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

  • 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.

Pediatric Considerations
  • 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.

Diagnosis

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

Essential Workup

  • 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 Interpretation

Lab
  • 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.
  • ABG:
    • 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.

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 PRBCs if no response to 2 L of crystalloid.
  • If patient is in profound shock, consider immediate transfusion of O-negative blood.

Ed Treatment/Procedures

  • 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

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
  • IV antibiotics: Broad-spectrum aerobic with anaerobic coverage such as a 2nd-generation cephalosporin

Pediatric Considerations
  • Crystalloid infusion is 20 mL/kg if patient is in shock.
  • PRBC dose is 1 mL/kg.

Ongoing Care

Disposition

Admission Criteria
  • 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.

Discharge Criteria
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.

Additional Reading

  • 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]

Codes

ICD-9

  • 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

ICD-10

  • 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

SNOMED

  • 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)

Authors

Stewart R. Coffman


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