Life Threatening but Preventable and Treatable Medical Complications of Abdominal Trauma

Abstract

Management of the patient who underwent trauma involves simultaneous interaction buy different physicians and surgeons. The physician, surgeon and anesthesiologist usually form a team, all of whom bring their different perspective and expertise for treatment of the patient. This starts a series of events that culminates in medical evaluation, anesthetic assessment, preoperative assessment, perioperative management and post operative management of the patient as a whole. The evaluation of any trauma patient begins with evaluating the airway, accessing the breathing, and managing the circulation. After deep initial management of the patient either surgical or medical, prognosis of patient depends on follow up monitoring and care, as mortality in such patients is very high due to complications as listed below, whose early diagnosis and management will be discussed in detail in our chapter: inadequate resuscitation; delays in diagnosis and treatment; intra-abdominal sepsis; deep vein thrombosis, pulmonary embolism and thromboembolic events; hematological disorders like anemias, bleeding disorders, thrombocytopenia etc.; cardiac complications like arrhythmias, stress cardiomyopathy etc.; pulmonary and gastrointestinal complications like HAP, paralytic ileus, GERD etc.; metabolic disorders like acidosis, alkalosis, dyselectrolemia etc.; trauma complicated due to pregnancy, addictions and comorbid conditions like DM, HTN etc.

1. Introduction

Abdominal trauma causes multi system disorder with many reasons causing morbidity and mortality. While the primary site of injury is given utmost importance, simultaneous initial resuscitation should be initiated at the earliest. Here in this chapter we try and discuss very common, lethal complications of abdominal trauma which are commonly missed leading to bad outcome. A multidisciplinary team is needed to treat the patient as a whole and therefore need multiple referrals and consultation.

After initial evaluation and management as following a detailed survey needs to be done:-.

• Primary survey: A, B, C, D, E evaluation and stabilization of Airway, Breathing, Circulation, Disability (neurologic status), and Exposure/Environmental control.

• Secondary survey: Head-to-toe examination after initial stabilization.

• Selective use of CT and other imaging studies.

Evaluation and treatment are done simultaneously. Done as A, B, C, D, E, for Airway, Breathing, Circulation, Disability (neurologic status), and Exposure/Environmental control. All major body systems are thoroughly and rapidly examined for any serious injury or abnormalities (known as primary survey); followed by a very detailed examination (known as secondary survey), once the patient is stabilized.

The 10 Commandments for powerful consultation have been pro-posed by using Goldman and associates in 1983 [1]. 1. To determine the question and address the question. 2. To perform the consultation in a timely. 3. To perform a thorough evaluation. 4. Writing a concise and appropriate consultation report. 5. Recommendations needed should be made clear and concise. 6. To provide early and prompt communication. 7. Do not “clear for OR.” Physician should identify all risks and attempt to correct them and optimize the patient for surgery. 8. To provide detailed, routinely and appropriate follow-up. 9. Role should be known appropriately: pure consultant versus co-manager. 10. Provide treatment options and alternative approaches and teach others tactfully.

2. Preoperative assessment of patient

Regular test needed for every patient needs haemogram, liver and function test, urinalysis, sugars, electrocardiography and chest X ray.

3. Antimicrobial prophylaxis

Factors involved in the development of postoperative infections [2] (Table 1):

• Pathogenic bacteria present at operative site in significant numbers.

• Environment of local wound: tissue fluids, blood, necrotic tissue

• Host immune status: age, immunocopromised, diabetes mellitus, obesity and nutrition

• Surgical skills needed and length of procedure.

• Presence of foreign body.

• Type of surgical procedure.

3.1 Non-antimicrobial interventions to decrease surgical site and related infections

• Preoperatively

  • reduce preoperative hospitalization.

  • Treatment of remote sites of infection prior to surgery.

  • Clipping of hair at site preferred, avoid shaving or delay until time of surgery.

  • Appropriate use of antibiotics preoperatively.

  • Correction of malnutrition and deficiencies.

  • Strict diabetes control.

• Intraoperatively/postoperatively

  • Skin preparation done carefully.

  • Rigorous use of aseptic technique.

  • High-flow filtered air or laminar flow use.

  • Reducing dead space.

  • Minimize the use of and duration of catheters and intravenous lines postoperatively.

  • Adequate hydration, oxygenation, and nutrition needs to be maintained postoperatively

3.2 General principles of antibiotic selection and use

See Table 2.

Type of procedure	Definition
Clean	Atraumatic; with no break; gastrointestinal, respiratory, genitourinary tracts not entered
Clean contaminated	Respiratory or gastrointestinal tract are entered but no spillage; entry into oropharynx, sterile genitourinary, or biliary tract; minor break in technique
Contaminated	Acute inflammation present; urine or bile infected; gross spillage; from gastrointestinal tract
Dirty	Established infection

Table 1.

Classification of surgical procedures by degree of contamination and risk of subsequent infection [3].

