Management of abdominal injury

The capability to utilize basic physical examination to assess an injured patient for the possibility of intra-abdominal injury requiring surgical treatment is deemed essential at all levels of the health care system. Also needed are the skills and equipment (BP cuff and stethoscope) to assess the patient for shock.

Such physical examination needs supplementation with ancillary diagnostic tests in equivocal cases and when the patient's abdominal examination is unreliable due to altered mental status. This is usually fulfilled by diagnostic peritoneal lavage (DPL), ultrasound or CT scan. The capability to perform DPL implies provision of the fluid and the inexpensive equipment involved, as well as the skills needed to perform the procedure safely. Such capability is deemed essential at hospitals at specialist and tertiary care levels. It is desirable at the GP-level hospital. This is especially the case for those GP-level hospitals with high trauma volumes. The need to assure adequate and safe performance of the procedure will often mandate continuing education and periodic practice, especially in circumstances of low trauma volumes, where the procedure is only infrequently utilized.The cost of this prevents DPL from being considered essential at all GP-level hospitals. In many countries, abdominal tap (without lavage) is the principal ancillary test used for abdominal evaluation. It is reasonable to continue this, especially in circumstances where the practitioner (usually a GP) is unskilled in the safe performance of DPL; where facilities are very basic and hence where a DPL would constitute an operating theatre case, with consequent delays; and where capabilities for urgent referral are limited. In such cases, knowledge of the limitations of abdominal tap without lavage is a necessary component of the skills needed to perform the procedure. It must be recognized that the DPL is a more sensitive test and is preferable if expertise and facilities permit it to be performed safely and efficiently. It must also be recognized that the degree to which abdominal tap (without lavage) increases the ability to detect haemoperitoneum, above and beyond physical examination alone, has not been well determined.

Ultrasound (US) shows considerable promise in the diagnosis of haemoperi-toneum. It is deemed desirable at all hospital levels. However, its cost prevents it from being considered essential. When utilized, it should be recognized that the skills needed to perform US examination for haemoperitoneum are different and somewhat more advanced than those needed to perform basic obstetric evaluation, which is available in many low- and middle-income environments. When designated essential for the evaluation of abdominal trauma in a national plan, the following need to be assured: 24-hour availability of the equipment (which implies timely repair of any malfunctioning equipment); 24-hour availability of staff skilled in the performance of the procedure; and ongoing monitoring of the accuracy of the results of the scans.

CT scanning adds some utility in the evaluation of the injured abdomen, especially as regards the retroperitoneal structures. It is desirable at the upper two hospital levels. Its cost prevents it from being deemed essential. When designated essential for the evaluation of abdominal trauma in a national plan, the same caveats apply as for the use of CT for head trauma: prompt availability without regard to ability to pay; maintenance and timely repair; and quality assurance monitoring.

The capability to perform a trauma laparotomy and to deal with the wide range of potential injuries to the intraperitoneal and retroperitoneal structures is one of the mainstays of definitive care of the seriously injured patient and is deemed essential for the specialist and tertiary care hospitals. This is primarily wherever fully trained general surgeons are available. As with neurosurgical and thoracic trauma operations, abdominal trauma operations can be roughly categorized into intermediate and advanced. Intermediate implies procedures such as exploration, recognition of injured structures, haemostasis through packing, splenectomy, hepatic packing and suturing, repair of perforated bowel, and bowel resection and anastomosis. Advanced implies procedures in the retroperitoneum, hepatic resection and other more difficult procedures.

The capability to perform intermediate trauma laparotomy is possibly required at GP hospitals. This is especially the case in rural, low-income settings, where general practitioners are called upon to perform a wide range of basic- to intemediate-level abdominal surgical procedures, such as Caesarean section, salpingectomy for ruptured ectopic pregnancy, plication of typhoid ileal perforation, and bowel resection for strangulated hernia. In such circumstances, trauma-related procedures that are often required include those intermediate-level procedures listed above. In some circumstances, they may include damage-control laparotomy prior to transfer to higher-level hospitals. Whenever GPs are called upon to perform aspects of trauma laparotomy, the skills needed to perform such

TABLE l Abdominal injury

Facility level

Resources

Basic

GP

Specialist

Tertiary

Clinical assessment

E

E

E

E

Diagnostic peritoneal lavage (DPL)

I

D

E

E

Ultrasonography

I

D

D

D

CT1 scan

I

I

D

D

Skills and equipment for intermediate laparotomy

I

PR

E

E

Skills and equipment for advanced laparotomy

I

I

E

E

1 CT: Computerized axial tomography.

1 CT: Computerized axial tomography.

procedures effectively and safely should be assured during basic medical school education and by continuing education courses.

At whatever facility trauma laparotomy of either intermediate or advanced level is performed on a routine basis, the quality of the procedures should be monitored and assured by some form of quality improvement programme. This would look at such aspects of care as missed injuries, delays in performance of emergency laparotomy and reoperation rates.

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