You are on page 1of 34

Background

The care of the trauma patient is demanding and requires speed and efficiency.
Evaluating patients who have sustained blunt abdominal trauma remains one of the
most challenging and resource-intensive aspects of acute trauma care.[1, 2]
Blunt abdominal trauma is a leading cause of morbidity and mortality among all age
groups. Identification of serious intra-abdominal pathology is often challenging.
Many injuries may not manifest during the initial assessment and treatment period.
Missed intra-abdominal injuries and concealed hemorrhage are frequent causes of
increased morbidity and mortality, especially in patients who survive the initial phase
after an injury.
Physical examination findings are notoriously unreliable. One reason is that
mechanisms of injury often result in other associated injuries that may divert the
physicians attention from potentially life-threatening intra-abdominal pathology.
Other common reasons are an altered mental state and drug and alcohol intoxication.
Coordinating a trauma resuscitation demands a thorough understanding of the
pathophysiology of trauma and shock, excellent clinical and diagnostic acumen, skill
with complex procedures, compassion, and the ability to think rationally in a chaotic
milieu.
Blunt abdominal trauma usually results from motor vehicle collisions (MVCs),
assaults, recreational accidents, or falls. The most commonly injured organs are the
spleen, liver, retroperitoneum, small bowel, kidneys (see the image below), bladder,
colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often
than women.

Blunt abdominal trauma. Right kidney injury with


blood in perirenal space. Injury resulted from high-speed motor vehicle collision
For more information, see the following:

Pediatric Abdominal Trauma

Penetrating Abdominal Trauma

Focused Assessment with Sonography in Trauma (FAST)

Abdominal Vascular Injuries

Anatomy
The abdomen can be arbitrarily divided into 4 areas. The first is the intrathoracic
abdomen, which is the portion of the upper abdomen that lies beneath the rib cage. Its
contents include the diaphragm, liver, spleen, and stomach. The rib cage makes this
area inaccessible to palpation and complete examination.
The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents
include the urinary bladder, urethra, rectum, small intestine, and, in females, ovaries,
fallopian tubes, and uterus. Injury to these structures may be extraperitoneal in nature
and therefore difficult to diagnose.
The third is the retroperitoneal abdomen, which contains the kidneys, ureters,
pancreas, aorta, and vena cava. Injuries to these structures are very difficult to
diagnose on the basis of physical examination findings. Evaluation of the structures in
this region may require computed tomography (CT) scanning, angiography, and
intravenous pyelography (IVP).
The fourth is the true abdomen, which contains the small and large intestines, the
uterus (if gravid), and the bladder (when distended). Perforation of these organs is
associated with significant physical findings and usually manifests with pain and
tenderness from peritonitis. Plain x-ray films are helpful if free air is present.
Additionally, diagnostic peritoneal lavage (DPL) is a useful adjunct.

Pathophysiology
Intra-abdominal injuries secondary to blunt force are attributed to collisions between
the injured person and the external environment and to acceleration or deceleration
forces acting on the persons internal organs. Blunt force injuries to the abdomen can
generally be explained by 3 mechanisms.
The first mechanism is deceleration. Rapid deceleration causes differential movement
among adjacent structures. As a result, shear forces are created and cause hollow,
solid, visceral organs and vascular pedicles to tear, especially at relatively fixed points
of attachment. For example, the distal aorta is attached to the thoracic spine and
decelerates much more quickly than the relatively mobile aortic arch. As a result,
shear forces in the aorta may cause it to rupture. Similar situations can occur at the
renal pedicles and at the cervicothoracic junction of the spinal cord.
Classic deceleration injuries include hepatic tear along the ligamentum teres and
intimal injuries to the renal arteries. As bowel loops travel from their mesenteric
attachments, thrombosis and mesenteric tears, with resultant splanchnic vessel
injuries, can result.
The second mechanism involves crushing. Intra-abdominal contents are crushed
between the anterior abdominal wall and the vertebral column or posterior thoracic

cage. This produces a crushing effect, to which solid viscera (eg, spleen, liver,
kidneys) are especially vulnerable.
The third mechanism is external compression, whether from direct blows or from
external compression against a fixed object (eg, lap belt, spinal column). External
compressive forces result in a sudden and dramatic rise in intra-abdominal pressure
and culminate in rupture of a hollow viscous organ (ie, in accordance with the
principles of Boyle law).
The liver and spleen seem to be the most frequently injured organs, though reports
vary. The small and large intestines are the next most frequently injured organs.
Recent studies show an increased number of hepatic injuries, perhaps reflecting
increased use of CT scanning and concomitant identification of more injuries.

Etiology
Vehicular trauma is by far the leading cause of blunt abdominal trauma in the civilian
population. Auto-to-auto and auto-to-pedestrian collisions have been cited as causes
in 50-75% of cases. Other common etiologies include falls and industrial or
recreational accidents. Rare causes of blunt abdominal injuries include iatrogenic
trauma during cardiopulmonary resuscitation, manual thrusts to clear an airway, and
the Heimlich maneuver.

