What is the management of abdominal trauma in zones 1-3 (abdominal zones, divided into 3 areas for trauma assessment)?

From the Guidelines

The management of abdominal trauma in zones 1-3 should prioritize a systematic approach based on the patient's hemodynamic status and injury pattern, with non-operative management (NOM) being the treatment of choice for hemodynamically stable patients and operative management (OM) for unstable patients, as recommended by the WSES 2020 guidelines 1. The approach to managing abdominal trauma in zones 1-3 involves several key considerations, including:

• Diagnostic methods, such as E-FAST and CT scan with intravenous contrast, which are determined by the hemodynamic status of the patient 1
• The use of NOM for hemodynamically stable minor, moderate, and severe injuries in the absence of other internal injuries requiring surgery, with the caveat that NOM should be considered only in selected settings for transient responders with moderate to severe injuries 1
• The role of OM for hemodynamically unstable and non-responder patients, with primary surgical intention being to control hemorrhage and bile leak and initiate damage control resuscitation as soon as possible 1
• The potential use of angioembolization as a useful tool in case of persistent arterial bleeding after non-hemostatic or damage control procedures 1
• The importance of early mobilization and enteral feeding in stable patients, as well as the consideration of mechanical prophylaxis and LMWH-based prophylaxis for thrombo-prophylaxis 1 Key principles of management include:
• A focus on damage control resuscitation with balanced blood products, limited crystalloid use, and correction of coagulopathy, acidosis, and hypothermia
• The use of temporary abdominal closure techniques for damage control surgery
• The consideration of interventional radiology for selected injuries, such as angioembolization for arterial bleeding
• The importance of serial clinical evaluations and monitoring in patients undergoing NOM, to detect any change in clinical status and promptly intervene if necessary 1

From the Research

Management of Abdominal Trauma in Zones 1-3

The management of abdominal trauma in zones 1-3 involves a multidisciplinary approach, including surgical and non-surgical interventions.

• The abdominal zones are divided into three areas for trauma assessment, with zone 1 being the most critical area, including the upper abdominal region, and zones 2 and 3 being the middle and lower abdominal regions, respectively.
• For patients with penetrating abdominal trauma who are haemodynamically stable and have no signs of peritonitis, there is no evidence to support the use of surgery over an observation protocol 2, 3.
• In cases where immediate surgical intervention is needed, 'damage control' is the best option, and if not, conservative management is superior to operative management in terms of survival for the majority of intraabdominal injury 4.
• The management of the open abdomen is a complex subject, and the use of negative pressure therapy is a recommended approach for managing the open abdomen 5.
• Abdominal vascular injuries are a common cause of death post-trauma, and early control of bleeding can decrease mortality in these patients. The abdominal vasculature is divided into three zones, each requiring a different operative strategy for exposure 6.

Surgical Interventions

Surgical interventions for abdominal trauma in zones 1-3 may include:

• Diagnostic laparoscopy or laparotomy to assess the extent of injury
• Repair of damaged organs or vessels
• Temporary abdominal closure methods, such as negative pressure therapy, to manage the open abdomen
• Resuscitative endovascular balloon occlusion of the aorta to achieve proximal aortic occlusion

Non-Surgical Interventions

Non-surgical interventions for abdominal trauma in zones 1-3 may include:

• Observation protocol for patients with penetrating abdominal trauma who are haemodynamically stable and have no signs of peritonitis
• Conservative management, including bed rest, pain management, and monitoring of vital signs
• Early enteral feeding, even in the presence of an open abdomen, to promote healing and reduce complications 4.