When I examined her, she had signs of peritoneal irritation and needed surgery.

b) Closed Abdominal Trauma: Not Penetrating

Blunt traumas usually occur in patients in car accidents. These patients should be kept under observation as internal bleeding may persist so slightly that it takes some time to manifest itself. Any patient who has been in a crash or collision should be evaluated by specialized personnel. Closed abdominal trauma patients undergo a scan called ecoFAST (Focused Abdominal Sonography for Trauma), which is nothing more than an ultrasound scan directed at specific areas of the abdomen

where intra-abdominal fluid normally accumulates. In the figure, you can see that the black stripe, marked with arrows, indicates the presence of liquid in that area.

Sometimes paramedics have one of these machines and the exam can be done as soon as they arrive so they have more information about the condition of the patient’s internal organs. WHAT ELSE CAN I DO? In the patient’s body, you should be attending to two specific areas: the periumbilical region and the sides. When, after an accident, bruising begins to appear in these areas, it is indicative of significant internal bleeding. That patient requires surgery. If at any time the patient begins to lose consciousness, try to raise his legs above his head to encourage blood flow to the brain.