Abdominal Trauma, Blunt
- 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.
- 60% result from motor vehicle collisions.
- Solid organs are injured more frequently than hollow viscus 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.
- Lap-belt abrasions can be indicative of significant intra-abdominal injuries.
- 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 IV 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
- Focused abdominal sonography for trauma (FAST) to detect intraperitoneal fluid:
- US 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
Diagnostic Tests and InterpretationLab
- Hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
- Type and screen is essential. Cross-match PRBC units for unstable patients.
- Urinalysis for blood:
- Microscopic hematuria in the presence of shock is an indication for genitourinary evaluation.
- Base deficit may suggest hypovolemic shock and help guide the resuscitation.
See “Essential Workup.”
See “Essential Workup”
Lower thoracic injury may cause abdominal pain.
- Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg
- Normal vital signs do not preclude significant intra-abdominal pathology.
- Ensure adequate airway:
- Intubate if needed.
- O2 100% by nonrebreather face mask
- 2 large-bore IV lines with crystalloid infusion
- Begin infusion of PRBCs if no response to 2 L of crystalloid.
- If patient is in profound shock, consider immediate transfusion of O-negative 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 immunoglobulin: 250 U IM for patients who have not had complete series
- IV antibiotics: Broad-spectrum aerobic with anaerobic coverage such as a 2nd-generation cephalosporin
- Crystalloid infusion is 20 mL/kg if patient is in shock.
- PRBC dose is 1 mL/kg.
- Postoperative cases
- Equivocal findings on diagnostic peritoneal lavage, FAST exam, or CT
- Many blunt abdominal trauma patients benefit from admission, monitoring, and serial abdominal exams.
No patient in whom you suspect intra-abdominal injury should be discharged home without an appropriate period of observation, despite negative exam or imaging studies.
Pearls and Pitfalls
- Do not delay blood products when patient is in obvious shock despite normal Hct.
- Avoid overaggressive resuscitation with crystalloids.
- Obtain a pregnancy test in all females of childbearing age.
- Do not transport unstable patients to CT for diagnostic imaging.
- Amoroso TA. Evaluation of the patient with blunt abdominal trauma: An evidence based approach. Emerg Med Clin North Am. 1999;17:63–75. [PMID:10101341]
- 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. [PMID:14707951]
- 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. [PMID:19561757]
- 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. [PMID:11442520]
- 459.0 Hemorrhage, unspecified
- 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
- 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ
- 864.00 Injury to liver without mention of open wound into cavity, unspecified injury
- 863.20 Injury to small intestine, unspecified site, without open wound into cavity
- 863.40 Injury to colon, unspecified site, without mention of open wound into cavity
- Hemorrhage, not elsewhere classified
- Unspecified injury of spleen, initial encounter
- Unspecified injury of unspecified intra-abdominal organ, initial encounter
- Unspecified injury of liver, initial encounter
- Unsp injury of unsp part of small intestine, init encntr
- Unspecified injury of unspecified part of colon, initial encounter
- 424863004 Blunt injury of abdomen (disorder)
- 443826006 hemorrhage into peritoneal cavity (disorder)
- 210180009 Closed injury of spleen (disorder)
- 34798003 injury of liver without open wound into abdominal cavity (disorder)
- 125625000 injury of intestine (disorder)
- 125627008 Injury of small intestine (disorder)
- 125636007 injury of large intestine (disorder)
Stewart R. Coffman
© Wolters Kluwer Health Lippincott Williams & Wilkins
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