Guidelines

The Victorian State Trauma System provides support and retrieval services for critically injured patients requiring definitive care, transfer and management. This abdominal trauma guideline provides evidence based advice on the initial management and transfer of major trauma patients who present to Victorian health services with severe abdominal injuries.

This abdominal trauma guideline is developed for all clinical staff involved in the care of trauma patients in Victoria. It is intended for use by frontline clinical staff that provide early care for major trauma patients; those working outside a Major Trauma Service (MTS) and those working directly at a Major Trauma Service (MTS).

The guideline has been assessed utilising the AGREEII methodology for guideline development and is under the auspice of the Victorian State Trauma Committee (VSTC).

• Management of abdominal trauma largely depends upon the haemodynamic stability of the patient.
• Blunt and penetrating abdominal trauma have different care pathways.
• Widespread availability of CT scanning has seen a shift in the management of haemodynamically stable blunt abdominal trauma patients towards non-operative management.
• Delay in diagnosis and treatment of hollow viscus injury leads to early peritonitis, haemodynamic instability and increased mortality and morbidity.
• Consultation with ARV for advice and transfer to a MTS should be initiated for all penetrating abdominal trauma and in significant blunt trauma.

Introduction

Abdominal trauma accounts for 22% of body regions injured in major trauma and can be difficult to diagnose and manage.2 A high index of suspicion should be maintained for any multi-trauma patient, particularly where the mechanism of injury may suggest significant abdominal injury. Understanding the types of injuries is important for the planning and organisation of trauma services. Penetrating injuries are frequently isolated injuries, but may cause severe organ or vessel disruption and rapid bleeding. Securing breathing and control of bleeding are often the priorities with this type of injury.

The vast majority (over 90%) of major trauma in Australia is caused by blunt injury mechanisms, such as those caused by motor vehicle collisions (MVC), falls, and being forcefully struck. Blunt injuries less often present with rapid exsanguination, but are more often associated with multiple organ failure, combinations of airway, breathing, circulatory, neurological and musculoskeletal deficiencies, and permanent physical and cognitive disabilities among survivors.

Missed abdominal injuries are a major cause of avoidable death in trauma patients.3 The principles of initial management focus on the detection of any injury and determining the need for urgent intervention. Investigations such as the Focused Assessment of Sonography in Trauma (FAST) and Computerised Tomography (CT) scanning can determine the presence of injuries in combination with assessment.

Make early contact with ARV for advice from the major trauma services and to initiate retrieval.

• Blunt and penetrating abdominal trauma have different care pathways.
• Delay in diagnosis and treatment of hollow viscous injury leads to an increase in mortality and morbidity.
• Indications for emergency laparotomy rely on haemodynamic instability.

Make early contact with ARV for advice from the major trauma services and to initiate retrieval.

• Early identification of coagulation status is vital to initial management.
• Bleeding can rapidly become life threatening in the patient taking oral anti-coagulants.
• Early consultation with trauma services and haematologist via ARV will guide ongoing management.

Post-resuscitation care, prioritising surgical haemorrhage control and fluid resuscitation to target SBP 90mmHg (110mmHg if there is a head injury) or consciousness until this is achieved.

Make early contact with ARV for advice from the major trauma services and to initiate retrieval.

• The primary survey is designed to detect and treat actual or imminent life threats.
• Avoidance of hypovolaemia in trauma is a cornerstone of management.
• Trauma patients are at risk from complications due to hypothermia.

All penetrating injuries (except isolated / superficial limb injuries)

Blunt injuries:

• Serious injury to a single body region such that specialised careor intervention may be required, or such that life, limb or long term quality of life may be at risk.
• Significant Injuries involving more than one body region.

Specific Injuries:

• Limb amputations / limb threatening injuries.
• Serious crush injury.
• Major compound fractureor open dislocation.
• Fracture to two or more of the following: femur / tibia / humerus.
• Fractured pelvis.

Burns:

• Burns > 20% (adult) or 10% (child).
• Suspected respiratory tract burns.
• High Voltage Electrical Injury.

Neuro-trauma:

• Neurological deficits.
• Skull fracture.
• Abnormal CT scan findings.

Spinal trauma:

• Significant spinal fracture.
• Minor spinal cord or nerve root injury.
• Presence of neurological deficits.
• In isolated spinal cord trauma, the patient should be transferred from a primary hospital to the Victorian Spinal Cord Service – Austin Health, paediatric patients should be transferred and managed at the Royal Children’s Hospital.

Paediatric Trauma:

• Any of the above conditions when inchildren are indications for transfer in a paediatric patient.

Obstetric Trauma:

• Evidence of fetal distress.
• Fetus beyond 24 weeks gestation.
• Possibility of trauma to the uterus.
• All obstetric major trauma patients should be transferred to the RoyalMelbourne Hospital where they will have urgent obstetric assessment.

Make early contact with ARV for advice from the major trauma services and to initiate retrieval.

• Fetal survival depends on effective maternal resuscitation.
• Maternal position – 1 or 2 handed manual uterine displacement or left tilt 15-30*.
• Maternal hypovolaemia will significantly impact on fetal outcomes.

Make early contact with ARV for advice from the major trauma services and to initiate retrieval.

• Older patients are more vulnerable and less adaptable to physiological changes due to pre-existing health issues.
• A high index of suspicion of injury should be considered even with mild injury mechanism.
• Medications may mask signs of shock.