Nature of operation	Common pathogens	Recommended drugs	Adult dose before surger#
Cardiothoracic (including pacemaker placement)	Staphylococcus aureus, Staphylococcus epidermidis	Cefazolin; Cefuroxime; Vancomycin	1–2 g IV; 1.5 g IV; 1 g IV
Gastrointestinal
Esophageal, gastroduodenal	Enteric gram negative; bacilli, gram-; positive cocci	Cefazolin	1–2 g IV
Biliary tract; (including cholecystectomy)	Enteric gram-negative; Bacilli, enterococci, clostridia	Cefazolin	1–2 g IV
Colorectal (including appendectomy, non-perforated)	Enteric gram-negative; bacilli, anaerobes,; enterococci	Oral: neomycin; plus erythromycin base OR; metronidazole; Parenteral: ertapenem or cefotetan or cefoxitin OR; cefazolin plus; metronidazole$	1 g IV; 1–2 g IV; 1–2 g IV; 1–2 g IV; 0.5–1 g IV
Rupture of viscus	Anaerobes, Enteric gram-negative; bacilli,; enterococci	Ertapenem or; cefoxitin or; cefotetan with or without gentamicin$	1 g IV; 1–2 g IV; 1–2 g IV; 1.5 mg/kg IV q8h
Genitourinary	Enterococci, enteric gram-negative; bacilli	Ciprofloxacin	500 mg PO or 400 mg IV
Gynecologic and; Obstetric trauma	Enteric gram-negative; bacilli, anaerobes,; group B streptococci, enterococci	Cefotetan or; cefoxitin or; cefazolin	1–2 g IV; 1–2 g IV; 1–2 g IV
Abortion and Dilatation and curettage	Enteric gram-negative; bacilli, anaerobes,; group B streptococci, enterococci	First trimester:-; Aqueous penicillin G OR doxycycline; Second trimester: Cefazolin	2 million units IV; 300 mg PO; 1–2 g IV
Vascular; Arterial surgery involving a pros-; thesis, abdominal aorta, or; groin incision	S. aureus,; S. epidermidis, enteric gram-negative bacilli	Cefazolin OR; Vancomycin	1–2 g IV; 1 g IV

Table 2.

Antimicrobial prophylaxis for prevention of specific surgical site infections [4].

^#

Given as single dose within 60 min before operation. For prolonged operations, additional doses may be necessary. If vancomycin or a fluoroquinolone is used, give 60 to 120 min before incision.

^$

Continue for 3 to 5 days post trauma. Need to expand coverage for nosocomial pathogens in postoperative dehiscence.

3.3 Causes of post traumatic and surgical fever

• Non-infectious

  Adrenal insufficiency

  Alcohol withdrawal

  Atelectasis

  Blood (hematoma/CSF)

  Dehydration

  Drug fever (including anesthetics)

  Intravascular device infections

  Malignant hyperthermia

  Myocardial infarction

  Neoplasms, rhabdomyolysis

  Pancreatitis

  Pheochromocytoma

  Pericarditis/Dressler’s syndrome

  Pulmonary embolism

  Thyrotoxicosis

  Tissue trauma

  Transfusion reaction

• Infectious causes

  Abscess

  Bloodstream infections

  Cholecystitis

  Clostridium difficile colitis

  Endocarditis

  Infusion-related infections

  Parotitis, Peritonitis

  Pneumonia

  Prostatitis

  Surgical site infections

  Superficial incisional infection

  Deep incisional/space infection

  Thrombophlebitis

  Transfusion related(CMV, hepatitis)

  Urinary tract infection

4. Patients AT high risk for regurgitation of gastric contents

Regurgitation of gastric contents needs to be prevented in trauma patient at it leads to multiple complications like aspiration pneumonia, ARDS, metabolic disturbances etc.

• Gastric Distention

  • preoperative fasting is inadequate

    1. gastric emptying delayed

    2. Functional

    3. Obesity

    4. Pain

    5. Sepsis

    6. Uremia

    7. Pregnancy

    8. Shock

    9. Stupor/coma

    10. Autonomic neuropathy (e.g., diabetes, Shy-Drager syndrome)

    11. Recent abdominal surgery

  • Drug-induced

    1. Anticholinergics

    2. Opioids

    3. Antiparkinsonian agents

  • Intestinal obstruction/pseudo-obstruction

    1. Alcohol ingestion

• Gastroesophageal Reflux:- drug induced, idiopathic, obesity or pregnancy related, collagen-vascular diseases

• Esophageal Disease like neoplasms, foreign body, webs or strictures

5. Risk factors for venous thromboembolism

• Surgery

• Trauma (major or lower extremity)

• Advanced age

• Obesity

• Central venous catheters

• Heart or respiratory failure

• Immobility, paresis

• Previous deep vein thrombosis or pulmonary embolism

• Varicose veins

• Inflammatory bowel disease

• Pregnancy and the postpartum period

• Estrogen-containing oral contraceptives or hormone replacement therapy, Selective estrogen-receptor modulators

• Myeloproliferative disorders, Paroxysmal nocturnal hemoglobinuria

• Smoking

• Malignant disease

• Cancer therapy (hormonal therapy, chemotherapy, or radiotherapy)

• Nephrotic syndrome

• Inherited or acquired thrombophilia

5.1 Prophylaxis for thromboembolisim

• Heparin prophylaxis

  • 5000 U subcutaneously administered 2 h before surgery.

