Principles of Critical Care > Part X. The Surgical Patient > Chapter 95. Torso Trauma Jameel Ali

Specific Abdominal Injuries—Diagnosis and Management Principles

"Although the nonsurgeon intensivist does not need detailed knowledge of the surgical management of specific intraabdominal injuries, some familiarity with the diagnostic and management principles to be applied in the surgical treatment of specific intraabdominal organ injuries is likely to improve the confidence with which these patients are managed in the ICU.The diagnosis of stomach injury is suggested by epigastric pain and pain at the shoulder tip if there is free perforation. Usually there is very minimal hemorrhage, and the patient's hemodynamic status is not particularly affected. Upright chest x-ray reveals free air under the diaphragm. The diagnosis also may be suggested by bloody aspirate from the nasogastric tube.In most instances, once the peritoneal blood has been aspirated, a nonbleeding hepatic laceration is identified. Such lacerations require drainage and no further surgical exploration. If hepatic bleeding is still active at the time of laparotomy, then the initial maneuver is to pack the liver area very tightly with dry gauze and continue with the remainder of the laparotomy for approximately 15 minutes. This allows time for stabilization of the patient's hemodynamic status, as well as time for replacement of fluid deficits. If, on removal of the pack, the bleeding has stopped, as is frequently the case, then the treatment is drainage of the perihepatic space. Failure to control bleeding by this technique necessitates clamping the portal triad, examining the wounds to determine the source of hemorrhage, and direct suture ligation of the..."