Abdominal and Pelvic Trauma
238 Surgical Emergencies
5 Operating room thoracotomy
Transfer patients with the following injuries immediately to the operating
theatre for an urgent thoracotomy:
(i) Penetrating cardiac injury.
(ii) Massive haemothorax with >1500 mL initial drainage or
>200 mL/h for 2–4 h.
(iii) Persistent large air leak suggesting tracheobronchial injury.
(iv) Cardiac tamponade following trauma.ABDOMINAL AND PELVIC TRAUMA
Blunt abdominal trauma
DIAGNOSIS
1 This should be suspected in t he following:
(i) Road traffic crash or a fall from a height, particularly if there is
evidence of chest, pelvic or long-bone injury (e.g. injuries on
either side of the abdomen).
(ii) Trauma victims with unexplained hypotension in the absence of
obvious external bleeding or a thoracic injury.
2 Ask about referred shoulder-tip pain or localized pain suggesting lower rib,
pelvic or thoracolumbar spine injury.
3 Look for the imprint of clothing or tyre marks as indicators of potential
intra-abdominal injury.
(i) Bruising from a lap seat belt may be associated with duodenal,
pancreatic or small bowel injury, and/or fracture-dislocation of
the lumbar spine.
4 Examine the chest, as well as the abdomen, pelvic area and perineum includ-
ing genitalia. Consider a vaginal examination when there are signs of local
injury.
5 Log-roll the patient to examine the thoracolumbar spine. Inspect the buttock
area and perform a rectal examination.
6 Insert two large-bore i.v. cannulae and send blood for FBC, U&Es, LFTs,
blood sugar, lipase/amylase, and cross-match at least 4 units of blood.
7 Request initial radiology including chest, pelvis and thoracolumbar spine
X-rays. A plain abdominal film is rarely indicated.
(i) Erect CXR: this may demonstrate a thoracic injury or free gas
under the diaphragm. Look particularly for lower rib fractures
that may be associated with liver, splenic and renal injury.