  • 5000 U subcutaneously administered, q8h or q12h postoperatively.

This regimen is followed until the patient is discharged.

• Low-molecular-weight heparin prophlaxis

  Dalteparin: 5000 U subcutaneously administered, q24h (to be initiated on evening of surgery).

  Fondaparinux: 2.5 mg, subcutaneously administered, started 6 h after surgery followed by once daily.

  Enoxaparin: 40 mg subcutaneously administered, q24 hourly (to be initiated on evening of surgery). 30 mg administered subcutaneously q24h, if creatinine clearance of less than 30 mL/min [5].

• WARFARIN PROPHYLAXIS

1. 10 mg by mouth the evening before surgery.

   5 mg by mouth the evening of surgery

   Adjust dose daily based on an INR of 2 to 3.

   Maintain warfarin until discharge.

2. 10 mg by mouth the evening of surgery.

   No warfarin on postoperative day 1

   On postoperative day 2, begin warfarin to adjust INR to 2 to 3

   Maintain warfarin until discharge

We recommend the following regimen for prophylaxis post surgery for abdominal trauma:-

• Low-risk surgery including minor procedure, no risk factors for VTE, age > 40 years:- ambulation initiated at the earliest postoperatively.

• Moderate-risk surgery including non major procedure, age >60 years with no VTE risk factors, age 40–60 years with VTE risk factors or major procedure.

  Treatment:- Heparin: 5000 U, SC, q12 hourly.

  Enoxaparin: 40 mg, SC, started 12 h postoperatively, followed by 40 mg, SC, q24 hourly.

  Dalteparin: 5000 IU, SC, started 12 h postoperatively, followed by 5000 IU, SC, q24 hourly

• High-risk surgery including non major surgery with age > 60 yr.; VTE risk factors; major surgery, age > 40 yr., or presence of VTE risk factors

  Treatment:-Heparin: 5000 U q8 hourly.

  Enoxaparin: 40 mg, SC, started 12 hourly postoperatively, followed by 40 mg, SC, q24 hourly.

  Dalteparin: 2500 IU, SC, 1–2 h preoperatively then 2500 IU, SC, 12 h postoperatively, followed by 5000 IU, SC, q24 hourly

• Very high-risk surgery including major surgery, multiple VTE risk factors present or age >60 years

  Treatment: External pneumatic compression with anticoagulant therapy including;- Heparin: 5000 U, SC, q8 hourly.

  Enoxaparin: 40 mg, SC, started 12 hours postoperatively, then 40 mg, SC, q24 hourly.

  Dalteparin: 5000 IU, SC, started 12 h postoperatively, followed by 5000 IU, SC, q24 hourly [6].

6. Evaluation of heamatological disorders

Internal bleeding is a major complication of both blunt and penetrating trauma. Signs and symptoms are Abdominal pain, distension of abdomen and these symptoms get worse as the bleeding continues. Light-headedness, fainting can cause hypotension and hypovolemic shock. A large area of skin can get deep purple stained known as ecchymosis caused as a result from bleeding into the skin or soft tissues [7] (Figures 1 and 2).

Figure 1.

Diagnostic evaluation of anemia. MCV, mean corpuscular.

Figure 2.

Evaluation of erythrocytosis.

6.1 Indications for phlebotomy in erythrocytosis

• Relative erythrocytosis: Not indicated.

• Stress erythrocytosis: Not indicated.

• Appropriate erythrocytosis resulting from cardiopulmonary disease: To hematocrit 50–60%.

• Inappropriate primary erythrocytosis (polycythemia vera): To hematocrit <45%.

• Inappropriate secondary erythrocytosis: To hematocrit <50%.

Other common hematological disorders needing attention:- sickle cell anemia, leukcopenia, nutritional deficiencies, bone marrow suppression, thalassemia, chronic renal failure, hemolytic anemias etc.

Figure 3.

Coagulation scheme with anticoagulant mechanisms. FSP:- fibrin split products; PT:-prothrombin time; PTT:- partial thromboplastin time; tPA:- tissue plasminogen activator.

6.2 Steps of homeostasis

Injury to vessel wall ➔ primary vasoconstriction ➔ interaction of von Willebrand protein with sub endothelium ➔ formation of platelet plug ➔ fibrin formation ➔ clot dissolution and endothelial regeneration (Figure 3).

Assessment of homeostasis: careful history, bleeding time, prothrombin time, APTT, PT-INR, platelet count (Table 3).

Pathophysiology	Causes	Significant findings
Production decreased	Aplastic anemia	leukopenia, anemia, abnormal bone marrow, Folate deficiency abnormal, vitamin B12 low, radiotherapy or chemotherapy
Sequestration	hypersplenisim	Splenomegaly, hypercellular bone marrow, anemia, leukopenia, normal smear
Destruction increased	Idiopathic thrombocytopenic; purpura, acquired immunodeficiency; syndrome, drug induced, systemic; lupus erythematosus	Hematocrit,white blood cell count are usually normal with; normal smear, megakaryocytic hyperplasia

Table 3.

