Ads 468x60px



Monday, February 2, 2009

Abdominal Trauma, Blunt

Abdominal Trauma, Blunt


· Injury results from a sudden increase of pressure to abdomen.

  • Solid organ injury usually manifests as hemorrhage.
  • Hollow viscous injuries result in bleeding and peritonitis from contamination with bowel contents.


  • Sixty percent result from motor vehicle collisions.
  • Solid organs are injured more frequently than hollow viscous organs.
  • The spleen is the most frequently injured organ (25%), followed by the liver (15%), intestines (15%), retroperitoneal structures (13%), and kidney (12%).
  • Less frequently injured are the mesentery, pancreas, diaphragm, urinary bladder, urethra, and vascular structures.

Pediatric Considerations

  • Children tend to tolerate trauma better because of the more elastic nature of their tissues.
  • Owing to the smaller size of the intrathoracic abdomen, the spleen and liver are more exposed to injury because they lie partially outside the bony rib cage.


Signs and Symptoms

  • Spectrum from abdominal pain, signs of peritoneal irritation, to hypovolemic shock
  • Nausea or vomiting
  • Labored respiration from diaphragm irritation or upper abdominal injury
  • Left shoulder pain with inspiration (Kehr sign) from diaphragmatic irritation owing to bleeding
  • Delayed presentation possible with small bowel injury

Essential Workup

  • Evaluate and stabilize airway, breathing, and circulation (ABCs).
  • Primary objective is to determine need for operative intervention.
  • Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation.
  • Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation.
  • Remember that the limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference.
  • Abrasions or ecchymoses may be indicators of intra-abdominal injury:
    • Roll the patient to assess the back.
  • Bowel sounds may be absent from peritoneal irritation (late finding).
  • Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
  • Plain film of the pelvis:
    • Fracture of the pelvis and gross hematuria may indicate genitourinary injury.
    • Further evaluation of these structures with retrograde urethrogram, cystogram, or intravenous pyelogram
  • CT most useful in assessing need for operative intervention and for evaluating the retroperitoneal space and solid organs:
    • Patient must be stable enough to make trip to scanner.
    • Also useful for suspected renal injury
  • FAST (focused abdominal sonography for trauma) to detect intraperitoneal fluid
    • Ultrasonography is rapid, requires no contrast agents, and is noninvasive.
    • Operator dependent
  • Diagnostic peritoneal lavage (useful for revealing injuries in the intrathoracic abdomen, pelvic abdomen, and true abdomen) primarily indicated for unstable patients:
    • Positive with gross blood, RBC count of >100,000/mm3, WBC count of 500/mm3, or presence of bile, feces, or food particles



  • Hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
  • Type and cross is essential.
  • Urinalysis for blood:
    • Microscopic hematuria in the presence of shock is an indication for genitourinary evaluation.
  • Arterial blood gases:
    • Base deficit may suggest hypovolemic shock and help guide the resuscitation.

See Essential Workup.

Diagnostic Procedures/Surgery
See Essential Workup.

Differential Diagnosis
Lower thoracic injury may cause abdominal pain.


Pre Hospital

  • Aggressive fluid resuscitation is still considered standard of care.
  • Normal vital signs do not preclude significant intra-abdominal pathology.

Initial Stabilization

  • Ensure adequate airway:
    • Intubate if needed.
    • O2 100% by nonrebreather face mask
  • Two large-bore intravenous lines with crystalloid infusion
  • Begin infusion of packed RBCs if no response to 2 L of crystalloid.
  • If patient is in profound shock, consider transfusion of O-negative or type-specific blood.

ED Treatment

  • Continue stabilization begun in field.
  • Nasogastric tube to evacuate stomach, decrease distention, and decrease risk of aspiration:
    • May relieve respiratory distress if caused by a herniated stomach through the diaphragm

Medication (Drugs)

  • Tetanus toxoid booster: 0.5 mL IM for patients with open wounds
  • Tetanus immune globulin: 250 units IM for patients who have not had complete series
  • Intravenous antibiotics: broad-spectrum aerobic with anaerobic coverage such as a second-generation cephalosporin

Pediatric Considerations

  • Crystalloid infusion is 20 mL/kg if patient in shock.
  • Packed RBC dose is 1 mL/kg.


Admission Criteria

  • Postoperative cases
  • Equivocal findings on diagnostic peritoneal lavage, FAST exam, or CT
  • Many blunt abdominal trauma patient benefit from admission, monitoring, and serial abdominal examinations.

Discharge Criteria

No patient in whom you suspect intra-abdominal injury should be discharged home without an appropriate period of observation despite negative examination or imaging studies.

1. Amoroso TA. Evaluation of the patient with blunt abdominal trauma: an evidence based approach. Emerg Med Clin North Am. 1999;17:63-75.
2. Brasel KJ, et al. Incidence and significance of free fluid on abdominal CT in blunt trauma. J Trauma. 1995;44(5):889-892.
3. Davis JJ, Cohn I Jr, Nance FC. Diagnosis and management of blunt abdominal trauma. Ann Surg. 1976;183:672-678.
4. Holmes JF, et al. Performance of helical CT without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. 2004;43(1):120-128.
5. McGahan JP, Wang L, Richards JR. Focused abdominal ultrasound for trauma. Radiographics. 2001;21:91-99.
6. Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma. Br J Surg. 2001;88:901-912.


No comments: