Abdominal Trauma, Blunt

Author: Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine Coauthor(s): Jeffrey Salomone, MD, !"#MT$ , Assistant Professor, Department of eneral and Trauma Surgery, Emory University School of Medicine, rady Memorial !ospital Contri"utor #nformation and Disclosures Updated$ Aug %, %&&'

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Introdu(tion
Ba()*round
/lunt a"dominal trauma is a leading cause of mor"idity and mortality among all age groups0 #dentification of serious intra-a"dominal pathology is often challenging0 Many in1uries may not manifest during the initial assessment and treatment period0 Mechanisms of in1ury often result in other associated in1uries that may divert the physician2s attention from potentially life-threatening intra-a"dominal pathology0

athophysiolo*y
#n1ury to intra-a"dominal structures can "e classified into % primary mechanisms of in1ury3compression forces and deceleration forces0 Compression or concussive forces may result from direct "lo,s or e4ternal compression against a fi4ed o"1ect 5eg, lap "elt, spinal column60 Most commonly, these crushing forces cause tears and su"capsular hematomas to the solid viscera0 These forces also may deform hollo, organs and transiently increase intraluminal pressure, resulting in rupture0

This transient pressure increase is a common mechanism of "lunt trauma to the small "o,el0 Deceleration forces cause stretching and linear shearing "et,een relatively fi4ed and free o"1ects0 These longitudinal shearing forces tend to rupture supporting structures at the 1unction "et,een free and fi4ed segments0 Classic deceleration in1uries include hepatic tear along the ligamentum teres and intimal in1uries to the renal arteries0 As "o,el loops travel from their mesenteric attachments, throm"osis and mesenteric tears, ,ith resultant splanchnic vessel in1uries, can result0 The liver and spleen seem to "e the most fre7uently in1ured organs, although reports vary0 Small and large intestines are the ne4t most in1ured organs, respectively0 .ecent studies sho, an increased num"er of hepatic in1uries, perhaps reflecting increased use of CT scanning and concomitant identification of more in1uries0

+re,uen(y
-nited States True fre7uency is un*no,n0 Data collected from trauma centers reflect patients ,ho are transported to or see* care at these centers0 These data may not reflect patients presenting to other facilities0 #ncidence of out-of-hospital deaths is un*no,n0

8ne revie, from the 9ational Pediatric Trauma .egistry "y Cooper et al reported that :; of patients 5total<%=,>&?6 had a"dominal in1uries0 Eighty-three percent of those in1uries ,ere from "lunt mechanisms0 Automo"ile-related in1uries accounted for =@; of those in1uries0? Similar revie,s from adult trauma data"ases reflect that "lunt trauma is the leading cause of intra-a"dominal in1ury and that motor vehicle collisions are the leading mode of in1ury0 /lunt in1uries account for appro4imately t,o thirds of all in1uries0 !ollo, viscus trauma is more fre7uent in the presence of an associated, severe, solid organ in1ury, particularly to the pancreas0 Appro4imately t,o thirds of patients ,ith hollo, viscus trauma are in1ured in motor vehicle collisions0

International Data from the )orld !ealth 8rganiAation indicate that falls from heights of less than = meters are the leading cause of in1ury, and automo"ile crashes are the ne4t most fre7uent cause0 These data reflect all in1uries, not 1ust "lunt in1uries to the a"domen0

A revie, from Singapore descri"ed trauma as the leading cause of death in those aged ?-BB years0 Traffic accidents, sta" ,ounds, and falls from heights ,ere the leading modes of in1ury0 /lunt a"dominal trauma accounted for '@; of cases0%

A similar paper from #ndia reported that "lunt a"dominal trauma is more fre7uent in males aged %?->& yearsC the ma1ority of patients ,ere in1ured in automo"ile accidents0 A erman study indicated that, of patients ,ith vertical deceleration in1uries 5ie, falls from heights6, only =0@; had "lunt a"dominal in1uries0

Mortality.Morbidity

The 9ational Pediatric Trauma .egistry reported that @; of pediatric patients ,ith "lunt a"dominal trauma died0 8f these, only %%; ,ere reported as having intra-a"dominal in1uries as the li*ely cause of death0? A revie, from Australia of intestinal in1uries in "lunt trauma reported that :=; of in1uries occurred from vehicular accidents0 The mortality rate ,as D;0 #n a large revie, of operating room deaths in ,hich "lunt trauma accounted for D?; of all in1uries, a"dominal trauma ,as the primary identified cause of death in =>0B; of cases0

Se/
The male-to-female ratio is D&$B&, according to national and international data0

A*e
Most studies indicate that pea* incidence occurs in persons aged ?B->& years0 A revie, of ?@,%D? patients ,ith "lunt a"dominal trauma revealed e7ual incidence of hollo, viscus in1uries in "oth children 5ie, E?B y6 and adults0

Clini(al
0istory

#nitially, evaluation and resuscitation occur simultaneously0 #n general, do not o"tain a detailed history until life-threatening in1uries have "een identified and therapy has "een initiated0 !o,ever, to "etter predict in1ury patterns and to identify potential pitfalls, ascertain the mechanism of in1ury from "ystanders, paramedics, or police0 AM 1# is often useful as a mnemonic for remem"ering *ey elements of the history0 o A llergies o M edications o ast medical history o 1 ast meal or other inta*e o # vents leading to presentation

A history of out-of-hospital hypotension is a predictor of more significant intraa"dominal in1uries0 Even if normotensive upon ED arrival, consider the patient as having an increased ris*0

hysi(al

#nitial e4amination o After appropriate primary survey and initiation of resuscitation, focus attention on secondary survey of the a"domen0 o +or life-threatening in1uries that re7uire emergent surgery, delay comprehensive secondary survey until the patient has "een sta"iliAed0 o At the other end of the spectrum are victims of "lunt trauma ,ho have a "enign a"domen upon initial presentation0 Many in1uries initially are occult and manifest over time0 +re7uent serial e4aminations, in con1unction ,ith the appropriate diagnostic studies, such as a"dominal CT scan and "edside ultrasonography, are essential in any patient ,ith significant mechanism of in1ury0 #nspection o E4amine the a"domen to determine the presence of e4ternal signs of in1ury0 9ote patterns of a"rasion andFor ecchymotic areas0 o 9ote in1ury patterns that predict the potential for intra-a"dominal trauma 5eg, lap "elt a"rasions, steering ,heel3shaped contusions60 #n most studies, lap "elt mar*s have "een correlated ,ith rupture of the small intestine and an increased incidence of other intra-a"dominal in1uries0 o 8"serve the respiratory pattern "ecause a"dominal "reathing may indicate spinal cord in1ury0 9ote a"dominal distention and any discoloration0 o /radycardia may indicate the presence of free intraperitoneal "lood in a patient ,ith "lunt a"dominal in1uries0 o The Cullen sign 5ie, perium"ilical ecchymosis6 may indicate retroperitoneal hemorrhageC ho,ever, this symptom usually ta*es several hours to develop0 +lan* "ruising and s,elling may raise suspicion for a retroperitoneal in1ury0 o #nspect genitals and perineum for soft tissue in1uries, "leeding, and hematoma0 Auscultation o A"dominal "ruit may indicate underlying vascular disease or traumatic arteriovenous fistula0 o During auscultation, gently palpate the a"domen ,hile noting the patient2s reactions0 Palpation o Carefully palpate the entire a"domen ,hile assessing the patient2s response0 9ote a"normal masses, tenderness, and deformities0 o +ullness and doughy consistency may indicate intra-a"dominal hemorrhage0 Crepitation or insta"ility of the lo,er thoracic cage indicates the potential for splenic or hepatic in1uries associated ,ith lo,er ri" in1uries0

Pelvic insta"ility indicates the potential for lo,er urinary tract in1ury as ,ell as pelvic and retroperitoneal hematoma0 8pen pelvic fractures are associated ,ith a mortality rate e4ceeding =&;0 o Perform rectal and "imanual vaginal pelvic e4aminations to identify potential "leeding and in1ury0 o Perform a sensory e4amination of the chest and a"domen to evaluate the potential for spinal cord in1ury0 Spinal cord in1ury may interfere ,ith the accurate assessment of the a"domen "y causing decreased or a"sent pain perception0 o A"dominal distention may result from gastric dilation secondary to assisted ventilation or s,allo,ing of air0 o Signs of peritonitis 5eg, involuntary guarding, rigidity6 soon after an in1ury suggest lea*age of intestinal content0 Peritonitis due to intra-a"dominal hemorrhage may ta*e several hours to develop0 Percussion o Percussion tenderness constitutes a peritoneal sign0 o Tenderness mandates further evaluation and pro"a"ly surgical consultation0
o

Causes

The most common causes of "lunt a"dominal trauma are from motor vehicle accidents and automo"ile-pedestrian accidents0 8ther common etiologies include falls and industrial or recreational accidents0

Abdominal Trauma, Blunt: Differential Dia*noses 2 3or)up

Author: Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine Coauthor(s): Jeffrey Salomone, MD, !"#MT$ , Assistant Professor, Department of eneral and Trauma Surgery, Emory University School of Medicine, rady Memorial !ospital Contri"utor #nformation and Disclosures Updated$ Aug %, %&&'

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3or)up
1aboratory Studies

#n recent years, la"oratory evaluation of trauma victims has "een a matter of significant discussion0 Commonly recommended studies include serum glucose, complete "lood count 5C/C6, serum chemistries, serum amylase, urinalysis, coagulation studies, "lood type and match, arterial "lood gas 5A/ 6, "lood ethanol, urine drug screens, and a urine pregnancy test 5for females of child"earing age60 Complete "lood count o 9ormal hemoglo"in and hematocrit results do not rule out significant hemorrhage0 Patients "leed ,hole "lood0 Until "lood volume is replaced ,ith crystalloid solution or hormonal effects 5eg, adrenocorticotropic hormone GACT!H, aldosterone, antidiuretic hormone GAD!H6 and transcapillary refill occurs, anemia may not develop0 Do not ,ithhold transfusion in patients ,ho have relatively normal hematocrit results 5ie, I>&;6 "ut have evidence of clinical shoc*, serious in1uries 5eg, open-"oo* pelvic fracture6, or significant ongoing "lood loss0 o Use platelet transfusions to treat patients ,ith throm"ocytopenia 5ie, platelet count J=&,&&&FmK6 and ongoing hemorrhage0 o /edside diagnostic testing ,ith rapid hemoglo"in or hematocrit machines may 7uic*ly identify patients ,ho have physiologically significant volume deficits and hemodilution0 .eported hemoglo"in from A/ s also may "e useful in identifying anemia0 o Some studies have correlated a lo, initial hematocrit 5ie, J>&;6 ,ith significant in1uries0 Serum chemistries o .ecently, the usefulness of routine serum chemistries of trauma patients has "een 7uestioned0 Most trauma victims are younger than B& years and rarely are ta*ing medications that may alter electrolytes 5eg, diuretics, potassium replacements60 o The more prudent choice ,hen attempting to limit cost involves selective ordering of these studies0 /ase the selections on the patient2s medications, presence of concurrent nausea or vomiting, presence of dysrhythmias, or history of renal failure or other chronic medical pro"lems associated ,ith electrolyte im"alance0

#f "lood gas measurements are not routinely o"tained, serum chemistries that measure serum glucose and car"on dio4ide levels are indicated0 o .apid "edside "lood-glucose determination, o"tained ,ith a finger-stic* measuring device, is important for patients ,ith altered mental status0 Kiver function studies o K+Ts may "e useful in the patient ,ith "lunt a"dominal traumaC ho,ever, test findings may "e elevated for several reasons 5eg, alcohol a"use60 o 8ne study has sho,n that an aspartate aminotransferase 5AST6 or alanine aminotransferase 5AKT6 level more than ?>& U corresponds ,ith significant hepatic in1ury0 o Kactate dehydrogenase 5KD!6 and "iliru"in levels are not specific indicators of hepatic trauma0 Amylase measurement o Controversy surrounds the role of amylase determination in the presence of "lunt a"dominal trauma0 o An initial amylase determination has "een sho,n in multiple studies to "e neither sensitive nor specific for pancreatic in1uryC ho,ever, an a"normally elevated amylase level >-D hours after trauma has a much greater accuracy0 o Although some pancreatic in1uries may "e missed ,ith a CT scan performed soon after trauma, virtually all are identified if the scan is repeated in >D-B: hours0 Urinalysis o #ndications for diagnostic urinalysis include significant trauma to the a"domen andFor flan*, gross hematuria, microscopic hematuria in the setting of hypotension, and a significant deceleration mechanism0 o 8"tain a contrast nephrogram "y utiliAing intravenous pyelography 5#LP6 or CT scanning ,ith intravenous contrast0 o ross hematuria indicates a ,or*up that includes cystography and #LP or CT scanning of the a"domen ,ith contrast0 8"tain a serum or urine pregnancy test on all females of child"earing age0 Coagulation profile o The cost-effectiveness of routine prothrom"in time 5PT6Factivated partial throm"oplastin time 5aPTT6 determination upon admission is 7uestiona"le0 o 8"tain PTFaPTT in patients ,ho have a history of "lood dyscrasias 5eg, hemophilia6, ,ho have synthetic pro"lems 5eg, cirrhosis6, or ,ho ta*e anticoagulant medications 5eg, ,arfarin, heparin60 /lood type, screen, and crossmatch o Screen and type "lood from all trauma patients ,ith suspected "lunt a"dominal in1ury0 #f an in1ury is identified, this practice greatly reduces the time re7uired for crossmatch0 o Perform an initial crossmatch on a minimum of B-D units for those patients ,ith clear evidence of a"dominal in1ury and hemodynamic insta"ility0 o Until crossmatched "lood is availa"le, utiliAe 8-negative or type-specific "lood0
o

Arterial "lood gas measurement o A/ level may provide important information in ma1or trauma victims0 #n addition to information a"out o4ygenation 5eg, P8%, Sa8%6 and ventilation 5PC8%6, this test provides valua"le information regarding o4ygen delivery "y calculation of the A-a gradient0 o Upon initial hospital admission, suspect meta"olic acidemia to result from the lactic acidosis that accompanies shoc*0 o A moderate "ase deficit 5ie, more than -= mE76 indicates the need for aggressive resuscitation and determination of the etiology0 o Attempt to improve systemic o4ygen delivery "y ensuring an ade7uate Sa8% 5ie, I@&;6 and "y ac7uiring volume resuscitation ,ith crystalloid solutions and, if indicated, "lood0 o A/ s report total hemoglo"in more rapidly than C/Cs0 Drug and alcohol screens o Perform drug and alcohol screens on trauma patients ,ho have alterations in their level of consciousness0 o /reath or "lood testing may 7uantify alcohol level0

Ima*in* Studies

+ocused a"dominal sonogram for trauma o /edside ultrasonography in the form of focused a"dominal sonogram for trauma 5+AST6 has "een used in the evaluation of trauma patients in Europe for more than ?& years and is increasingly gaining acceptance in the United States0 +AST2s diagnostic accuracy generally is e7ual to that of diagnostic peritoneal lavage 5DPK60 Studies in the United States over the last fe, years have demonstrated the value of "edside sonography as a noninvasive approach for rapid evaluation of hemoperitoneum0 The studies demonstrate a degree of operator dependenceC ho,ever, some studies have sho,n that ,ith a structured learning session, even novice operators can identify free intra-a"dominal fluid, especially if greater than =&& mK of fluid is present0 o #n the patient ,ith isolated "lunt a"dominal trauma and multisystem in1uries, "edside ultrasonography performed "y an e4perienced sonographer can rapidly identify free intraperitoneal fluid0 The sensitivity for solid organ encapsulated in1ury is moderate in most studies0 !ollo, viscus in1ury rarely is identifiedC ho,ever, free fluid may "e visualiAed in these cases0 +or patients ,ith persistent pain or tenderness or for those developing peritoneal signs, consider +AST as a complementary measure to CT scan, DPK, or e4ploration0 o +AST evaluation of the a"domen consists of visualiAation of the pericardium 5from a su"4iphoid vie,6, the splenorenal and the hepatorenal spaces 5ie, Morison pouch6, the paracolic gutters, and the pouch of Douglas in the pelvis0 The Morison pouch vie, has "een sho,n to "e the most sensitive, regardless of the etiology of the fluid0

+ree fluid, generally assumed to "e "lood in the setting of a"dominal trauma, appears as a "lac* stripe0 +ree fluid in a hemodynamically unsta"le patient indicates the need for emergent laparotomyC ho,ever, CT scan may further evaluate the sta"le patient ,ith free fluid0 o Sensitivity and specificity of these studies range from :=-@=;0 CT scanning o Although e4pensive and potentially time-consuming, CT scan often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention0 o Transport only hemodynamically sta"le patients to the CT scanner0 )hen performing CT scan, closely and carefully monitor vital signs for clinical evidence of decompensation0 o CT scanning may miss in1uries to the diaphragm and perforations of the # tract, especially ,hen CT scanning is performed soon after the in1ury0 Pancreatic in1uries may not "e identified on initial CT scans "ut generally are found on follo,-up e4aminations performed on high-ris* patients0 +or selected patients, endoscopic retrograde cholangiopancreatography 5E.CP6 may complement CT scanning to rule out a ductal in1ury0 o The primary advantage of CT scanning is its high specificity and use for guiding nonoperative management of solid organ in1uries0 o Dra,"ac*s of CT scanning relate to the need to transport the patient from the trauma resuscitation area and the additional time re7uired to perform CT scanning compared to +AST or DPK0 The "est CT imagery re7uires "oth oral and intravenous contrast0 o Some controversy has arisen over the use of oral contrast and ,hether the additional information it provides negates the dra,"ac*s of increased time to administration and ris* of aspiration0 The value of oral contrast in diagnosing "o,el in1ury has "een de"ated, "ut no definitive ans,er e4ists at this time0
o

ro(edures

Diagnostic peritoneal lavage

o

DPK is used as a method of rapidly determining the presence of intraperitoneal "lood0 DPK is particularly useful if the history and a"dominal e4amination of a patient ,ho is unsta"le and has multisystem in1uries is either unrelia"le 5eg, head in1ury, alcohol, drug into4ication6 or e7uivocal 5eg, lo,er ri" fractures, pelvic fractures, confounding clinical e4amination60 DPK also is useful for patients in ,hom serial a"dominal e4aminations cannot "e performed 5eg, those in an angiographic suite or operating room during emergent orthopedic or neurosurgical procedures60 The preferred method involves an open or semiopen techni7ue that is performed in an infraum"ilical location0 #n pregnant patients or in patients ,ith particular ris* for potential pelvic hematoma, perform the DPK superior to the um"ilicus0

o o

o o o

+ollo,ing insertion of the catheter into the peritoneum, attempt to aspirate free intraperitoneal "lood 5at least ?=-%& mK60 A"dominal e4ploration is al,ays indicated if appro4imately ?& mK of "lood is aspirated upon insertion of the peritoneal catheter 5grossly positive6 in the unsta"le patient0 #f findings are negative, infuse ? K of crystalloid solution 5eg, lactated .inger solution6 into the peritoneum0 Then, allo, this fluid to drain "y gravity, and ensure la"oratory analysis is performed0 The presence of more than ?&&,&&& ./CFmm> or more than =&& )/CFmm> is considered a positive finding0 8ther results from DPK fluid that indicate the need for e4ploration include the presence of "ile or a"normally high amylase level 5indicative of intestinal perforation6, food fi"ers, or "acteria noted on microscopic e4amination0 #n some conte4ts, DPK may "e complemented ,ith a CT scan if the patient has positive lavage results "ut sta"iliAes0 The only a"solute contraindication for a DPK is for the patient ,ho re7uires emergent laparotomy regardless of the findings0 Complications of DPK include "leeding from the incision and catheter insertion, infection 5ie, ,ound, peritoneal6, and in1ury to intra-a"dominal structures 5eg, urinary "ladder, small "o,el, uterus60 These complications may increase the possi"ility of false-positive studies0 Additionally, infection of the incision, peritonitis from the catheter placement, laceration of the urinary "ladder, or in1ury to other intra-a"dominal organs can occur0 /leeding from the incision, dissection, or catheter insertion can cause false-positive results that may lead to unnecessary laparotomy0 Achieve appropriate hemostasis prior to entering the peritoneum and placing the catheter0

Abdominal Trauma, Blunt: Treatment 2 Medi(ation

Author: Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine Coauthor(s): Jeffrey Salomone, MD, !"#MT$ , Assistant Professor, Department of eneral and Trauma Surgery, Emory University School of Medicine, rady Memorial !ospital Contri"utor #nformation and Disclosures Updated$ Aug %, %&&'

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Treatment
rehospital Care

+ocus prehospital care on rapidly evaluating life-threatening pro"lems, initiating resuscitative measures, and initiating prompt transport to the closest appropriate hospital, ,hich typically is a trauma center0 Use endotracheal intu"ation to secure the air,ay of any patient ,ho is una"le to maintain the air,ay or ,ho has potential air,ay threats0 Secure the air,ay in con1unction ,ith in-line cervical immo"iliAation in any patient ,ho may have suffered cervical trauma0 Provide artificial ventilation "y using a high fraction of inspired o4ygen 5+#8%6 for patients ,ho e4hi"it compromised "reathing respirations0 Maintain o4ygenation at more than @&-@%; saturation0 E4ternal hemorrhage rarely is associated ,ith "lunt a"dominal trauma0 #f present, control the hemorrhage ,ith direct pressure0 9ote any signs of inade7uate systemic perfusion0 Consider intraperitoneal hemorrhage ,henever evidence of hemorrhagic shoc* is found in the a"sence of e4ternal hemorrhage0 #nitiate volume resuscitation ,ith crystalloid solutionC ho,ever, never delay patient transport ,hile intravenous lines are inserted0 En route, administer a fluid "olus of lactated .inger or normal saline solution to patients ,ith evidence of shoc*0 Titrate intravenous fluid therapy to the patient2s clinical response0 /ecause overaggressive volume resuscitation may lead to recurrent or increased hemorrhage, titrate intravenous fluids to a systolic "lood pressure of @&-?&& mm !g0 This practice should provide the mean "lood pressure necessary to maintain perfusion of the vital organs0 Ac7uire e4peditious and complete spinal immo"iliAation on patients ,ith multisystem in1uries and on patients ,ith a mechanism of in1ury that has potential for spinal cord trauma0 #n the rural setting, the pneumatic antishoc* garment may have a role for treating shoc* resulting from a severe pelvic fracture0 Transport patients ,ho meet physiologic or anatomic criteria to the closest trauma center0 Promptly notify the destination hospital in order for that facility to activate its trauma team and prepare for the patient0

#mer*en(y Department Care

Perform a rapid primary survey to identify immediate life-threatening pro"lems0 +ocus close attention on ,hether the patient can maintain the air,ay or if a potential threat is present0 Secure the air,ay "y orotracheal intu"ation, ,hich is performed ,ith concurrent in-line manual immo"iliAation of the cervical spine0 #f intu"ation is re7uired, and if possi"le, perform and record a "rief neurologic e4amination prior to neuromuscular "loc*ade and intu"ation0 Patients ,ho display apnea or hypoventilation re7uire respiratory support, as do those patients ,ith tachypnea0 Provide all patients ,ith supplemental o4ygen from a device capa"le of delivering a high +#8% 5eg, nonre"reather mas*60 Decreased or a"sent "reath sounds raise the possi"ility of hemothora4 or pneumothora4C therefore, consider needle decompression or tu"e thoracostomy, even prior to o"taining a chest radiograph0 #dentification of hypovolemia and signs of shoc* necessitate vigorous resuscitation and attempts to identify the source of "lood loss0 #nitiate at least % large-"ore 5eg, ?:-guage6 peripheral intravenous lines0 Use central lines 5prefera"ly femoral "y using a large-"ore line such as a Cordis catheter6 and cutdo,ns 5eg, saphenous, "rachial6 for patients in ,hom percutaneous peripheral access cannot "e esta"lished0 Administer a rapid "olus of crystalloid0 Perform physical e4amination that consists of a complete head-to-toe secondary survey, ,ith attention paid to evidence of the mechanism of in1ury and potentially in1ured areas0 /efore the placement of a nasogastric tu"e and +oley catheter, perform appropriate head, nec*, pelvic, perineum, and rectal e4aminations0 /ased on mechanism and physical e4amination, o"tain initial trauma radiographic studies0 #n general, trauma suite vie,s include a lateral cervical spine, anterior porta"le chest, and pelvis radiograph0 #n-line spinal immo"iliAation must "e continued until spinal fractures have "een ruled out0 Additional radiographs are indicated for other findings in the secondary survey0 After the primary survey and initial resuscitation have "egun, complete the secondary survey to identify all potential and present in1uries0 MKog-rollM the patient to e4amine the "ac* and palpate the entire spinal column0 #nvestigate for any signs of in1ury0 Perform a rectal e4amination0 #f signs of shoc* persist after an initial %-> liters of crystalloid infusion, administer "lood products0 Type 8 .h-negative "lood typically is given to ,omen of child"earing age0 Type 8-positive "lood may "e given safely to all other patients including men and postmenopausal ,omen0 As soon as availa"le, use typespecific or crossmatched "lood0 /edside ultrasonography using a trauma e4amination protocol 5eg, +AST6 can "e used to determine the presence of intraperitoneal hemorrhage 5see Media files ?%60 #f findings are negative or e7uivocal, a DPK may "e performed in hemodynamically unsta"le patients0 /ased on sta"ility, mechanism, and suspicion of intra-a"dominal in1ury, further investigation may "e ,arranted for patients ,ho are hemodynamically sta"le after the initial assessment and resuscitation and ,ho have negative or e7uivocal "edside ultrasonography andFor DPK results0 +urther investigation includes contrast-enhanced CT scans of the a"domen and pelvis or serial e4aminations and ultrasonography0

Consultations

The "est outcomes from trauma are o"tained "y involving consultants ,ho possess specific e4pertise and training in managing trauma patients0 Consider evaluation "y a trauma surgeon for all patients ,ith evidence of "lunt a"dominal trauma0 Clearly, patients ,ho have hemodynamic insta"ility or significant a"normalities found during physical e4aminations and diagnostic procedures re7uire involvement of a trauma surgeon0 Specific physical e4amination findings indicate timely surgical evaluation as follo,s$ o !istory of "lunt a"dominal trauma, shoc*, or a"normal vital signs 5eg, tachycardia, hypotension6 o Evidence of shoc* ,ithout o"vious e4ternal "lood loss o Evidence of peritonitis 5eg, mar*ed tenderness, involuntary guarding, percussion tenderness6 o +indings consistent ,ith potential intra-a"dominal in1ury 5eg, lap "elt signs, lo,er ri" fractures, lum"ar spine fractures6 o Altered levels of consciousness or sensation, ,hether due to drugs, alcohol, or headFspinal in1ury o Patients ,ho re7uire other prolonged operative intervention 5eg, orthopedic procedures6 Specific findings on diagnostic studies, such as evidence of free fluid or solid organ in1ury on sonograms or CT scan, indicate timely involvement of a trauma surgeon0 Although a trend to,ard nonoperative management of hepatic, splenic, and renal in1uries in patients ,ho are hemodynamically normal has occurred, a trained trauma surgeon must oversee this care0 8ther specific findings that indicate timely trauma surgeon involvement are as follo,s$ o Positive findings on DPK o Evidence of e4travasated contrast or e4traluminal air on an upper # series 5eg, duodenal rupture6, plain a"dominal radiography, or cystography o Serious pelvic fractures o Evidence of "ladder rupture on contrast cystogram or gross hematuria o Elevated findings on liver function studies

Abdominal Trauma, Blunt: +ollo'$up

Author: Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine Coauthor(s): Jeffrey Salomone, MD, !"#MT$ , Assistant Professor, Department of eneral and Trauma Surgery, Emory University School of Medicine, rady Memorial !ospital Contri"utor #nformation and Disclosures Updated$ Aug %, %&&'

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+ollo'$up
+urther Inpatient Care

Serial e4aminations o Serial ultrasonographic e4aminations may play a role in identifying occult in1uries0 o Any change in the physical e4amination that indicates peritoneal irritation ,arrants additional studies andFor laparotomy0

+urther %utpatient Care

/efore discharge, provide patients ,ith detailed instructions that descri"e signs of undiagnosed in1ury0 o #ncreased a"dominal pain or distention, nausea andFor vomiting, ,ea*ness, lightheadedness, or fainting, or ne, "leeding in urine or feces mandates immediate return and further evaluation0 o Ensure that close follo,-up care and repeat e4aminations are availa"le for all patients0

Inpatient 2 %utpatient Medi(ations

Nudiciously prescri"e pain medications to patients ,ho are discharged0 o To prevent mas*ed or delayed presentations, ensure that a close follo,-up for reevaluation is availa"le to all patients ,ho are provided pain medications0 o )ith the potential for hemorrhage, nonsteroidal anti-inflammatory drugs 59SA#Ds6 pro"a"ly should "e avoided0 o Acetaminophen ,ith or ,ithout small 7uantities of mild narcotic analgesics may "e all that should "e prescri"ed initially0 o MinimiAe use of analgesics in patients ,ho are admitted for o"servation0 Patients ,ho undergo laparotomy may re7uire routine perioperative anti"iotics0 Patients ,ith repaired hollo, organ in1ury may re7uire additional anti"iotics0

Transfer

#f e4pertise in managing "lunt a"dominal in1uries is unavaila"le, arrange patient transfer to the nearest appropriate trauma center as soon as in1ury is identified0 o Kengthy diagnostic ,or*up is counterproductive once it is recogniAed that a patient cannot "e managed at the initial facility0 o Physician-to-physician consultation must occur "efore transport to ensure that the receiving facility has the resources necessary to care for the patient0

Compli(ations

Complications can arise for identified and unidentified in1uries0 #ntra-a"dominal hemorrhage, infection, sepsis, and death can occur0 Delayed rupture or hemorrhage from solid organs, particularly the spleen, has "een descri"ed0 #n patients that undergo laparotomy and repair, complications are similar to other conditions that re7uire operative intervention0

ro*nosis

8verall prognosis for patients ,ho sustain "lunt a"dominal trauma is favora"le0 o )ithout statistics that indicate the num"er of out-of-hospital deaths and the total num"er of patients ,ith "lunt trauma to the a"domen, a description of the specific prognosis for patients ,ith intra-a"dominal in1uries is difficult0 o Mortality rates for hospitaliAed patients are appro4imately =-?&;0