Causes of thrombocytopenia: which needed to be treated according to cause after abdominal trauma for optimal homeostasis.

Differential diagnosis for deranged coagulation test

• Prolonged bleeding time: Thrombocytopenia, von Willebrand disease, platelet function defect,

• Prolonged PT: liver disease, vitamin K deficiency, factor VII deficiency, warfarin use

• Prolonged PTT: Factor XII, XI, IX, or VIII deficiency, von Willebrand disease, heparin induced, DIC.

• Prolonged PT and PTT: Vitamin K deficiency, DIC, warfarin induced.

After diagnosis of bleeding disorder the treatment should be initiated accordingly with platelet or fresh frozen plasma infusions, corticosteroids, anti D etc [8].

7. Assessment of respiratory pathologies

See Figures 4 and 5.

Figure 4.

Pathophysiology of the events leading to postoperative pulmonary complications. V/Q, ventilation/perfusion.

Figure 5.

Pathogenesis of major post traumatic pulmonary complications.

7.1 Risk factors for post traumatic pulmonary complications

See Table 4.

Patient-related	Procedure-related
General health and nutritional status Age Low albumin >Functional status Weight loss >10% ASA Class Goldman class Respiratory status COPD history Tobacco use Sputum production Pneumonia Dyspnea OSA Neurological status Impaired sensorium CVA history Fluid status CHF history Renal failure Low or high BUN Preoperative blood transfusion Immune status Chronic steroid use Alcohol use	Incision near diaphragm Thoracic surgery Upper abdominal surgery AAA repair Surgery technique Open vs. laparoscopic Anesthesia duration >2 h Use of spinal/epidural anesthesia vs. general anesthesia Use of long-acting neuromuscular blockade (pancuronium) Pain control with parenteral narcotics vs. epidural analgesia Postoperative Nasogastric tube placement

Table 4.

Risk factors for post traumatic pulmonary complication.

7.2 Causes of post traumatic pleural effusions

A) Transudate:-

• Congestive heart failure

• Hypervolemia

• Ascites

• Misplaced central venous catheter

• Pulmonary embolism (rarely)

• Postpericardiotomy syndrome

• Diaphragmatic contusion

B) Exudate:-

• Pneumonia

• Pulmonary embolism

• Subphrenic abscess

• Empyema

• Atelectasis

8. Assessment of cardiovascular diseaes

8.1 Clinical predictors of increased perioperative cardiovascular risk (myocardial infarction, congestive heart failure, death)

• Major [9]

  • Unstable coronary syndromes

  • Acute MI (documented MI less than 7 days previously)

  • Recent (greater than 7 days but less than or equal to 30 days).

  • Significant arrhythmias

  • myocardial infarction with evidence of important ischemic risk by clinical symptoms or non-invasive study

  • Severe valvular disease

  • Unstable or severe angina (Canadian class III or IV)

  • High grade atrioventricular block

  • Symptomatic ventricular arrhythmias in the presence of underlying heart disease

  • Decompensated congestive heart failure

  • Supraventricular arrhythmias with uncontrolled ventricular rate

• Intermediate

  • Previous myocardial infarction by history or pathologic Q waves

  • Mild angina pectoris (Canadian class I or II)

  • congestive heart failure

  • Renal insufficiency (serum Cr > 2.0 mg/dl)

  • Diabetes mellitus

• Minor

  • Abnormal electrocardiogram (left ventricular hypertrophy, left bundle branch block, ST–T abnormalities)

  • Low functional capacity like inability to climb one flight of stairs

  • Rhythm other than sinus (e.g., atrial fibrillation)

  • Advanced age

  • History of cerebrovascular accident

  • Uncontrolled systemic hypertension

8.2 Arrhythmias and conduction abnormalities

• Perioperative risk factors for arrythmia:

  • male sex

  • age 70 years or older

  • significant valvular disease

  • history of supraventricular arrhythmia, asthma, congestive heart failure

  • premature atrial complexes on preoperative electrocardiography

• Common arrhythmias in abdominal trauma patients

  • Sinus tachycardia:- Sinus tachycardia is a rhythm abnormality, usually benign. Heart rate is between 100 and 160 beats/min, regular rhythm with a normal P wave before each QRS complex.

  • Reflex bradycardia.

  • Atrial premature contractions, atrial flutter and fibrillation.

  • Paroxysmal supraventricular tachycardia:- characterized by the sudden onset of a rapid regular rhythm with rates between 150 and 250 beats/min.

  • Multifocal atrial tachycardia (MAT):- is an automatic arrhythmia characterized by an atrial rate greater than 100 beats/min with organized, discrete, non-sinus P-waves with at least three different forms in the same electrocardiographic lead.

  • Ventricular premature contractions and non-sustained ventricular tachycardia.

  • Sustained ventricular tachycardia and ventricular Fibrillation.

