Abdominal Trauma, Blunt
Basics
Description
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
Etiology
- Motor vehicle collisions 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
Pediatric Considerations
- Children can lose large amounts of intra-abdominal blood quickly due to smaller blood volumes
- Owing to the smaller size of the intrathoracic abdomen, the spleen and liver are more exposed to injury because they lie partially outside the boney rib cage
- Unrecognized pediatric abdominal trauma is a significant contributor to mortality among traumatic injuries in children
Diagnosis
Signs and Symptoms
Signs and Symptoms
- Patients present with a spectrum of symptoms from abdominal pain, signs of peritoneal irritation to hypovolemic shock
- 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
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 should be done to assess for boney trauma or blood
- Insert Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
- CT is most useful in assessing the need for operative intervention and for evaluating the retroperitoneal space and solid organs
- There are few indications for diagnostic peritoneal lavage in a hemodynamically stable patient when CT is readily available
- CXR can aid in detection of pneumoperitoneum or ruptured diaphragm
- Pelvis radiograph:
- Fracture of the pelvis and gross hematuria may indicate genitourinary injury
- Further evaluation of these structures with retrograde urethrogram or cystogram
- Focused abdominal sonography for trauma (FAST) to detect free intraperitoneal fluid:
- Ultrasound is rapid, requires no contrast agents, and is noninvasive
- Operator dependent
- Does not exclude intra-abdominal injury
Diagnostic Tests and Interpretation
LabDiagnostic Tests and Interpretation
- Check hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
- Check coagulation markers (platelets, prothrombin, and partial thromboplastin time). Effects of some anticoagulants may not be accurately reflected in lab values
- Type and screen is essential. Cross-match packed red blood cell units for unstable patients
- Urinalysis for blood:
- Microscopic hematuria in the presence of shock should prompt genitourinary evaluation
- Pregnancy test for females of child-bearing age
- Ethanol concentration
- Arterial blood gas:
- Base deficit may suggest hypovolemic shock and help guide the resuscitation
Imaging
See Essential Workup
Diagnostic Procedures/Other
See Essential Workup
Differential Diagnosis
Differential Diagnosis
- Lower thoracic injury may cause abdominal pain
- Fractures (rib, pelvis) may cause abdominal pain
Treatment
Pre Hospital
Pre Hospital
- Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg
- Normal vital signs do not preclude significant intra-abdominal pathology
Initial Stabilization/Therapy
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
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
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
Pediatric Considerations
- Initial volume resuscitation consists of a 20 mL/kg crystalloid fluid bolus (can be repeated)
- If abnormal hemodynamics persist, administer 10 mL/kg PRBC
Ongoing Care
Disposition
Admission CriteriaDisposition
- Patients who require surgical intervention
- Equivocal findings on FAST exam or CT
Discharge Criteria
- Patients with isolated blunt abdominal trauma who are clinically stable and have a negative abdominal CT (with intravenous contrast) can be considered for safe discharge
- No patient with suspected intra-abdominal injury should be discharged
Pearls and Pitfalls
- Do not delay blood products when patient is in obvious shock despite normal hemoglobin/hematocrit
- Obtain a pregnancy test in all females of childbearing age
- Do not transport unstable patients to CT for diagnostic imaging
- Inquire about the use of anticoagulants
Additional Reading
- American College of Emergency Physicians; Clinical Policies Subcommittee on Acute Blunt Abdominal Trauma. Clinical policy: Critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med. 2004;43(2):278–290.
- Carter JW, Falco MH, Chopko MS, et al. Do we really rely on fast for decision-making in the management of blunt abdominal trauma? Injury. 2015;46(5):817–821.
- Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. 2004;43(1):120–128.
- Kendall JL, Faragher J, Hewitt GJ, et al. Emergency department ultrasound is not a sensitive detector of solid organ injury. West J Emerg Med. 2009;10(1):1–5.
- 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.
- Wegner S, Colletti JE, Van Wie D. Pediatric blunt abdominal trauma. Pediatr Clin North Am. 2006;53(2):243–256.
Authors
Frances E. Rudolf
Allyson A. Kreshak
© Wolters Kluwer Health Lippincott Williams & Wilkins
Citation
Schaider, Jeffrey J., et al., editors. "Abdominal Trauma, Blunt." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307486/all/Abdominal_Trauma__Blunt.
Abdominal Trauma, Blunt. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307486/all/Abdominal_Trauma__Blunt. Accessed December 5, 2024.
Abdominal Trauma, Blunt. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307486/all/Abdominal_Trauma__Blunt
Abdominal Trauma, Blunt [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 05]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307486/all/Abdominal_Trauma__Blunt.
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