Epidemiology
United States statistics
By nearly every measure, injury ranks as one of the most pressing health issues in the
United States. More than 150,000 people die each year as a result of injuries, such as
motor vehicle crashes, fires, falls, drowning, poisoning, suicide, and homicide.
Injuries are the leading cause of death and disability for US children and young
adults.
According to the 2000 statistics from the National Center for Injury Prevention and
Control, trauma (unintentional and intentional) was the leading cause of death in
persons aged 1-44 years. Further review of the data reveals that in those aged 15-25
years, 14,113 persons died from unintentional injuries, 73% of which were related to
vehicular trauma. In individuals aged 25-34 years, 57% of the 11,769 deaths reported
were from motor vehicle collisions.
In 2001, approximately 30 million people visited emergency departments (EDs) for
the treatment of nonfatal injuries, and more than 72,000 people were disabled by
injuries. Injury imposes exceptional costs, both in health care dollars and in human
losses, to society.
The true frequency of blunt abdominal trauma, however, is unknown. Data collected
from trauma centers reflect patients who are transported to or seek care at these
centers; these data may not reflect patients presenting to other facilities. The incidence
of out-of-hospital deaths is unknown.

One review from the National Pediatric Trauma Registry by Cooper et al reported that
8% of patients (total=25,301) had abdominal injuries. Eighty-three percent of those
injuries were from blunt mechanisms. Automobile-related injuries accounted for 59%
of those injuries.[3] Similar reviews from adult trauma databases reflect that blunt
trauma is the leading cause of intra-abdominal injury and that MVC is the leading
mode of injury. Blunt injuries account for approximately two thirds of all injuries.
Hollow viscus trauma is more frequent in the presence of an associated, severe, solid
organ injury, particularly to the pancreas. Approximately two thirds of patients with
hollow viscus trauma are injured in MVCs.

International statistics
In 1990, approximately 5 million people died worldwide as a result of injury. The risk
of death from injury varied strongly by region, age, and sex. Approximately 2 male
deaths due to violence were reported for every female death. Injuries accounted for
approximately 12.5% of all male deaths, compared with 7.4% of female deaths.
Globally, injury accounts for 10% of all deaths; however, injuries in sub-Saharan
Africa are far more destructive than in other areas. In sub-Saharan Africa, the risk of
death from trauma is highest in those aged 15-60 years, and the proportion of such
deaths from trauma is higher than in any other region of the world. South Africa, for
instance, has a traffic death rate per unit of distance traveled that is surpassed only by
those of Korea, Kenya, and Morocco.
Estimates indicate that by 2020, 8.4 million people will die yearly from injury, and
injuries from traffic collisions will be the third most common cause of disability
worldwide and the second most common cause in the developing world.
Data from the World Health Organization (WHO) indicate that falls from heights of
less than 5 meters are the leading cause of injury, and automobile crashes are the next
most frequent cause. These data reflect all injuries, not just blunt injuries to the
abdomen.
A review from Singapore described trauma as the leading cause of death in those aged
1-44 years. Traffic accidents, stab wounds, and falls from heights were the leading
modes of injury. Blunt abdominal trauma accounted for 79% of cases.[4]
A similar paper from India reported that blunt abdominal trauma is more frequent in
males aged 21-30 years; the majority of patients were injured in automobile accidents.
A German study indicated that, of patients with vertical deceleration injuries (ie, falls
from heights), only 5.9% had blunt abdominal injuries.

Age-related differences in incidence


Most studies indicate that the peak incidence is in persons aged 14-30 years. A review
of 19,261 patients with blunt abdominal trauma revealed equal incidence of hollow
viscus injuries in both children (ie, 14 y) and adults.

Sex-related differences in incidence

According to national and international data, blunt abdominal trauma is more


common in men. The male-to-female ratio is 60:40.

Prognosis
Overall prognosis for patients who sustain blunt abdominal trauma is favorable.
Without statistics that indicate the number of out-of-hospital deaths and the total
number of patients with blunt trauma to the abdomen, a description of the specific
prognosis for patients with intra-abdominal injuries is difficult. Mortality rates for
hospitalized patients are approximately 5-10%.
The National Pediatric Trauma Registry reported that 9% of pediatric patients with
blunt abdominal trauma died. Of these, only 22% were reported as having intraabdominal injuries as the likely cause of death.[3]
A review from Australia of intestinal injuries in blunt trauma reported that 85% of
injuries occurred from vehicular accidents. The mortality rate was 6%. In a large
review of operating room deaths in which blunt trauma accounted for 61% of all
injuries, abdominal trauma was the primary identified cause of death in 53.4% of
cases.

Patient Education
Proper adjustment of restraints in motor vehicles is an important aspect of patient
education. The following are key recommendations:

Wear lap belts in conjunction with shoulder restraints.

Adjust lap belts so that they fit snugly, and place them across the lower
abdomen and below the iliac crests.

Wear restraints even in vehicles equipped with supplemental vehicle restraints


(eg, airbags).

Adjust seats and steering wheels so that the distance between the abdominal
wall and the steering wheel is as wide as possible while still allowing proper
control of the vehicle.

Advise patients to practice defensive driving by observing speed limits and keeping a
safe distance between them and other automobiles on the road.
For patient education resources, see the Kidneys and Urinary System Center, as well
as Blood in the Urine and Bruises.

History
Initially, evaluation and resuscitation of a trauma patient occur simultaneously. In
general, do not obtain a detailed history until life-threatening injuries have been

identified and therapy has been initiated. The initial assessment begins at the scene of
the injury, with information provided by the patient, family, bystanders, or
paramedics, or police.
Important factors relevant to the care of a patient with blunt abdominal trauma,
specifically those involving motor vehicles, include the following:

The extent of vehicular damage

Whether prolonged extrication was required

Whether the passenger space was intruded

Whether a passenger died

Whether the person was ejected from the vehicle

The role of safety devices such as seat belts and airbags

The presence of alcohol or drug use

The presence of a head or spinal cord injury

Whether psychiatric problems were evident

Important elements of the pertinent history include the following:

Allergies

Medications

Past medical and surgical history

Time of last meal

Immunization status

Events leading to the incident

Social history, including history of substance abuse

Information from family and friends

The mnemonic AMPLE (A llergies, M edications, P ast medical history, L ast meal or
other intake, and E vents leading to presentation) is often useful as a means of
remembering key elements of the history.

A history of out-of-hospital hypotension is a predictor of more significant intraabdominal injuries. Even if the patient is normotensive at arrival in the emergency
department (ED), he or she should be considered to be at increased risk.

Physical Examination
Primary survey
Resuscitation is performed concomitantly and continues as the physical examination
is completed. Priorities in resuscitation and diagnosis are established on the basis of
hemodynamic stability and the degree of injury. The goal of the primary survey, as
directed by the Advanced Trauma Life Support (ATLS) protocol, is to identify and
expediently treat life-threatening injuries. The protocol includes the following:

Airway, with cervical spine precautions

Breathing

Circulation

Disability

Exposure

It is imperative for all personnel involved in the direct care of a trauma patient to
exercise universal precautions against body fluid exposure. The incidence of
infectious diseases (eg, HIV, hepatitis) is significantly higher in trauma patients than
in the general public, with some centers reporting rates as high as 19%. Even in
medical centers with relatively low rates of communicable diseases, safely
determining who is infected with such pathogens is impossible.
The standard barrier precautions include a hat, eye shield, face mask, gown, gloves,
and shoe covers. Unannounced trauma arrival is probably the most common situation
that leads to a breach in barrier precautions. Personnel must be instructed to adhere to
these guidelines at all times, even if it means a 30-second delay in patient care.

Secondary survey
After an appropriate primary survey and initiation of resuscitation, attention should be
focused on the secondary survey of the abdomen. The secondary survey is the
identification of all injuries via a head-to-toe examination. For life-threatening
injuries that necessitate emergency surgery, a comprehensive secondary survey should
be delayed until the patient has been stabilized.
At the other end of the spectrum are victims of blunt trauma who have a benign
abdomen upon initial presentation. Many injuries initially are occult and manifest
over time. Frequent serial examinations, in conjunction with the appropriate

diagnostic studies, such as abdominal computed tomography (CT) and bedside


ultrasonography, are essential in any patient with a significant mechanism of injury.
The evaluation of a patient with blunt abdominal trauma must be accomplished with
the entire patient in mind, with all injuries prioritized accordingly. This implies that
injuries involving the head, the respiratory system, or the cardiovascular system may
take precedence over an abdominal injury.
The abdomen should neither be ignored nor be the sole focus of the treating clinician
and surgeon. In an unstable patient, the question of abdominal involvement must be
expediently addressed. This is accomplished by identifying free intra-abdominal fluid
with diagnostic peritoneal lavage (DPL) or focused assessment with sonography for
trauma (FAST). The objective is rapid identification of those patients who need a
laparotomy.
The initial clinical assessment of patients with blunt abdominal trauma is often
difficult and notably inaccurate. Associated injuries often cause tenderness and
spasms in the abdominal wall and make diagnosis difficult. Lower rib fractures, pelvic
fractures, and abdominal wall contusions may mimic the signs of peritonitis. In a
collected series of 955 patients, Powell et al reported that clinical evaluation alone has
an accuracy rate of only 65% for detecting the presence or absence of intraperitoneal
blood.[5]
In general, accuracy increases if the patient is reevaluated repeatedly and at frequent
intervals. However, repeated examinations may not be feasible in patients who need
general anesthesia and surgery for other injuries. The greatest compromise of the
physical examination occurs in the setting of neurologic dysfunction, which may be
caused by head injury or substance abuse.
The most reliable signs and symptoms in alert patients are pain, tenderness,
gastrointestinal hemorrhage, hypovolemia, and evidence of peritoneal irritation.
However, large amounts of blood can accumulate in the peritoneal and pelvic cavities
without any significant or early changes in the physical examination findings.
Bradycardia may indicate the presence of free intraperitoneal blood in a patient with
blunt abdominal injuries.
The respiratory pattern should be observed because abdominal breathing may indicate
spinal cord injury. A sensory examination of the chest and abdomen should be
performed to evaluate the potential for spinal cord injury. Spinal cord injury may
interfere with the accurate assessment of the abdomen by causing decreased or absent
pain perception.
The abdominal examination must be systematic. The abdomen is inspected for
abrasions or ecchymosis. Particular attention should be paid to injury patterns that
predict the potential for intra-abdominal trauma (eg, lap belt abrasions, steering
wheelshaped contusions). In most studies, lap belt marks have been correlated with
rupture of the small intestine and an increased incidence of other intra-abdominal
injuries.

Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign)
indicates retroperitoneal hemorrhage, but this is usually delayed for several hours to
days.
Visual inspection for abdominal distention, which may be due to pneumoperitoneum,
gastric dilatation secondary to assisted ventilation or swallowing of air, or ileus
produced by peritoneal irritation, is important.
Auscultation of bowel sounds in the thorax may indicate the presence of a
diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease or
traumatic arteriovenous fistula.
Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound
tenderness, which suggests peritoneal injury. Such signs appearing soon after an
injury suggest leakage of intestinal content. Peritonitis due to intra-abdominal
hemorrhage may take several hours to develop.
Fullness and doughy consistency on palpation may indicate intra-abdominal
hemorrhage. Crepitation or instability of the lower thoracic cage indicates the
potential for splenic or hepatic injuries associated with lower rib injuries.
Tenderness on percussion constitutes a peritoneal sign. Tenderness mandates further
evaluation and probably surgical consultation.
Rectal and bimanual vaginal pelvic examinations should be performed.[6] A rectal
examination should be done to search for evidence of bony penetration resulting from
a pelvic fracture, and the stool should be evaluated for gross or occult blood. The
evaluation of rectal tone is important for determining the patients neurologic status,
and palpation of a high-riding prostate suggests urethral injury.
The genitals and perineum should be examined for soft tissue injuries, bleeding, and
hematoma. Pelvic instability indicates the potential for lower urinary tract injury, as
well as pelvic and retroperitoneal hematoma. Open pelvic fractures are associated
with a mortality rate exceeding 50%.
A nasogastric tube should be placed routinely (in the absence of contraindications, eg,
basilar skull fracture) to decompress the stomach and to assess for the presence of
blood. If the patient has evidence of a maxillofacial injury, an orogastric tube is
preferred.
As the assessment continues, a Foley catheter is placed and a sample of urine is sent
for analysis for microscopic hematuria. If injury to the urethra or bladder is suggested
because of an associated pelvic fracture, then a retrograde urethrogram is performed
before catheterization.
With respect to the primary and secondary surveys, pediatric patients are assessed and
treatedat least initiallyas adults. However, there are obvious anatomic and
clinical differences between children and adults that must be kept in mind, including
the following:

A pediatric patients physiologic response to injury is different.

Effective communication with a child is not always possible.

Physical examination findings become more important in children.

A pediatric patients blood volume is smaller, predisposing to rapid


exsanguinations.

Technical procedures in pediatric patients tend to be more time consuming and


challenging.

A childs relatively large body surface area contributes to rapid heat loss.

Perhaps the most significant difference between pediatric and adult blunt trauma is
that, for the most part, pediatric patients can be resuscitated and treated
nonoperatively. Some pediatric surgeons often transfuse up to 40 mL/kg of blood
products in an effort to stabilize a pediatric patient. Obviously, if this fails and the
child continues to be unstable, laparotomy is indicated.

Tertiary survey
The concept of the tertiary trauma survey was first introduced by Enderson et al to
assist in the diagnosis of any injuries that may have been missed during the primary
and secondary surveys.[7] The tertiary survey involves a repetition of the primary and
secondary surveys and a revision of all laboratory and radiographic studies. In 1
study, a tertiary trauma survey detected 56% of injuries missed during the initial
assessment within 24 hours of admission.[8]

Diagnostic Considerations
Identification of intra-abdominal injuries can be challenging. Common pitfalls in
diagnosis include the following:

