Professional Documents
Culture Documents
The care of the trauma patient is demanding and requires speed and efficiency.
Evaluating patients who have sustained blunt abdominal trauma remains one of the
most challenging and resource-intensive aspects of acute trauma care.[1, 2]
Blunt abdominal trauma is a leading cause of morbidity and mortality among all age
groups. Identification of serious intra-abdominal pathology is often challenging.
Many injuries may not manifest during the initial assessment and treatment period.
Missed intra-abdominal injuries and concealed hemorrhage are frequent causes of
increased morbidity and mortality, especially in patients who survive the initial phase
after an injury.
Physical examination findings are notoriously unreliable. One reason is that
mechanisms of injury often result in other associated injuries that may divert the
physicians attention from potentially life-threatening intra-abdominal pathology.
Other common reasons are an altered mental state and drug and alcohol intoxication.
Coordinating a trauma resuscitation demands a thorough understanding of the
pathophysiology of trauma and shock, excellent clinical and diagnostic acumen, skill
with complex procedures, compassion, and the ability to think rationally in a chaotic
milieu.
Blunt abdominal trauma usually results from motor vehicle collisions (MVCs),
assaults, recreational accidents, or falls. The most commonly injured organs are the
spleen, liver, retroperitoneum, small bowel, kidneys (see the image below), bladder,
colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often
than women.
Anatomy
The abdomen can be arbitrarily divided into 4 areas. The first is the intrathoracic
abdomen, which is the portion of the upper abdomen that lies beneath the rib cage. Its
contents include the diaphragm, liver, spleen, and stomach. The rib cage makes this
area inaccessible to palpation and complete examination.
The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents
include the urinary bladder, urethra, rectum, small intestine, and, in females, ovaries,
fallopian tubes, and uterus. Injury to these structures may be extraperitoneal in nature
and therefore difficult to diagnose.
The third is the retroperitoneal abdomen, which contains the kidneys, ureters,
pancreas, aorta, and vena cava. Injuries to these structures are very difficult to
diagnose on the basis of physical examination findings. Evaluation of the structures in
this region may require computed tomography (CT) scanning, angiography, and
intravenous pyelography (IVP).
The fourth is the true abdomen, which contains the small and large intestines, the
uterus (if gravid), and the bladder (when distended). Perforation of these organs is
associated with significant physical findings and usually manifests with pain and
tenderness from peritonitis. Plain x-ray films are helpful if free air is present.
Additionally, diagnostic peritoneal lavage (DPL) is a useful adjunct.
Pathophysiology
Intra-abdominal injuries secondary to blunt force are attributed to collisions between
the injured person and the external environment and to acceleration or deceleration
forces acting on the persons internal organs. Blunt force injuries to the abdomen can
generally be explained by 3 mechanisms.
The first mechanism is deceleration. Rapid deceleration causes differential movement
among adjacent structures. As a result, shear forces are created and cause hollow,
solid, visceral organs and vascular pedicles to tear, especially at relatively fixed points
of attachment. For example, the distal aorta is attached to the thoracic spine and
decelerates much more quickly than the relatively mobile aortic arch. As a result,
shear forces in the aorta may cause it to rupture. Similar situations can occur at the
renal pedicles and at the cervicothoracic junction of the spinal cord.
Classic deceleration injuries include hepatic tear along the ligamentum teres and
intimal injuries to the renal arteries. As bowel loops travel from their mesenteric
attachments, thrombosis and mesenteric tears, with resultant splanchnic vessel
injuries, can result.
The second mechanism involves crushing. Intra-abdominal contents are crushed
between the anterior abdominal wall and the vertebral column or posterior thoracic
cage. This produces a crushing effect, to which solid viscera (eg, spleen, liver,
kidneys) are especially vulnerable.
The third mechanism is external compression, whether from direct blows or from
external compression against a fixed object (eg, lap belt, spinal column). External
compressive forces result in a sudden and dramatic rise in intra-abdominal pressure
and culminate in rupture of a hollow viscous organ (ie, in accordance with the
principles of Boyle law).
The liver and spleen seem to be the most frequently injured organs, though reports
vary. The small and large intestines are the next most frequently injured organs.
Recent studies show an increased number of hepatic injuries, perhaps reflecting
increased use of CT scanning and concomitant identification of more injuries.
Etiology
Vehicular trauma is by far the leading cause of blunt abdominal trauma in the civilian
population. Auto-to-auto and auto-to-pedestrian collisions have been cited as causes
in 50-75% of cases. Other common etiologies include falls and industrial or
recreational accidents. Rare causes of blunt abdominal injuries include iatrogenic
trauma during cardiopulmonary resuscitation, manual thrusts to clear an airway, and
the Heimlich maneuver.
Epidemiology
United States statistics
By nearly every measure, injury ranks as one of the most pressing health issues in the
United States. More than 150,000 people die each year as a result of injuries, such as
motor vehicle crashes, fires, falls, drowning, poisoning, suicide, and homicide.