atient #du(ation

Proper ad1ustment of restraints in motor vehicles is an important aspect of patient education0 o )ear lap "elts in con1unction ,ith shoulder restraints0 o )ear lap "elts snug and place them across the lo,er a"domen and "elo, the iliac crests0 o )ear restraints even in vehicles e7uipped ,ith supplemental vehicle restraints 5eg, air"ags60 o Ad1ust seats and steering ,heels to ma4imiAe the distance "et,een the a"dominal ,all and steering ,heel, ,hile still allo,ing proper control of the vehicle0 Advise patients to practice defensive driving "y o"serving speed limits and *eeping a safe distance "et,een them and other automo"iles on the road0 +or e4cellent patient education resources, visit eMedicine2s Kidneys and Urinary System Center0 Also, see eMedicine2s patient education article /lood in the Urine0

Mis(ellaneous
Medi(ole*al itfalls

+ailure to suspect intra-a"dominal in1ury from appropriate mechanisms +ailure to evaluate a"dominalFflan*Fcostal margin pain after "lunt a"dominal in1ury +ailure to o"tain timely surgical consultation and operative intervention +ailure to recogniAe intra-a"dominal hemorrhage and delay operation for additional diagnostic testing in the face of hemodynamic compromise

.eferences

Contents
%&er&ie': Abdominal Trauma, Blunt Differential Diagnoses ( )or*up$A"dominal Trauma, /lunt Treatment ( Medication$ A"dominal Trauma, /lunt +ollo,-up$ A"dominal Trauma, /lunt Multimedia$ A"dominal Trauma, /lunt

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+urther "eadin*
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4ey'ords
intra-a"dominal trauma, intra-a"dominal in1ury, "lunt a"dominal in1ury, motor vehicle collision, motor vehicle accident, MLA, "lunt trauma G CK8SE )#9D8) H

Contributor Information and Dis(losures

Author Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine Noseph A Salomone, ###, MD is a mem"er of the follo,ing medical societies$ American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association Disclosure$ 9othing to disclose Coauthor(s) Jeffrey Salomone, MD, !"#MT$ , Assistant Professor, Department of eneral and Trauma Surgery, Emory University School of Medicine, rady Memorial !ospital Neffrey P Salomone, MD, 9.EMT-P is a mem"er of the follo,ing medical societies$ American College of Surgeons, American Medical Association, Medical Association of eorgia, 9ational Association of EMS Physicians, and Society of Critical Care Medicine Disclosure$ Schering plough Consulting fee for ConsultingC Merc* !onoraria for Spea*ing and teachingC 9AEMT-Pre!ospital Trauma Kife Support 9one for Editing P!TKS te4t"oo*C all royalties paid to 9AEMTC 8rtho-Mc9eil Consulting fee for Consulting Medi(al #ditor Samuel M 4eim, MD, Associate Professor, Department of Emergency Medicine, University of AriAona College of Medicine Samuel M Keim, MD is a mem"er of the follo,ing medical societies$ American Academy of Emergency Medicine, American College of Emergency Physicians,

American Medical Association, American Pu"lic !ealth Association, and Society for Academic Emergency Medicine Disclosure$ 9othing to disclose harma(y #ditor +ran(is(o Tala&era, harmD, hD, Senior Pharmacy Editor, eMedicine Disclosure$ 9othing to disclose Mana*in* #ditor #ri( 1e*ome, MD, .esidency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine 9e, Oor* University, 9e, Oor* University !ospital, /ellevue !ospital Center, Manhattan LA Eric Kegome, MD is a mem"er of the follo,ing medical societies$ Alpha 8mega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine .esidency Directors, and Society for Academic Emergency Medicine Disclosure$ 9othing to disclose CM# #ditor John D 0alam)a, MD, MS, Associate Professor of Medicine, !arvard Medical School, /eth #srael Deaconess Medical CenterC Chief #nformation 8fficer, Care roup !ealthcare System and !arvard Medical SchoolC Attending Physician, Division of Emergency Medicine, /eth #srael Deaconess Medical Center Nohn D !alam*a, MD, MS is a mem"er of the follo,ing medical societies$ American College of Emergency Physicians, American Medical #nformatics Association, Phi /eta Kappa, and Society for Academic Emergency Medicine Disclosure$ 9othing to disclose Chief #ditor "i() 4ul)arni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Oale-9e, !aven !ospital .ic* Kul*arni, MD is a mem"er of the follo,ing medical societies$ Alpha 8mega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical #nformatics Association, Phi /eta Kappa, and Society for Academic Emergency Medicine Disclosure$ )e"MD Salary for Employment

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