Abdominal Trauma, Blunt

Basics

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 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

  • 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

  • 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

Lab
  • 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

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

Treatment

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

  • 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

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 Criteria
  • 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


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