When do you explore a zone 2 abdominal injury in trauma?

From the Guidelines

Exploration of a zone 2 abdominal injury trauma is indicated when there is hemodynamic instability, signs of ongoing bleeding, or when diagnostic imaging reveals significant injury, as evidenced by the 2020 guidelines on liver trauma 1. When managing zone 2 abdominal injuries, it is crucial to prioritize the patient's hemodynamic status, as determined by the diagnostic methods on admission, which include extended-focused abdominal sonography for trauma (E-FAST) and CT scan with intravenous contrast for hemodynamically stable patients 1.

• Key considerations for exploration include:
  • Hemodynamic instability despite resuscitation efforts
  • Signs of ongoing bleeding or hollow viscus injury
  • Peritoneal signs, evisceration, or free intraperitoneal air on diagnostic imaging
  • Significant solid organ injury with active bleeding, as indicated by active contrast extravasation on CT scan 1
• The approach to surgical exploration typically involves a midline laparotomy to access the abdominal cavity, allowing for direct control of bleeding sources, repair of intestinal injuries, and assessment of adjacent structures.
• While non-operative management may be considered for hemodynamically stable patients without clear indications for surgery, close monitoring and a low threshold for surgical intervention are essential to prevent delayed recognition of hollow viscus injuries, which can lead to peritonitis, sepsis, and increased mortality.
• The use of CT scan with intravenous contrast as the gold standard in trauma imaging assessment, with a sensitivity and specificity approaching 96-100%, supports the importance of early and accurate diagnosis in guiding management decisions 1.

From the Research

Zone 2 Abdominal Injury Trauma Exploration

• The exploration of a zone 2 abdominal injury trauma is typically guided by the patient's hemodynamic status and the presence of specific injuries 2.
• In general, immediate surgery is indicated for unstable patients, while angiography can be considered for stable patients 2.
• The surgeon should be prepared to perform perihepatic or pelvic packing and employ endovascular techniques as appropriate, and to explore all central retroperitoneal hematomas, retroperitoneal hematoma located in the flanks except when stable in the hemodynamically unstable patient, and those in the pelvis only if the patient is stable 2.
• The use of prophylactic antibiotics in penetrating abdominal trauma has been shown to decrease infection rates, and current guidelines recommend administering a single pre-operative broad spectrum antibiotic dose, with aerobic and anaerobic cover, and continuation (up to 24 hours) only in the event of a hollow viscus perforation found at exploratory laparotomy 3, 4, 5.

Timing of Exploration

• The timing of exploration for a zone 2 abdominal injury trauma depends on the patient's condition and the presence of specific injuries, with immediate surgery indicated for unstable patients and angiography considered for stable patients 2.
• In cases where damage control laparotomy is performed, there is evidence to support a Level I recommendation that prophylactic antibiotics should only be administered for 24 hours in the presence of a hollow viscus injury 5.

Diagnostic Tools

• Ultrasound, computed tomography scans, and routine physical examinations are used to make prompt diagnoses, trend injuries, and recognize deterioration of clinical status in patients with abdominal trauma 6.