Injuries are the leading cause of death and disability for US children and young
adults.
According to the 2000 statistics from the National Center for Injury Prevention and
Control, trauma (unintentional and intentional) was the leading cause of death in
persons aged 1-44 years. Further review of the data reveals that in those aged 15-25
years, 14,113 persons died from unintentional injuries, 73% of which were related to
vehicular trauma. In individuals aged 25-34 years, 57% of the 11,769 deaths reported
were from motor vehicle collisions.
In 2001, approximately 30 million people visited emergency departments (EDs) for
the treatment of nonfatal injuries, and more than 72,000 people were disabled by
injuries. Injury imposes exceptional costs, both in health care dollars and in human
losses, to society.
The true frequency of blunt abdominal trauma, however, is unknown. Data collected
from trauma centers reflect patients who are transported to or seek care at these
centers; these data may not reflect patients presenting to other facilities. The incidence
of out-of-hospital deaths is unknown.
One review from the National Pediatric Trauma Registry by Cooper et al reported that
8% of patients (total=25,301) had abdominal injuries. Eighty-three percent of those
injuries were from blunt mechanisms. Automobile-related injuries accounted for 59%
of those injuries.[3] Similar reviews from adult trauma databases reflect that blunt
trauma is the leading cause of intra-abdominal injury and that MVC is the leading
mode of injury. Blunt injuries account for approximately two thirds of all injuries.
Hollow viscus trauma is more frequent in the presence of an associated, severe, solid
organ injury, particularly to the pancreas. Approximately two thirds of patients with
hollow viscus trauma are injured in MVCs.
International statistics
In 1990, approximately 5 million people died worldwide as a result of injury. The risk
of death from injury varied strongly by region, age, and sex. Approximately 2 male
deaths due to violence were reported for every female death. Injuries accounted for
approximately 12.5% of all male deaths, compared with 7.4% of female deaths.
Globally, injury accounts for 10% of all deaths; however, injuries in sub-Saharan
Africa are far more destructive than in other areas. In sub-Saharan Africa, the risk of
death from trauma is highest in those aged 15-60 years, and the proportion of such
deaths from trauma is higher than in any other region of the world. South Africa, for
instance, has a traffic death rate per unit of distance traveled that is surpassed only by
those of Korea, Kenya, and Morocco.
Estimates indicate that by 2020, 8.4 million people will die yearly from injury, and
injuries from traffic collisions will be the third most common cause of disability
worldwide and the second most common cause in the developing world.
Data from the World Health Organization (WHO) indicate that falls from heights of
less than 5 meters are the leading cause of injury, and automobile crashes are the next
most frequent cause. These data reflect all injuries, not just blunt injuries to the
abdomen.
A review from Singapore described trauma as the leading cause of death in those aged
1-44 years. Traffic accidents, stab wounds, and falls from heights were the leading
modes of injury. Blunt abdominal trauma accounted for 79% of cases.[4]
A similar paper from India reported that blunt abdominal trauma is more frequent in
males aged 21-30 years; the majority of patients were injured in automobile accidents.
A German study indicated that, of patients with vertical deceleration injuries (ie, falls
from heights), only 5.9% had blunt abdominal injuries.
Prognosis
Overall prognosis for patients who sustain blunt abdominal trauma is favorable.
Without statistics that indicate the number of out-of-hospital deaths and the total
number of patients with blunt trauma to the abdomen, a description of the specific
prognosis for patients with intra-abdominal injuries is difficult. Mortality rates for
hospitalized patients are approximately 5-10%.
The National Pediatric Trauma Registry reported that 9% of pediatric patients with
blunt abdominal trauma died. Of these, only 22% were reported as having intraabdominal injuries as the likely cause of death.[3]
A review from Australia of intestinal injuries in blunt trauma reported that 85% of
injuries occurred from vehicular accidents. The mortality rate was 6%. In a large
review of operating room deaths in which blunt trauma accounted for 61% of all
injuries, abdominal trauma was the primary identified cause of death in 53.4% of
cases.
Patient Education
Proper adjustment of restraints in motor vehicles is an important aspect of patient
education. The following are key recommendations:
Adjust lap belts so that they fit snugly, and place them across the lower
abdomen and below the iliac crests.
Adjust seats and steering wheels so that the distance between the abdominal
wall and the steering wheel is as wide as possible while still allowing proper
control of the vehicle.
Advise patients to practice defensive driving by observing speed limits and keeping a
safe distance between them and other automobiles on the road.
For patient education resources, see the Kidneys and Urinary System Center, as well
as Blood in the Urine and Bruises.
History
Initially, evaluation and resuscitation of a trauma patient occur simultaneously. In
general, do not obtain a detailed history until life-threatening injuries have been
identified and therapy has been initiated. The initial assessment begins at the scene of
the injury, with information provided by the patient, family, bystanders, or
paramedics, or police.