Failure to suspect intra-abdominal injury from appropriate mechanisms

Failure to evaluate abdominal/flank/costal margin pain after blunt abdominal


injury

Failure to obtain timely surgical consultation and operative intervention

Failure to recognize intra-abdominal hemorrhage and delay operation for


additional diagnostic testing in the face of hemodynamic compromise

Differentials

Domestic Violence

Hemorrhagic Stroke

Hypovolemic Shock

Lower Genitourinary Trauma

Penetrating Abdominal Trauma in Emergency Medicine

Pregnancy Trauma

Upper Genitourinary Trauma

Approach Considerations
In recent years, laboratory evaluation of trauma patients has been a matter of
significant discussion. Commonly recommended studies include serum glucose,
complete blood count (CBC), serum chemistries, serum amylase, urinalysis,
coagulation studies, blood typing and cross-matching, arterial blood gases (ABGs),
blood ethanol, urine drug screens, and a urine pregnancy test (for females of
childbearing age).
Serum electrolyte values, creatinine level, and glucose values are often obtained for
reference, but typically they have little or no value in the initial management period.
Aggressive radiographic and surgical investigation is indicated in patients with
persistent hyperamylasemia or hyperlipasemia, conditions that suggest significant
intra-abdominal injury.
All patients should have their tetanus immunization history reviewed. If it is not
current, prophylaxis should be given.
The most important initial concern in the evaluation of a patient with blunt abdominal
trauma is an assessment of hemodynamic stability. In the hemodynamically unstable
patient, a rapid evaluation must be made regarding the presence of hemoperitoneum.
This can be accomplished by means of diagnostic peritoneal lavage (DPL) or the
focused assessment with sonography for trauma (FAST). Radiographic studies of the
abdomen are indicated in stable patients when the physical examination findings are
inconclusive.
Go to Focused Assessment with Sonography in Trauma (FAST) for complete
information on this topic.

Blood Studies
Complete blood count
The presence of massive hemorrhage is usually obvious from hemodynamic
parameters, and an abnormal hematocrit value merely confirms the diagnosis. Normal

hemoglobin and hematocrit results do not rule out significant hemorrhage. Patients
bleed whole blood. Until blood volume is replaced with crystalloid solution or
hormonal effects (eg, adrenocorticotropic hormone [ACTH], aldosterone, antidiuretic
hormone [ADH]) and transcapillary refill occurs, anemia may not develop.
Bedside diagnostic testing with rapid hemoglobin or hematocrit machines may
quickly identify patients who have physiologically significant volume deficits and
hemodilution. Reported hemoglobin from ABG measurements also may be useful in
identifying anemia. Some studies have correlated a low initial hematocrit (ie, < 30%)
with significant injuries.
Do not withhold transfusion in patients who have relatively normal hematocrit results
(ie, >30%) but have evidence of clinical shock, serious injuries (eg, open-book pelvic
fracture), or significant ongoing blood loss. Hemodynamic instability in an adult
despite the administration of 2 L of fluid indicates ongoing blood loss and is an
indication for immediate blood transfusion. Use platelet transfusions to treat patients
with thrombocytopenia (ie, platelet count < 50,000/L) and ongoing hemorrhage.
An elevated white blood cell (WBC) count on admission is nonspecific and does not
predict the presence of a hollow viscus injury (HVI). The diagnostic value of serial
WBC counts for predicting HVI within the first 24 hours after trauma is very limited.
[9]

Serum electrolyte measurements


Recently, the usefulness of routine serum chemistries of trauma patients has been
questioned. Most trauma victims are younger than 40 years and rarely are taking
medications that may alter electrolytes (eg, diuretics, potassium replacements).
The more prudent choice when attempting to limit cost involves selective ordering of
these studies. Selection should be based on the patients medications, the presence of
concurrent nausea or vomiting, the presence of dysrhythmias, or a history of renal
failure or other chronic medical problems associated with electrolyte imbalance.

Serum glucose and carbon dioxide measurements


If blood gas measurements are not routinely obtained, serum chemistries that measure
serum glucose and carbon dioxide levels are indicated. Rapid bedside blood-glucose
determination, obtained with a finger-stick measuring device, is important for patients
with altered mental status.

Liver function tests


Liver function tests (LFTs) may be useful in the patient with blunt abdominal trauma;
however, test findings may be elevated for several reasons (eg, alcohol abuse).[10] One
study has shown that an aspartate aminotransferase (AST) or alanine aminotransferase
(ALT) level more than 130 U corresponds with significant hepatic injury.[11] Lactate
dehydrogenase (LDH) and bilirubin levels are not specific indicators of hepatic
trauma.

Serum amylase or lipase measurements


The serum lipase or amylase level is neither sensitive nor specific as a marker for
major pancreatic or enteric injury. Normal levels do not exclude a major pancreatic
injury. Elevated levels may be caused by injuries to the head and face or by an
assortment of nontraumatic causes (eg, alcohol, narcotics, various other drugs).
Amylase or lipase levels may be elevated because of pancreatic ischemia caused by
the systemic hypotension that accompanies trauma.
However, persistent hyperamylasemia or hyperlipasemia (eg, abnormal elevation 3-6
hours after trauma) should raise the suggestion of significant intra-abdominal injury
and is an indication for aggressive radiographic and surgical investigation.

Coagulation profile
The cost-effectiveness of routine prothrombin time (PT)/activated partial
thromboplastin time (aPTT) determination upon admission is questionable. PT or
aPTT should be measured in patients who have a history of blood dyscrasias (eg,
hemophilia), who have synthetic problems (eg, cirrhosis), or who take anticoagulant
medications (eg, warfarin, heparin).

