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.

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.


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

  • 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.

See “Essential Workup.”

Diagnostic Procedures/Other
See “Essential Workup

Differential Diagnosis

Lower thoracic injury may cause abdominal pain.


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


  • 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


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]



  • 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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