Important factors relevant to the care of a patient with blunt abdominal trauma,
specifically those involving motor vehicles, include the following:
Allergies
Medications
Immunization status
The mnemonic AMPLE (A llergies, M edications, P ast medical history, L ast meal or
other intake, and E vents leading to presentation) is often useful as a means of
remembering key elements of the history.
A history of out-of-hospital hypotension is a predictor of more significant intraabdominal injuries. Even if the patient is normotensive at arrival in the emergency
department (ED), he or she should be considered to be at increased risk.
Physical Examination
Primary survey
Resuscitation is performed concomitantly and continues as the physical examination
is completed. Priorities in resuscitation and diagnosis are established on the basis of
hemodynamic stability and the degree of injury. The goal of the primary survey, as
directed by the Advanced Trauma Life Support (ATLS) protocol, is to identify and
expediently treat life-threatening injuries. The protocol includes the following:
Breathing
Circulation
Disability
Exposure
It is imperative for all personnel involved in the direct care of a trauma patient to
exercise universal precautions against body fluid exposure. The incidence of
infectious diseases (eg, HIV, hepatitis) is significantly higher in trauma patients than
in the general public, with some centers reporting rates as high as 19%. Even in
medical centers with relatively low rates of communicable diseases, safely
determining who is infected with such pathogens is impossible.
The standard barrier precautions include a hat, eye shield, face mask, gown, gloves,
and shoe covers. Unannounced trauma arrival is probably the most common situation
that leads to a breach in barrier precautions. Personnel must be instructed to adhere to
these guidelines at all times, even if it means a 30-second delay in patient care.
Secondary survey
After an appropriate primary survey and initiation of resuscitation, attention should be
focused on the secondary survey of the abdomen. The secondary survey is the
identification of all injuries via a head-to-toe examination. For life-threatening
injuries that necessitate emergency surgery, a comprehensive secondary survey should
be delayed until the patient has been stabilized.
At the other end of the spectrum are victims of blunt trauma who have a benign
abdomen upon initial presentation. Many injuries initially are occult and manifest
over time. Frequent serial examinations, in conjunction with the appropriate
Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign)
indicates retroperitoneal hemorrhage, but this is usually delayed for several hours to
days.
Visual inspection for abdominal distention, which may be due to pneumoperitoneum,
gastric dilatation secondary to assisted ventilation or swallowing of air, or ileus
produced by peritoneal irritation, is important.
Auscultation of bowel sounds in the thorax may indicate the presence of a
diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease or
traumatic arteriovenous fistula.
Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound
tenderness, which suggests peritoneal injury. Such signs appearing soon after an
injury suggest leakage of intestinal content. Peritonitis due to intra-abdominal
hemorrhage may take several hours to develop.
Fullness and doughy consistency on palpation may indicate intra-abdominal
hemorrhage. Crepitation or instability of the lower thoracic cage indicates the
potential for splenic or hepatic injuries associated with lower rib injuries.
Tenderness on percussion constitutes a peritoneal sign. Tenderness mandates further
evaluation and probably surgical consultation.
Rectal and bimanual vaginal pelvic examinations should be performed.[6] A rectal
examination should be done to search for evidence of bony penetration resulting from
a pelvic fracture, and the stool should be evaluated for gross or occult blood. The
evaluation of rectal tone is important for determining the patients neurologic status,
and palpation of a high-riding prostate suggests urethral injury.
The genitals and perineum should be examined for soft tissue injuries, bleeding, and
hematoma. Pelvic instability indicates the potential for lower urinary tract injury, as
well as pelvic and retroperitoneal hematoma. Open pelvic fractures are associated
with a mortality rate exceeding 50%.
A nasogastric tube should be placed routinely (in the absence of contraindications, eg,
basilar skull fracture) to decompress the stomach and to assess for the presence of
blood. If the patient has evidence of a maxillofacial injury, an orogastric tube is
preferred.
As the assessment continues, a Foley catheter is placed and a sample of urine is sent
for analysis for microscopic hematuria. If injury to the urethra or bladder is suggested
because of an associated pelvic fracture, then a retrograde urethrogram is performed
before catheterization.
With respect to the primary and secondary surveys, pediatric patients are assessed and
treatedat least initiallyas adults. However, there are obvious anatomic and
clinical differences between children and adults that must be kept in mind, including
the following:
A childs relatively large body surface area contributes to rapid heat loss.
Perhaps the most significant difference between pediatric and adult blunt trauma is
that, for the most part, pediatric patients can be resuscitated and treated
nonoperatively. Some pediatric surgeons often transfuse up to 40 mL/kg of blood
products in an effort to stabilize a pediatric patient. Obviously, if this fails and the
child continues to be unstable, laparotomy is indicated.