Blood typing, screening, and cross-matching


Blood from all trauma patients with suspected blunt abdominal injury should be
screened and typed. If an injury is identified, this practice greatly reduces the time
required for cross-matching. An initial cross-match should be performed on a
minimum of 4-6 units for those patients with clear evidence of abdominal injury and
hemodynamic instability. Until cross-matched blood is available, O-negative or typespecific blood should be used.

Arterial blood gas measurements


ABG values may provide important information in major trauma victims. In addition
to information about oxygenation (eg, partial pressure of oxygen [PO2] and arterial
oxygen saturation [SaO2]) and ventilation (partial pressure of carbon dioxide [PCO2]),
this test provides valuable information regarding oxygen delivery through calculation
of the alveolar-arterial (A-a) gradient. ABG determinations also report total
hemoglobin more rapidly than CBCs.
Upon initial hospital admission, suspect metabolic acidemia to result from the lactic
acidosis that accompanies shock. A moderate base deficit (ie, more than 5 mEq)
indicates the need for aggressive resuscitation and determination of the etiology.
Attempt to improve systemic oxygen delivery by ensuring an adequate SaO2 (ie,
>90%) and by acquiring volume resuscitation with crystalloid solutions and, if
indicated, blood.

Drug and alcohol screening

Perform drug and alcohol screens on trauma patients who have alterations in their
level of consciousness. Breath or blood testing may quantify alcohol level.

Urine Studies
Indications for diagnostic urinalysis include significant trauma to the abdomen and/or
flank, gross hematuria, microscopic hematuria in the setting of hypotension, and a
significant deceleration mechanism.[12]
Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP) or
computed tomography (CT) scanning with intravenous (IV) contrast. Gross hematuria
indicates a workup that includes cystography and IVP or CT scanning of the abdomen
with contrast.
Perform a urine toxicologic screen as appropriate. Obtain a serum or urine pregnancy
test on all females of childbearing age.

Plain Radiography
Although their overall value in the evaluation of patients with blunt abdominal trauma
is limited, plain films can demonstrate numerous findings. The chest radiograph may
aid in the diagnosis of abdominal injuries such as ruptured hemidiaphragm (eg, a
nasogastric tube seen in the chest) or pneumoperitoneum.
The pelvic or chest radiograph can demonstrate fractures of the thoracolumbar spine.
The presence of transverse fractures of the vertebral bodies (ie, Chance fractures)
suggests a higher likelihood of blunt injuries to the bowel. In addition, free
intraperitoneal air, or trapped retroperitoneal air from duodenal perforation, may be
seen.

Ultrasonography
The use of diagnostic ultrasonography to evaluate a patient with blunt trauma for
abdominal injuries has been advocated since the 1970s. European and Asian
investigators have extensive experience with this technology and are leaders in the use
of ultrasound for the diagnosis of blunt abdominal trauma.
The first American report of physician-performed abdominal ultrasonography in the
evaluation of blunt abdominal trauma was published in 1992 by Tso and colleagues.[13]
Since then, numerous articles have been published in the United States advocating the
use of ultrasound (ie, FAST) in the evaluation of the patient with blunt abdominal
trauma.
Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination
that can be performed by emergency clinicians and trauma surgeons to detect
hemoperitoneum. In fact, in many medical centers, the FAST examination has
virtually replaced DPL as the procedure of choice in the evaluation of
hemodynamically unstable trauma patients.

The FAST examination is based on the assumption that all clinically significant
abdominal injuries are associated with hemoperitoneum. However, the detection of
free intraperitoneal fluid is based on factors such as the body habitus, injury location,
presence of clotted blood, position of the patient, and amount of free fluid present.
In a patient with isolated blunt abdominal trauma and multisystem injuries, FAST
performed by an experienced sonographer can rapidly identify free intraperitoneal
fluid (generally appearing as a black stripe). The sensitivity for solid organ
encapsulated injury is moderate in most studies. Hollow viscus injury (HVI) rarely is
identified; however, free fluid may be visualized. For patients with persistent pain or
tenderness or those developing peritoneal signs, FAST may be considered as a
complementary measure to CT scanning, DPL, or exploration.
The minimum threshold for detecting hemoperitoneum is unknown and remains a
subject of interest. Kawaguchi and colleagues found that 70 mL of blood could be
detected,[14] whereas Tiling et al found that 30 mL is the minimum requirement for
detection with ultrasonography.[15] They also concluded that a small anechoic stripe in
the Morison pouch represents approximately 250 mL of fluid, whereas 0.5-cm and 1cm stripes represent approximately 500 mL and 1 L of free fluid, respectively.
The current FAST examination protocol consists of 4 acoustic windows with the
patient supine. These windows are pericardiac, perihepatic, perisplenic, and pelvic
(known as the 4 P s). An examination is interpreted as positive if free fluid is found in
any of the 4 acoustic windows and as negative if no fluid is seen. An examination is
deemed indeterminate if any of the windows cannot be adequately assessed.
The pericardial window is obtained via a subcostal or transthoracic approach. It
provides a 4-chamber view of the heart and can detect the presence of
hemopericardium, which is demonstrated by the separation of the visceral and parietal
pericardial layers. The perihepatic window yields views of portions of the liver,
diaphragm, and right kidney. It reveals fluid in the Morison pouch (see the images
below), the subphrenic space, and the right pleural space.

