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.
- 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
- 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.
See Essential Workup.
Lower thoracic injury may cause abdominal pain.
- Aggressive fluid resuscitation is still considered standard of care.
- Normal vital signs do not preclude significant intra-abdominal pathology.
- 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.
- 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
- 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
- Crystalloid infusion is 20 mL/kg if patient in shock.
- Packed RBC dose is 1 mL/kg.
- 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.
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.
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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.
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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.