Tertiary survey
The concept of the tertiary trauma survey was first introduced by Enderson et al to
assist in the diagnosis of any injuries that may have been missed during the primary
and secondary surveys.[7] The tertiary survey involves a repetition of the primary and
secondary surveys and a revision of all laboratory and radiographic studies. In 1
study, a tertiary trauma survey detected 56% of injuries missed during the initial
assessment within 24 hours of admission.[8]
Diagnostic Considerations
Identification of intra-abdominal injuries can be challenging. Common pitfalls in
diagnosis include the following:
Differentials
Domestic Violence
Hemorrhagic Stroke
Hypovolemic Shock
Pregnancy Trauma
Approach Considerations
In recent years, laboratory evaluation of trauma patients has been a matter of
significant discussion. Commonly recommended studies include serum glucose,
complete blood count (CBC), serum chemistries, serum amylase, urinalysis,
coagulation studies, blood typing and cross-matching, arterial blood gases (ABGs),
blood ethanol, urine drug screens, and a urine pregnancy test (for females of
childbearing age).
Serum electrolyte values, creatinine level, and glucose values are often obtained for
reference, but typically they have little or no value in the initial management period.
Aggressive radiographic and surgical investigation is indicated in patients with
persistent hyperamylasemia or hyperlipasemia, conditions that suggest significant
intra-abdominal injury.
All patients should have their tetanus immunization history reviewed. If it is not
current, prophylaxis should be given.
The most important initial concern in the evaluation of a patient with blunt abdominal
trauma is an assessment of hemodynamic stability. In the hemodynamically unstable
patient, a rapid evaluation must be made regarding the presence of hemoperitoneum.
This can be accomplished by means of diagnostic peritoneal lavage (DPL) or the
focused assessment with sonography for trauma (FAST). Radiographic studies of the
abdomen are indicated in stable patients when the physical examination findings are
inconclusive.
Go to Focused Assessment with Sonography in Trauma (FAST) for complete
information on this topic.
Blood Studies
Complete blood count
The presence of massive hemorrhage is usually obvious from hemodynamic
parameters, and an abnormal hematocrit value merely confirms the diagnosis. Normal
hemoglobin and hematocrit results do not rule out significant hemorrhage. Patients
bleed whole blood. Until blood volume is replaced with crystalloid solution or
hormonal effects (eg, adrenocorticotropic hormone [ACTH], aldosterone, antidiuretic
hormone [ADH]) and transcapillary refill occurs, anemia may not develop.
Bedside diagnostic testing with rapid hemoglobin or hematocrit machines may
quickly identify patients who have physiologically significant volume deficits and
hemodilution. Reported hemoglobin from ABG measurements also may be useful in
identifying anemia. Some studies have correlated a low initial hematocrit (ie, < 30%)
with significant injuries.
Do not withhold transfusion in patients who have relatively normal hematocrit results
(ie, >30%) but have evidence of clinical shock, serious injuries (eg, open-book pelvic
fracture), or significant ongoing blood loss. Hemodynamic instability in an adult
despite the administration of 2 L of fluid indicates ongoing blood loss and is an
indication for immediate blood transfusion. Use platelet transfusions to treat patients
with thrombocytopenia (ie, platelet count < 50,000/L) and ongoing hemorrhage.
An elevated white blood cell (WBC) count on admission is nonspecific and does not
predict the presence of a hollow viscus injury (HVI). The diagnostic value of serial
WBC counts for predicting HVI within the first 24 hours after trauma is very limited.
[9]
Coagulation profile
The cost-effectiveness of routine prothrombin time (PT)/activated partial
thromboplastin time (aPTT) determination upon admission is questionable. PT or
aPTT should be measured in patients who have a history of blood dyscrasias (eg,
hemophilia), who have synthetic problems (eg, cirrhosis), or who take anticoagulant
medications (eg, warfarin, heparin).
Perform drug and alcohol screens on trauma patients who have alterations in their
level of consciousness. Breath or blood testing may quantify alcohol level.
Urine Studies
Indications for diagnostic urinalysis include significant trauma to the abdomen and/or
flank, gross hematuria, microscopic hematuria in the setting of hypotension, and a
significant deceleration mechanism.[12]
Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP) or
computed tomography (CT) scanning with intravenous (IV) contrast. Gross hematuria
indicates a workup that includes cystography and IVP or CT scanning of the abdomen
with contrast.
Perform a urine toxicologic screen as appropriate. Obtain a serum or urine pregnancy
test on all females of childbearing age.
Plain Radiography
Although their overall value in the evaluation of patients with blunt abdominal trauma
is limited, plain films can demonstrate numerous findings. The chest radiograph may
aid in the diagnosis of abdominal injuries such as ruptured hemidiaphragm (eg, a
nasogastric tube seen in the chest) or pneumoperitoneum.
The pelvic or chest radiograph can demonstrate fractures of the thoracolumbar spine.