Blunt abdominal trauma. Normal Morison pouch (ie,

no free fluid).
Morison pouch

Blunt abdominal trauma. Free fluid in

The perisplenic window provides views of the spleen and the left kidney and reveals
fluid in the splenorenal recess (see the images below), the left pleural space, and the
subphrenic space. The pelvic window makes use of the bladder as a sonographic
window and thus is best accomplished while the patient has a full bladder. In males,
free fluid is seen as an anechoic area (sonographically black) in the rectovesicular
pouch or cephalad to the bladder. In females, fluid accumulates in the Douglas pouch,
posterior to the uterus.

Blunt abdominal trauma. Normal splenorenal recess.

Blunt abdominal trauma. Free fluid in splenorenal


recess.

FASTs diagnostic accuracy generally is equal to that of DPL. Studies in the United
States have demonstrated the value of bedside sonography as a noninvasive approach
for rapid evaluation of hemoperitoneum. The studies demonstrate a degree of operator
dependence; however, some studies have shown that with a structured learning
session, even novice operators can identify free intra-abdominal fluid, especially if
more than 500 mL of fluid is present. Sensitivity and specificity of these studies range
from 85% to 95%.[16, 17, 18, 19, 20]
As noted, FAST relies on hemoperitoneum to identify patients with injury. Chiu and
colleagues, in their study of 772 patients with blunt trauma undergoing FAST scans,
reported 52 patients had an abdominal injury.[21] Of the 52 patients, 15 (29%) had no
hemoperitoneum on FAST or CT scan results. These findings suggest that the reliance
on hemoperitoneum as the sole indicator of abdominal visceral injury limits the utility
of FAST as a diagnostic screening tool in stable patients with blunt abdominal trauma.
Rozycki et al studied 1540 patients and reported that ultrasonography was the most
sensitive and specific modality for the evaluation of hypotensive patients with blunt
abdominal trauma (sensitivity and specificity, 100%).[20]
Hemodynamically stable patients with positive FAST results may require a CT scan to
better define the nature and extent of their injuries. Taking every patient with a
positive FAST result to the operating room may result in an unacceptably high
laparotomy rate.
Hemodynamically stable patients with negative FAST results require close
observation, serial abdominal examinations, and a follow-up FAST examination.
However, strongly consider performing a CT scan, especially if the patient is
intoxicated or has other associated injuries.
Hemodynamically unstable patients with negative FAST results are a diagnostic
challenge. Options include DPL, exploratory laparotomy, and, possibly, a CT scan
after aggressive resuscitation.
Go to Focused Assessment with Sonography in Trauma (FAST) for complete
information on this topic.

Computed Tomography
Although expensive and potentially time-consuming, CT scanning often provides the
most detailed images of traumatic pathology and may assist in determination of
operative intervention.[22, 23, 24, 25] CT remains the criterion standard for the detection of
solid organ injuries (see the image below). In addition, a CT scan of the abdomen can
reveal other associated injuries, notably vertebral and pelvic fractures and injuries in
the thoracic cavity.

Blunt abdominal trauma with liver laceration.


CT scanning, unlike DPL or FAST, has the capability to determine the source of
hemorrhage (see the image below). In addition, many retroperitoneal injuries go
unnoticed with DPL and FAST examinations.

Blunt abdominal trauma with splenic injury and


hemoperitoneum.
Transport only hemodynamically stable patients to the CT scanner. When performing
CT scans, closely and carefully monitor vital signs for clinical evidence of
decompensation. Preliminary evidence suggests that a flat vena cava on CT scan is a
marker for underresuscitation and may be correlated with higher mortality and
hemodynamic decompensation.[26]
CT scans provide excellent imaging of the pancreas, duodenum, and genitourinary
system. The images can help quantitate the amount of blood in the abdomen and can
reveal individual organs with precision. The primary advantage of CT scanning is its
high specificity and use for guiding nonoperative management of solid organ injuries.
Drawbacks of CT scanning relate to the need to transport the patient from the trauma
resuscitation area and the additional time required to perform CT scanning compared
to FAST or DPL.
In addition, CT scanning may miss injuries to the diaphragm and perforations of the
gastrointestinal (GI) tract, especially when performed soon after the injury. Although
some pancreatic injuries may be missed with a CT scan performed soon after trauma,
virtually all are identified if the scan is repeated in 36-48 hours. For selected patients,
endoscopic retrograde cholangiopancreatography (ERCP) may complement CT
scanning to rule out a ductal injury.
Finally, CT scanning is relatively expensive and time consuming and requires oral or
intravenous (IV) contrast, which may cause adverse reactions. The best CT imagery
requires both oral and IV contrast. Some controversy has arisen over the use of oral

contrast and whether the additional information it provides negates the drawbacks of
increased time to administration and risk of aspiration. The value of oral contrast in
diagnosing bowel injury has been debated, but no definitive answer exists at this time.

