Description

• Injury results from a sudden increase of pressure to abdomen
• Solid organ injury usually manifests as hemorrhage
• Hollow viscus injuries result in bleeding and peritonitis from contamination with bowel contents

Etiology

• Motor vehicle collisions and pedestrian versus auto are the greatest cause of blunt abdominal trauma
• Solid organs are injured more frequently than hollow viscus organs
• The liver and spleen are the most frequently injured organs, followed by the intestines and retroperitoneal structures
• Less frequently injured are the mesentery, pancreas, diaphragm, urinary bladder, urethra, and vascular structures

Signs And Symptoms

• Patients present with a spectrum of symptoms from abdominal pain, signs of peritoneal irritation to hypovolemic shock
• Lack of abdominal pain or tenderness does not exclude the possibility of significant intra-abdominal injury
• Nausea or vomiting
• Labored respiration can be present 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
• Associated injuries (fractures, abdominal wall injuries) may mimic abdominal injuries
• Abrasions or ecchymosis may be indicators of intra-abdominal injury:
  • Lap-belt abrasions can be indicative of significant intra-abdominal injuries
  • Flank and periumbilical bruising can represent retroperitoneal hemorrhage (late finding)
• Bowel sounds may be absent from peritoneal irritation (late finding)

Essential Workup

• Evaluate and stabilize airway, breathing, and circulation
• Primary objective is to determine need for operative intervention
• Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation, but the examination is limited in detecting intraperitoneal blood
• Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation
• The limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference
• Rectal exam may be selectively done in patients whose clinical exam is equivocal for neurologic injury
• Insert Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
• Focused Assessment with Sonography (FAST) in patients with systolic blood pressure <90 mm Hg, may be used to identify intraperitoneal fluid and the need for emergent laparotomy. FAST is operator dependent and does not exclude intra-abdominal injury
• Abdominal CT with intravenous contrast is useful in detecting potential injuries in clinically stable patients with symptoms concerning for intra-abdominal and retroperitoneal injuries
• Few indications exist for diagnostic peritoneal lavage (DPL) in a hemodynamically stable patient when CT imaging is available. DPL has been largely replaced with the use of FAST and CT imaging
• Chest radiograph can aid in the detection of findings suggesting intra-abdominal injury, such as pneumoperitoneum or ruptured diaphragm and lower rib fractures
• Pelvis radiograph can aid in the detection of pelvis fractures and hip injuries. Fracture of the pelvis and gross hematuria may indicate genitourinary injury. Further evaluation of these structures may be done with retrograde urethrogram or cystogram
• Laboratory evaluation includes complete blood count, comprehensive metabolic panel, lipase, urinalysis, and pregnancy test for females of child-bearing age

Diagnostic Tests And Interpretation

Differential Diagnosis

• Lower thoracic injury may cause abdominal pain
• Fractures (rib, pelvis) may cause abdominal pain

Prehospital

• Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg (permissive hypotension)
• Normal vital signs do not preclude significant intra-abdominal pathology

Initial Stabilization/Therapy

• Ensure adequate airway:
  • Intubate if needed
  • O₂ 100% by nonrebreather face mask
• 2 large-bore IV lines with crystalloid infusion
• Begin infusion of packed red blood cells if no hemodynamic response to 1 L of crystalloid
• If patient is in profound shock, consider immediate transfusion of O-negative blood
• Consider TXA for hemorrhage
• Surgical intervention with laparotomy by a qualified surgeon is indicated for uncontrolled shock, findings of hemoperitoneum, clinical signs of peritonitis, or clinical deterioration during observation

Ed Treatment/Procedures

• See Essential Workup
• 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

• Tetanus toxoid booster: 0.5 mL IM for patients with open wounds
• Tetanus immunoglobulin: 250 U IM for patients who have not had complete series
• Intravenous broad-spectrum antibiotics should be administered when laparotomy is indicated
• Correct coagulopathy when clinically indicated
• Administered analgesia when needed. Avoid nonsteroidal anti-inflammatory drugs due to risk of bleeding

Disposition