The presence of transverse fractures of the vertebral bodies (ie, Chance fractures)
suggests a higher likelihood of blunt injuries to the bowel. In addition, free
intraperitoneal air, or trapped retroperitoneal air from duodenal perforation, may be
seen.
Ultrasonography
The use of diagnostic ultrasonography to evaluate a patient with blunt trauma for
abdominal injuries has been advocated since the 1970s. European and Asian
investigators have extensive experience with this technology and are leaders in the use
of ultrasound for the diagnosis of blunt abdominal trauma.
The first American report of physician-performed abdominal ultrasonography in the
evaluation of blunt abdominal trauma was published in 1992 by Tso and colleagues.[13]
Since then, numerous articles have been published in the United States advocating the
use of ultrasound (ie, FAST) in the evaluation of the patient with blunt abdominal
trauma.
Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination
that can be performed by emergency clinicians and trauma surgeons to detect
hemoperitoneum. In fact, in many medical centers, the FAST examination has
virtually replaced DPL as the procedure of choice in the evaluation of
hemodynamically unstable trauma patients.
The FAST examination is based on the assumption that all clinically significant
abdominal injuries are associated with hemoperitoneum. However, the detection of
free intraperitoneal fluid is based on factors such as the body habitus, injury location,
presence of clotted blood, position of the patient, and amount of free fluid present.
In a patient with isolated blunt abdominal trauma and multisystem injuries, FAST
performed by an experienced sonographer can rapidly identify free intraperitoneal
fluid (generally appearing as a black stripe). The sensitivity for solid organ
encapsulated injury is moderate in most studies. Hollow viscus injury (HVI) rarely is
identified; however, free fluid may be visualized. For patients with persistent pain or
tenderness or those developing peritoneal signs, FAST may be considered as a
complementary measure to CT scanning, DPL, or exploration.
The minimum threshold for detecting hemoperitoneum is unknown and remains a
subject of interest. Kawaguchi and colleagues found that 70 mL of blood could be
detected,[14] whereas Tiling et al found that 30 mL is the minimum requirement for
detection with ultrasonography.[15] They also concluded that a small anechoic stripe in
the Morison pouch represents approximately 250 mL of fluid, whereas 0.5-cm and 1cm stripes represent approximately 500 mL and 1 L of free fluid, respectively.
The current FAST examination protocol consists of 4 acoustic windows with the
patient supine. These windows are pericardiac, perihepatic, perisplenic, and pelvic
(known as the 4 P s). An examination is interpreted as positive if free fluid is found in
any of the 4 acoustic windows and as negative if no fluid is seen. An examination is
deemed indeterminate if any of the windows cannot be adequately assessed.
The pericardial window is obtained via a subcostal or transthoracic approach. It
provides a 4-chamber view of the heart and can detect the presence of
hemopericardium, which is demonstrated by the separation of the visceral and parietal
pericardial layers. The perihepatic window yields views of portions of the liver,
diaphragm, and right kidney. It reveals fluid in the Morison pouch (see the images
below), the subphrenic space, and the right pleural space.
no free fluid).
Morison pouch
The perisplenic window provides views of the spleen and the left kidney and reveals
fluid in the splenorenal recess (see the images below), the left pleural space, and the
subphrenic space. The pelvic window makes use of the bladder as a sonographic
window and thus is best accomplished while the patient has a full bladder. In males,
free fluid is seen as an anechoic area (sonographically black) in the rectovesicular
pouch or cephalad to the bladder. In females, fluid accumulates in the Douglas pouch,
posterior to the uterus.
FASTs diagnostic accuracy generally is equal to that of DPL. Studies in the United
States have demonstrated the value of bedside sonography as a noninvasive approach
for rapid evaluation of hemoperitoneum. The studies demonstrate a degree of operator
dependence; however, some studies have shown that with a structured learning
session, even novice operators can identify free intra-abdominal fluid, especially if
more than 500 mL of fluid is present. Sensitivity and specificity of these studies range
from 85% to 95%.[16, 17, 18, 19, 20]
As noted, FAST relies on hemoperitoneum to identify patients with injury. Chiu and
colleagues, in their study of 772 patients with blunt trauma undergoing FAST scans,
reported 52 patients had an abdominal injury.[21] Of the 52 patients, 15 (29%) had no
hemoperitoneum on FAST or CT scan results. These findings suggest that the reliance
on hemoperitoneum as the sole indicator of abdominal visceral injury limits the utility
of FAST as a diagnostic screening tool in stable patients with blunt abdominal trauma.
Rozycki et al studied 1540 patients and reported that ultrasonography was the most
sensitive and specific modality for the evaluation of hypotensive patients with blunt
abdominal trauma (sensitivity and specificity, 100%).[20]
Hemodynamically stable patients with positive FAST results may require a CT scan to
better define the nature and extent of their injuries. Taking every patient with a
positive FAST result to the operating room may result in an unacceptably high
laparotomy rate.