  • Long QT syndrome:- is a heterogeneous group of disorders characterized by a prolonged QT interval when corrected for heart rate, malignant ventricular arrhythmias (classically the torsades de pointes form of ventricular tachycardia), and the risk of sudden death. Causes:- Antiarrhythmic drugs (Type IA agents (e.g., quinidine), Type III agents (Amiodarone), Tricyclic antidepressants, antibiotics (e.g., erythromycin, azithromycin, ketoconazole), Metabolic and electrolyte disorders (Hypokalemia, Hypomagnesemia), Nutritional disorders (starvation, liquid protein diets), Subarachnoid hemorrhage, Intracerebral hemorrhage, Head trauma, Encephalitis.

8.3 Indications for implantation of cardiac pacemakers

• Third-degree or advanced second-degree AV block associated with symptomatic bradycardia [10]

• Second-degree AV block with symptomatic bradycardia, bifascicular block with intermittent complete heart block with symptomatic bradycardia or symptomatic bifascicular block with intermittent type II block

• Second-degree AV block with sinus node dysfunction and symptomatic bradycardia

• After acute myocardial infarction with persistent second-degree AV block, bilateral bundle–branch block or third-degree AV block.

• Symptomatic and persistent second- or third-degree AV block.

8.4 Endocarditis prophylactic regimens for gastrointestinal injury surgery in abdominal trauma patient

Bacterial endocarditis prophylaxis is indicated for patients with specific cardiac structural abnormalities who are at risk for bacteremia resulting from the disruption of mucosal surfaces colonized with bacteria [11] (Table 5).

Situation	Agent	Regimen
High-risk patients	Ampicillin and gentamicin	Adults: ampicillin 2gms intravenous or intramuscular and gentamicin 1.5 mg/kg; (maximum dose 120 mg) 1st dose administered within 30 mints of initiation of; Procedure followed 6 h later, ampicillin 1 g intravenous or intramuscular or oral amoxicillin; 1 gms.; Children: ampicillin 50 mg/kg intravenous or intramuscular (maximum dose 2gms); and gentamicin 1.5 mg/kg, 1st dose administered within 30 mints of initiation of; procedure followed 6 h later with ampicillin 25 mg/kg intramuscular r intravenous or oral; amoxicillin 25 mg/kg
High-risk patients with allergy to penicillin group	Vancomycin and gentamicin	Adults: vancomycin 1gm intravenous over 1–2 h with gentamicin; 1.5 mg/kg, intravenous or intramuscular (maximum dose 120 mg),; injection/infusion completed within 30 min of initiation of surgery; Children: vancomycin 20 mg/kg, intravenous over 1–2 h with; gentamicin 1.5 mg/kg, intravenous or intramuscular, injection/; infusion completed within 30 min of initiation of surgery
Moderate risk patient	Amoxicillin/ ampicillin	Adults: Oral amoxicillin 2gms, 1 h before sugery, or; ampicillin 2gms intravenous or intramuscular, to be given with 30 min of initiation of surgery; Children: Oral amoxicillin 50 mg/kg, given 1 h before surgery,; or ampicillin 50 mg/kg intravenous or intramuscular, within 30 min of initiation of surgery
Moderate-risk with allergy; to penicillin group	vancomycin	Adults: vancomycin 1gm, intravenous, infused over 1–2 h,; within 30 min of surgery initiation; Children: vancomycin 20 mg/kg, intravenous, infusion completed over 1–2 h of 30 min of surgery initiation.

Table 5.

Antibiotic prophylaxis for prevention of bacterial endocarditis in trauma patients.

9. Assessment of gastrontestinal diseases

9.1 Factors that contribute to prolonged postoperative ileus

• Underlying medical conditions

  • Sepsis

  • Collagen vascular diseases

  • Amyloidosis

  • Diabetes mellitus

  • Thyroid disease

  • Peritonitis

  • Ischemic bowel disease

  • Electrolyte disturbances (e.g., hypokalemia)

• Intraoperative bowel manipulation

  • Open surgical procedure

  • Type of anesthesia

• Drugs

  • Opiates (e.g., morphine, codeine)

  • Opioids (e.g., fentanyl, pethidine, tramadol)

  • Nonsteroidal anti-inflammatory drugs (e.g., diclofenac, naproxen)

  • Phenytoin

  • Anticholinergic agents (e.g., trihexyphenidyl, benztropine, amantadine)

9.2 Factors that contribute to colonic PSEUDO-obstruction

• Age

• Alcoholism

• Drugs

  • Narcotics

  • Antidepressants

  • Anticholinergics

  • Clonidine

  • Phenothiazines

• Metabolic causes

• Electrolyte imbalance

• Acid–base disturbances

• Hypothyroidism

• Diabetes mellitus

• Uremia

• Sepsis

• Inflammatory processes (e.g., pancreatitis and cholecy stitis)

• Infection

• Respiratory failure

9.3 Factors contributing to post- trauma nausea, vomiting

• Length of anesthesia

• Type of trauma (abdominal, gynecologic, urologic etc)

• Female

• Drugs

  • General anesthetics

  • Opiate analgesics

  • Digitalis

• Postoperative ileus or pain

• Gastroparesis

• Refeeding after prolonged disuse of gastrointestinal tract

• Inflammatory processes

  • Peritonitis

  • Acute pancreatitis or cholecystitis

• Metabolic factors

  • Uremia

  • Hyperglycemia/hypoglycemia

• Electrolyte disturbances

• Dehydration

• Mechanical causes

  • Gastric outlet obstruction

  • Intestinal obstruction

Other complications which are common post trauma are gastrointestinal bleeding, gastric and stress ulcers, diarrhea, esophagitis, ischaemic collitis, pseudomembrane collitis, Mesenteric Ischemia and Infarction, Colonic Diverticulosis and angiodysplasia, intra abdominal hemorrhage [12].