Hemodynamically stable patients with negative FAST results require close
observation, serial abdominal examinations, and a follow-up FAST examination.
However, strongly consider performing a CT scan, especially if the patient is
intoxicated or has other associated injuries.
Hemodynamically unstable patients with negative FAST results are a diagnostic
challenge. Options include DPL, exploratory laparotomy, and, possibly, a CT scan
after aggressive resuscitation.
Go to Focused Assessment with Sonography in Trauma (FAST) for complete
information on this topic.
Computed Tomography
Although expensive and potentially time-consuming, CT scanning often provides the
most detailed images of traumatic pathology and may assist in determination of
operative intervention.[22, 23, 24, 25] CT remains the criterion standard for the detection of
solid organ injuries (see the image below). In addition, a CT scan of the abdomen can
reveal other associated injuries, notably vertebral and pelvic fractures and injuries in
the thoracic cavity.
contrast and whether the additional information it provides negates the drawbacks of
increased time to administration and risk of aspiration. The value of oral contrast in
diagnosing bowel injury has been debated, but no definitive answer exists at this time.
Diagnostic Laparoscopy
The introduction of minimally invasive surgery has revolutionized many surgical
diagnostic protocols. In the late 1980s and early 1990s, there was considerable interest
in the use of laparoscopy for evaluation and management of blunt and penetrating
abdominal trauma. Subsequent studies, however, revealed major limitations to this
approach and cautioned against its widespread use. The most important limitation is
inability to reliably identify hollow viscus and retroperitoneal injuries, even in the
hands of experienced laparoscopists.
Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for the
introduction of the laparoscope and creating other ports for retractors, clamps, and
other tools necessary for visualization of the repair.
Diagnostic laparoscopy has been most useful in the evaluation of possible
diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on the left
side.[27, 28, 29] In blunt trauma, it has no clear advantages over less invasive modalities
such as DPL and CT scanning; furthermore, complications can result from trocar
misplacement.
The only absolute contraindication to DPL is the obvious need for laparotomy.
Relative contraindications include morbid obesity, a history of multiple abdominal
surgeries, and pregnancy.
Various methods of introducing the catheter into the peritoneal space have been
described. These include the open, semiopen, and closed methods. The open method
requires an infraumbilical skin incision that is extended to and through the linea alba.
(In pregnant patients or in patients with particular risk for potential pelvic hematoma,
the incision should be placed superior to the umbilicus.) The peritoneum is opened,
and the catheter is inserted under direct visualization.
The semiopen method is identical, except that the peritoneum is not opened and the
catheter is delivered percutaneously through the peritoneum into the peritoneal cavity.
The closed technique requires the catheter to be inserted blindly through the skin,
subcutaneous tissue, linea alba, and peritoneum.
The closed and semiopen techniques at the infraumbilical site are preferred at most
centers. The fully open method is the most technically demanding and is restricted to
those situations in which the closed or semiopen technique is unsuccessful or is
deemed unsafe (eg, patients with pelvic fractures, pregnancy, obesity, or prior
abdominal operations).
After insertion of the catheter into the peritoneum, attempt to aspirate free
intraperitoneal blood (at least 15-20 mL). DPL results are considered positive in a
blunt trauma patient if 10 mL of grossly bloody aspirate is obtained before infusion of
the lavage fluid or if the siphoned lavage fluid contains more than 100,000 red blood
cells (RBCs)/L, more than 500 white blood cells (WBCs)/L, elevated amylase
content, bile, bacteria, vegetable matter, or urine. Only approximately 30 mL of blood
is needed in the peritoneum to produce a microscopically positive DPL result.
If findings are negative, infuse 1 L of crystalloid solution (eg, lactated Ringer
solution) into the peritoneum. Then, allow this fluid to drain by gravity, and ensure
that laboratory analysis is performed.
Complications of DPL include bleeding from the incision and catheter insertion,
infection (ie, wound, peritoneal), and injury to intra-abdominal structures (eg, urinary
bladder, small bowel, uterus). These complications may increase the possibility of
false-positive studies. Additionally, infection of the incision, peritonitis from the
catheter placement, laceration of the urinary bladder, or injury to other intraabdominal organs can occur.
Bleeding from the incision, dissection, or catheter insertion can cause false-positive
results that may lead to unnecessary laparotomy. Achieve appropriate hemostasis prior
to entering the peritoneum and placing the catheter. False-positive DPL results can
occur if an infraumbilical approach is used in a patient with a pelvic fracture. A pelvic
x-ray film should be obtained prior to performing DPL if a pelvic fracture is
suggested. Before DPL is attempted, the urinary bladder and stomach should be
decompressed.
DPL has been shown in some studies to have a diagnostic accuracy of 98-100%, a
sensitivity of 98-100%, and a specificity of 90-96%. It has some advantages,
including high sensitivity, rapidity, and immediate interpretation. The main limitations
of DPL include its potential for iatrogenic abdominal injury and its high sensitivity,
which can lead to nontherapeutic laparotomies.
With the availability of fast, noninvasive, and better imaging modalities (eg, FAST,
CT scanning), the role of DPL is now limited to the evaluation of unstable trauma
patients in whom FAST results are negative or inconclusive. In some contexts, DPL
may be complemented with a CT scan if the patient has positive lavage results but
stabilizes.
Prehospital Care
Prehospital care focuses on rapidly evaluating life-threatening problems, initiating
resuscitative measures, and initiating prompt transport to a definitive care site.[33, 34]
The injured patient is at risk for progressive deterioration from continued bleeding
and requires rapid transport to a trauma center or the closest appropriate facility, with
appropriate stabilization procedures performed en route. Hence, securing the airway,
placing large-bore intravenous (IV) lines, and administering IV fluid must take place
en route, unless transport is delayed.
A study by Nirula et al demonstrates the importance of field triage protocols that
allow immediate transport to definitive care sites for very severely injured patients.[35]
In the study, the odds of death were 3.8 times greater for patients initially triaged to a
nontrauma center. Such responses require preplanning within a mature trauma system
and mandate appropriate prehospital training and protocols.
Use endotracheal intubation to secure the airway of any patient who is unable to
maintain the airway or who has potential airway threats. Secure the airway in
conjunction with in-line cervical immobilization in any patient who may have
suffered cervical trauma. Provide artificial ventilation by using a high fraction of
inspired oxygen (FIO2) for patients who exhibit compromised breathing respirations.
Maintain oxygen saturation (SaO2) at more than 90-92%.
External hemorrhage rarely is associated with blunt abdominal trauma. If external
bleeding is present, control it with direct pressure. Note any signs of inadequate
Approach Considerations
Treatment of blunt abdominal trauma begins at the scene of the injury and is
continued upon the patients arrival at the emergency department (ED) or trauma
center. Management may involve nonoperative measures or surgical treatment, as
appropriate.
Indications for laparotomy in a patient with blunt abdominal injury include the
following:
Signs of peritonitis
patients may be allowed a thoracotomy in the ED only if they have signs of life upon
arrival.
Nonoperative Management
Nonoperative management (NOM) strategies based on CT scan diagnosis and the
hemodynamic stability of the patient are now being used in adults for the treatment of
solid organ injuries, primarily those to the liver and spleen. In blunt abdominal
trauma, including severe solid organ injuries, selective nonoperative management has
become the standard of care.
Angiography is a valuable modality in nonoperative management of abdominal solid
organ injuries from blunt trauma in adults. It is used aggressively for nonoperative
control of hemorrhage, thereby obviating nontherapeutic cost-inefficient laparotomies.
Splenic artery embolotherapy (SAE), although not standard of care, is another
nonoperative management modality for adult blunt splenic injury. Requarth et al
conducted a metaanalysis comparing outcomes data for observational management
versus SAE by splenic injury grade cohort. Results show the failure rate of
observational management increases with splenic injury grade, whereas the failure
rate of SAE does not change significantly from splenic injury grades 1 to 5. In grade 4
and 5 injuries, SAE is associated with significantly higher salvage rates. The SAE
success rate noted may in part be due to the fact that SAE was introduced later in the
experience surveyed, and the improved NOM failure rate may be due to other factors
that came into play as the experience proceeded.[39]
The trend toward simply observing hemodynamically stable patients with injuries
involving the spleen, liver, or kidneys is becoming more popular. In a study of
pediatric patients, those with blunt abdominal trauma who were hemodynamically
stable after fluid replacement of less than 40 mL/kg, had proven evidence of solid
organ injuries, and remained stable were admitted to the pediatric intensive care unit
(ICU) under surgical management. No deaths and no immediate or long-term
complications were reported in this group.
If the decision has been made to observe the patient, closely monitor vital signs and
frequently repeat the physical examination. An increased temperature or respiratory
rate can indicate a perforated viscus or the formation of an abscess. Pulse and blood
pressure can also change with sepsis or intra-abdominal bleeding. Physical
examination findings reflecting peritonitis are an indication for surgical intervention.
Surgical Management
Resuscitative thoracotomy
Resuscitative thoracotomy in the ED is only occasionally life-saving. It is an
aggressive, desperate measure intended to save a patient whose death is thought to be
imminent or otherwise inevitable. Survival with good neurologic recovery is more
likely for patients with penetrating trauma than for patients with blunt trauma.
Thoracotomy may have a role in selected patients with penetrating injuries to the
neck, chest, or extremities and those with signs of life within 5 minutes of arrival in
the ED.