9.4 Causes of post traumatic jaundice

See Table 6.

Increased hepatic bilirubin load	Intrahepatic parenchymal disease
Hemolysis after Transfusions; Haematoma Underlying hemolytic anemia	Drugs Antibiotics Amoxicillin-clavulanic acid Penicillins Rifampin Chloramphenicol Sulfonamides Erythromycins Tetracycline Isoniazid Nitrofurantoin Anesthetic drugs
Pre existing liver disease; Gilbert’s syndrome(Unconjugated hyperbilirubinemia resulting from a congenital defect in the; hepatic uptake of bilirubi); Dubin-Johnson syndrome(Conjugated hyperbilirubinemia resulting from a congenital defect in secretion; of bilirubin from hepatocytes)	Other drugs Androgens, estrogens Phenothiazines Phenytoin Fluconazole Methyldopa
Extrahepatic Obstruction; Common bile duct stone Cholecystitis Pancreatitis Biliary stricture, leak, or tumor	Other Causes Parenteral nutrition; Viral hepatitis; Sepsis; Ischemic hepatitis

Table 6.

Post traumatic jaundice causes.

9.5 Local complications of abdominal trauma

Early Late

Wound infection Ulcer recurrence

Anastomotic leak Recurrent bleeding from ulcer

Bile duct injury Gastric outlet obstruction

Delayed gastric emptying Afferent loop syndrome

Anastomotic bleeding Dumping syndrome

Anemia Malabsorption

Bile reflux gastritis

Postvagotomy diarrhea

Osteomalacia and osteoporosis

Post-gastrectomy carcinoma

Pancreatitis

10. Assessment of renal disoders, electrolyte imbalance

10.1 Causes of perioperative renal failure

• Decreased renal perfusion

  • Intravascular volume depletion

  • Congestive heart failure

  • Sepsis

  • Cardiopulmonary bypass

  • Anesthetic effects on renal blood flow

  • Aortic cross-clamping

  • Use of non-steroidal anti-inflammatory drugs or cycloxygenase inhibitors

  • Use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers

• Nephrotoxin exposure

  • Aminoglycosides

  • Radiocontrast agents

  • Anesthetic agents

  • Myoglobin/rhabdomyolysis

10.2 Indications for acute dialysis

• Symptoms and signs associated with uremia in patients with creatinine clearance <20–25 ml/min per 1.73 m² [13].

• Nausea, vomiting, anorexia.

• Other gastrointestinal symptoms (gastritis with hemorrhage, colitis with or without hemorrhage).

• Altered mental status (lethargy, somnolence, malaise, stupor, coma, or delirium).

• Signs of uremic encephalopathy (asterixis, multifocal clonus, or seizures).

• Pericariditis.

• Bleeding diathesis from uremic platelet dysfunction.

• Refractory or progressive fluid overload.

• Uncontrolled hyperkalemia.

• Severe metabolic acidosis, especially in an oliguric patient.

• Acute and progressive worsening of renal function with.

• Blood urea nitrogen levels >70–100 mg/dl.

• Measured creatinine clearance <15–20 ml/min.

10.3 Causes of peritraumatic hyperkalemia

Hyperkalemia is very commonly associated with trauma reason of which are enlisted below (Table 7).

Mechanisim	Causes
Increased potassium load	Increased catabolism Blood transfusion Reabsorption of hematoma Tissue breakdown Red blood cell salvage Potassium administration
Impaired transcellular; potassium shift	Fasting state (insulinopenia) Beta blockers
Decreased potassium; excretion	Volume depletion Constipation Medications:-Trimethoprim-sulfamethoxazole, Potassium sparing diuretics, Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers

Table 7.

Hyperkalemia in trauma patient—causes.

11. Assessment of other disorders and abdominal injury

11.1 Management of adrenal insufficiency

• Inquire about any preoperative use of glucocorticoids (systemic or inhaled) and symptoms suggestive of adrenal insufficiency.

• Administer hydrocortisone 100 mg intravenously q 8 h. Give first dose at least 1 h before induction of anesthesia.

• Once the patient is stable after operation, taper the hydrocortisone dose over 3–4 days to maintenance levels (30 mg/d in at least two divided doses) or to the patient’s preoperative dose of glucocorticoid.

• Prevent volume depletion and hypoglycemia with the use of intravenous saline and glucose.

11.2 Approach to the delirious postoperative patient

• Detection is key; maintain high index of suspicion, especially for quiet, hypoactive delirious states. Consider bedside tests of memory and orientation or administration of more formal instruments such as Confusion Assessment Method (CAM).