A resuscitative thoracotomy is seldom of benefit for patients with cardiac arrest
secondary to blunt or head injury or for those without vital signs at the scene of the
accident. Patients with blunt thoracoabdominal trauma with pulseless electrical
activity upon arrival in the ED have a survival rate of virtually 0% and are poor
candidates for resuscitative thoracotomy. Patients with blunt trauma may be allowed a
thoracotomy in the ED only if they have signs of life upon arrival.
In a patient with hemoperitoneum from blunt thoracoabdominal trauma, the goals of a
resuscitative thoracotomy in the ED are (1) to cross-clamp the aorta, diverting
available blood to the coronaries and cerebral vessels during resuscitation; (2) to
evacuate pericardial tamponade; (3) to directly control thoracic hemorrhage; and (4)
to open the chest for cardiac massage.
It must be stressed, however, that in this digital era with high-resolution imaging the
need to take a patient for exploratory laparotomy only to establish a diagnosis may be
unnecessary and expensive if, for instance, the CT is negative and the patient is
hemodynamically stable.
Patients who had gross enteric contamination of the peritoneal cavity are given
appropriate antibiotics for 5-7 days.
If a pelvic hematoma was found and the patient continues to lose blood after external
fixation of a pelvic fracture, arteriography with embolization can be used to stop the
small percentage of arterial bleeding found in pelvic fractures.
In adults, splenic artery embolization has been shown to improve nonoperative splenic
salvage rates. A retrospective review showed that this procedure may be useful in the
adolescent population as well, particularly in patients with high-grade injuries or with
evidence of splenic vascular injury, although this is not the standard of care.[41]
Consultations
The best outcomes from trauma are obtained by involving consultants who possess
specific expertise and training in managing trauma patients. Consider evaluation by a
trauma surgeon for all patients with evidence of blunt abdominal trauma. Clearly,
hemodynamic instability or the identification of significant abnormalities during
physical examination or a diagnostic procedure necessitates the involvement of a
trauma surgeon.
Specific physical examination findings that call for timely surgical evaluation are as
follows:
Findings consistent with potential intra-abdominal injury (eg, lap belt signs,
lower rib fractures, lumbar spine fractures)
Specific findings on diagnostic studies that call for timely surgical evaluation include
evidence of free fluid or solid organ injury on sonograms or CT scans.
Long-Term Monitoring
Before discharge, provide patients with detailed instructions that describe signs of
undiagnosed injury. Increased abdominal pain or distention, nausea or vomiting,
weakness, lightheadedness or fainting, or new bleeding in urine or feces mandates
immediate return and further evaluation. Ensure that close follow-up care and repeat
examinations are available for all patients.
Medication Summary
Judiciously prescribe pain medications to patients who are discharged. To prevent
masked or delayed presentations, ensure that a close follow-up for reevaluation is
available to all patients who are provided pain medications. With the potential for
hemorrhage, nonsteroidal anti-inflammatory drugs (NSAIDs) probably should be
avoided. Acetaminophen with or without small quantities of mild narcotic analgesics
may be all that should be prescribed initially. Minimize use of analgesics in patients
who are admitted for observation.
Patients who undergo laparotomy may require routine perioperative antibiotics.
Patients with repaired hollow organ injury may require additional antibiotics.
Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes
pulmonary toilet, and prevents exacerbations in tachycardia and hypertension.
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Morphine is the drug of choice for narcotic analgesia due to its reliable and
predictable effects, safety profile, and ease of reversibility with naloxone. Like
fentanyl, morphine sulfate is easily titrated to desired level of pain control.
Morphine sulfate administered intravenously may be dosed in a number of ways. It is
commonly titrated until the desired effect is obtained.
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Hydromorphone (Dilaudid)
This combination is a mild narcotic analgesic. Provide the family with a small supply
for use when pain severity is greater than can be managed with acetaminophen alone.
Counsel parents to use for severe pain only, not as the first medication for each
symptom.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely
pathogens in the context of the clinical setting.
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Cefazolin
Cephalexin (Keflex)
Cefotaxime (Claforan)
Ceftriaxone (Rocephin)
It inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage
of active growth.
It is an antipseudomonal penicillin plus a beta-lactamase inhibitor that provides
coverage against most gram-positives, most gram negatives, and most anaerobes.
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Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Clindamycin is a lincosamide semisynthetic antibiotic produced by 7(S)-chlorosubstitution of 7(R)-hydroxyl group of the parent compound lincomycin. It inhibits
bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes,
causing RNA-dependent protein synthesis to arrest. It widely distributes in the body,
without penetration of the CNS. It is protein bound and is excreted by the liver and
kidneys.
It is available in a parenteral form (ie, clindamycin phosphate) and oral form (ie,
clindamycin hydrochloride). Oral clindamycin is absorbed rapidly and almost
completely and is not appreciably altered by the presence of food in the stomach.
Appropriate serum levels are reached and sustained for at least 6 hours following an
oral dose. No significant levels are attained in cerebrospinal fluid. It is also effective
against aerobic and anaerobic streptococci (except enterococci).