• Review all medications, including those that the patient may have been taking prior to hospitalization. Remember that several common medications have significant anticholinergic effects.

• Focused physical examination to detect infection, comorbid conditions causing hypoxia and pain due to injury. Assess volume status and rule out fecal impaction and urinary retention. Neurological examination to detect new, focal deficits.

• Further laboratory evaluation, as clinically appropriate may include complete blood count, serum electrolytes, pulse oximetry/arterial blood gas analysis and urinalysis. Consider chest X-ray to rule out pneumonia.

• Management strategies include environmental modifications, supportive measures and pharmacological treatment [14].

Risk factor for developing delirium in trauma patient:

• Age

• Preexisting central nervous system disease (e.g., dementia, Parkinson disease)

• Type and duration of surgery

• Sensory impairment (e.g., visual and hearing deficits)

• Hypoxia

• Metabolic derangements (e.g., hyponatremia, hyperglycemia, acid–base disorders, etc.)

• Infections

• Uncontrolled pain

• Chronic alcoholism

• Benzodiazepine dependence

11.3 Delayed consequences of abdominal trauma

• Rupture of hematoma

• Intra-abdominal abscess

• Obstruction or ileus of bowel

• Biliary leakage and/or biloma

• Abdominal compartment syndrome

• Delayed incisional hernia

  • Hematomas usually resolve spontaneously over time, depending on the size and location. Splenic hematomas or hepatic hematomas may rupture, causing significant delayed hemorrhage. Intestinal wall hematomas may perforate, typically within 48 to 72 h after injury, releasing intestinal contents and causing peritonitis, but without causing significant hemorrhage. Intestinal wall hematoma can cause intestinal stricture, typically months to years later.

  • Intra-abdominal abscess is the result of undetected hollow viscus perforation but may be a complication of laparotomy.

  • Bowel obstruction may develop after injury due to intestinal wall hematoma or adhesions caused by intestinal serosal or mesenteric tears. More commonly bowel obstruction is a complication of exploratory laparotomy.

  • Liver injury or bile duct injury can be lead to biliary leakage or biloma. Biliary leakage cause a systemic inflammatory response, severe pain or hyperbilirubinemia.

  • Abdominal compartment syndrome is similar to extremity compartment syndrome. Mesenteric and intestinal capillary leakage caused by prolonged abdominal surgical procedures, shock, systemic inflammatory response syndrome [SIRS] or systemic ischemia–reperfusion injury causing abdominal tissue edema. Peritoneal edema and ascites, increases intra-abdominal pressure (that is pressure more than 20 mm Hg), leading to pain, dysfunction of organs due to ischemia. A vicious cycle is formed where intestinal ischemia further causes edema .

  • Other affected organs dysfunction including renal insufficiency, elevated abdominal pressure interfering with respiration further causing hypoxemia or hypercarbia, decreased venous return from the lower extremities leading to hypotension, intracranial pressure increases due to increased central venous pressure, inadequate venous drainage from brain, decreased cerebral perfusion, worsening intracranial injuries.

Abdominal compartment syndrome occurs when there is vascular leak and high-volume fluid resuscitation usually more than 10 l. Develops after severe abdominal injury accompanied by shock, severe burns, sepsis, and pancreatitis also.

11.4 Spleenic injury

See Table 8.

Grades	Injury
1	Subcapsular hematoma involving less than 10% of surface area or laceration less than1 cm.
2	Subcapsular hematoma involving 10–50% of surface area, intraparenchymal hematoma less than 5 cm n size or laceration 1–3 cm deep sparing the trabecular vessel
3	Subcapsular hematoma involving more than 50% of surface area, intraparenchymal hematoma more than or equal to 5 cm in size, ruptured or expanding hematoma or laceration more than 3 cm deep or involvement of a trabecular vessel
4	Laceration involving segmental or hilar vessels which devascularizes more than 25% of spleen
5	Completely shattered spleen; Hilar vascular injury that devascularizes spleen

Table 8.

Grade of splenic injury.

The diagnosis is made with CT scan, followed by observation, angio-embolization, surgical repair or splenectomy.

11.5 Hepatic injury

See Table 9.

Grade	Injury
1	Subcapsular hematoma involving less than 10% of surface or laceration less than 1 cm.
2	Subcapsular hematoma involving 10–50% of surface area, intra-parenchymal hematoma less than 10 cm in size or laceration 1–3 cm deep and less than 10 cm in size
3	Subcapsular hematoma involving more than 50% of surface area, intra-parenchymal hematoma more than 10 cm size or ruptured or expanding hematoma or laceration more than 3 cm deep
4	Parenchymal disruption involving 25–75% of a hepatic lobe or 1–3 Couinaud segments within a single lobe
5	Parenchymal disruption involving more than 75% of one hepatic lobe or more than 3 Couinaud segments or juxtahepatic venous injuries present involving retrohepatic vena cava or central major hepatic veins
6	Hepatic avulsion

Table 9.

Grades of hepatic injury.

Diagnosis confirmed with CT scan followed by observation and surgical intervention [15].

11.6 Renal injury

• Renal injuries can be classified into severity of following 5 grades:

  • Grade 1: Subcapsular hematoma with or without renal contusion.

  • Grade 2: Laceration less than or equal to 1 cm in depth without any urinary extravasation.

  • Grade 3: Laceration more than 1 cm without urinary extravasation.

  • Grade 4: Laceration which involve collecting system with extravasation of urine; renal vascular injury of any segment; renal infarction; renal pelvis laceration with or without disruption of ureteropelvic.

  • Grade 5: Shattering or devascularization of kidney with active bleeding; main renal vascular avulsion or laceration.

• High-grade renal injury (significant deceleration injury, direct blow to flanks) is suspected if after blunt trauma any of the following occur;

  • Gross hematuria.

  • Microscopic hematuria with hypotension (systolic pressure < 90 mmHg).

  • Diffuse abdominal tenderness.

  • Vertebral transverse process or rib fractures [15].

• Diagnosis confirmed with clinical evaluation, CT scan, urinalysis. Treatment involves strict bed rest with close monitoring of vitals, surgical repair, angiographic intervention.

11.7 Urogenital organs

Bladder, testicular, urethral and uretral injury are common with abdominal trauma, need to be confirmed with ultrasonography, retrograde urethrography and CT scan, followed by surgical intervention and correction.

12. Discussion

The abdomen is one of the most common organs to be injured in any form of trauma. The initial resuscitation, primary and second survey, followed by FAST (focused assessment with sonography in trauma) can detect injuries. During follow up treatment detailed blood investigatins, ultasonography, CT scan of abdomen and others can detect injury of liver, spleen, pancreas, bowel alongwith common complications like intra abdominal bleeding, perforations, peritonitis etc. which can be managed surgically with laparotomy or non surgically. Also common medical conditions like uncontrolled sugars, blood pressures, rheumatological, asthma and other chronic disorders are very paticularly considered and corrected by the team of treating physicians. However, this chapter discusses the complications which very commonly occur in post trauma patients but are missed,as the main focus of treatment is limited around the trauma injury itself. In regular planned surgeries proper and stringent pre operative check up is done, optimization of patient is done, followed with srict antiseptic technique, but in trauma patient where time is the key to save the patients life these actions are often missed with lack of time to optimize the patient medically for a surgery. Sepis commonly occurs in trauma patients mostly due to primary contamination of the trauma site, but also laxity in following of antiseptic conditions, which can easily be avoided by antibiotic prophylaxis, interventions to reduce surgical site infetions as mentioned, classification of the wound, early recognition of post operative causes of fever and treatment intiation accordingly. In abdominal trauma,patient’s fasting status is not known and measures to prevent gastic content aspiration should be taken which may otherwise later lead to aspiration pneumonia, sepsis, etc. These patients are usually on bed rest for prolonged periods post trauma increasing the risk of venous thromboembolic events like pulmonary embolisim, strokes etc., which can be prevented with early mobilization, physiotherapy and adequate anticoagulation therapy. The dilemma of producing bleeds in trauma patients with anticoagulations can very well be avoided with strict monitoring and proper dosing as discussed in the chapter. Intra abdominal bleeds and hemorrhagic shock are diagnosed and treated with blood transfusions, intravenous fluids, vasopressors as and when needed, but other hematological complications like anemia, platelet disorders, coagulation disorder, erythrocytosis need attention and treatment. Assessment and attaining homeostasis helps in early recovery of wound and patient. Post traumatic lung complications are mentioned which need to be addressed as mentioned,as they can lead to prolonged need of ventilatory support and delayed healing. Cardiac abnormalities like arrhythmias and endocarditis are common in trauma patient and can lead to mortality. Acute renal injury due to pre renal and renal causes with elctrolyte imbalances can lead to early and fast deterioration of patient. Delirium in post traumatic patients is not uncommon and had multiple reasons, most of which if diagnosed timely can be treated completely, preventing any psychological sequelae. We attempt to discuss and bring into light the missed complications of abdominal trauma, so as to keep these in mind during treating an abdominal trauma patient, as the eyes see what the mind knows. The conditions mentioned above can easily be treated, significantly reducing mortality and morbidity, giving good quality of life to patient post recovery. However, treatment for each of these is beyond the scope of the chapter.

13. Conclusion

Abdominal trauma is the third organ system affected in trauma [16]. It is either blunt abdominal or penetrating abdominal trauma. While there are multiple modalities to diagnose with FAST, and other hidden trauma along with common complications. The chapter tries to cover the rare and very commonly missed complications of abdominal trauma, which are of utmost importance and can be easily diagnosed. We discuss complications like sepsis, gastric content regurgitation, ileus and obstruction, venous thrombo-embolisim, bleeding causing hemorrhagic shock, hematological complications, cardiovascular disorders like arrhythmias, endocarditis, renal and electrolyte disorders, dehydration, delirium, solid organ injuries. These in particular are addressed as these are ignored and lead to late mortality even after primary stabilization and hemodynamic correction. Timely treatment of these conditions leads to a good prognosis, significantly reducing morbidity and mortality associated with missed diagnosis of above mentioned complications. Thus, at the end we would like to conclude that treating a trauma patient as a whole is more important than just the injury.