Diagnostic Laparoscopy
The introduction of minimally invasive surgery has revolutionized many surgical
diagnostic protocols. In the late 1980s and early 1990s, there was considerable interest
in the use of laparoscopy for evaluation and management of blunt and penetrating
abdominal trauma. Subsequent studies, however, revealed major limitations to this
approach and cautioned against its widespread use. The most important limitation is
inability to reliably identify hollow viscus and retroperitoneal injuries, even in the
hands of experienced laparoscopists.
Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for the
introduction of the laparoscope and creating other ports for retractors, clamps, and
other tools necessary for visualization of the repair.
Diagnostic laparoscopy has been most useful in the evaluation of possible
diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on the left
side.[27, 28, 29] In blunt trauma, it has no clear advantages over less invasive modalities
such as DPL and CT scanning; furthermore, complications can result from trocar
misplacement.

Diagnostic Peritoneal Lavage


The idea of evaluating the abdomen by analyzing its contents was first used in the
diagnosis of acute abdominal conditions. In 1906, Salomon described the passage of a
urethral catheter by means of a trocar inserted through the abdominal wall to obtain
samples of peritoneal fluid with the aim of establishing the diagnosis of peritonitis
from infectious agents (eg, pneumococcal or tuberculous organisms). This technique
has since been refined and is now known as abdominal paracentesis.
In 1926, Neuhof and Cohen described the sampling of peritoneal fluid in cases of
acute pancreatitis and blunt abdominal trauma by passing a spinal needle through the
abdominal wall.[30] In 1965, Root et al reported the use of percutaneous DPL in
patients who had sustained blunt abdominal trauma.[31]
DPL is used as a method of rapidly determining the presence of intraperitoneal blood.
It is particularly useful if the history and abdominal examination of an unstable
patient with multisystem injuries are either unreliable (eg, because of head injury,
alcohol, or drug intoxication) or equivocal (eg, because of lower rib fractures, pelvic
fractures, or confounding clinical examination).
DPL is also useful for patients in whom serial abdominal examinations cannot be
performed (eg, those in an angiographic suite or operating room during emergency
orthopedic or neurosurgical procedures).[32]
DPL is indicated for the following patients in the setting of blunt trauma:

Patients with a spinal cord injury

Those with multiple injuries and unexplained shock

Obtunded patients with a possible abdominal injury

Intoxicated patients in whom abdominal injury is suggested

Patients with potential intra-abdominal injury who will undergo prolonged


anesthesia for another procedure

The only absolute contraindication to DPL is the obvious need for laparotomy.
Relative contraindications include morbid obesity, a history of multiple abdominal
surgeries, and pregnancy.
Various methods of introducing the catheter into the peritoneal space have been
described. These include the open, semiopen, and closed methods. The open method
requires an infraumbilical skin incision that is extended to and through the linea alba.
(In pregnant patients or in patients with particular risk for potential pelvic hematoma,
the incision should be placed superior to the umbilicus.) The peritoneum is opened,
and the catheter is inserted under direct visualization.
The semiopen method is identical, except that the peritoneum is not opened and the
catheter is delivered percutaneously through the peritoneum into the peritoneal cavity.
The closed technique requires the catheter to be inserted blindly through the skin,
subcutaneous tissue, linea alba, and peritoneum.
The closed and semiopen techniques at the infraumbilical site are preferred at most
centers. The fully open method is the most technically demanding and is restricted to
those situations in which the closed or semiopen technique is unsuccessful or is
deemed unsafe (eg, patients with pelvic fractures, pregnancy, obesity, or prior
abdominal operations).
After insertion of the catheter into the peritoneum, attempt to aspirate free
intraperitoneal blood (at least 15-20 mL). DPL results are considered positive in a
blunt trauma patient if 10 mL of grossly bloody aspirate is obtained before infusion of
the lavage fluid or if the siphoned lavage fluid contains more than 100,000 red blood
cells (RBCs)/L, more than 500 white blood cells (WBCs)/L, elevated amylase
content, bile, bacteria, vegetable matter, or urine. Only approximately 30 mL of blood
is needed in the peritoneum to produce a microscopically positive DPL result.
If findings are negative, infuse 1 L of crystalloid solution (eg, lactated Ringer
solution) into the peritoneum. Then, allow this fluid to drain by gravity, and ensure
that laboratory analysis is performed.
Complications of DPL include bleeding from the incision and catheter insertion,
infection (ie, wound, peritoneal), and injury to intra-abdominal structures (eg, urinary
bladder, small bowel, uterus). These complications may increase the possibility of
false-positive studies. Additionally, infection of the incision, peritonitis from the

catheter placement, laceration of the urinary bladder, or injury to other intraabdominal organs can occur.
Bleeding from the incision, dissection, or catheter insertion can cause false-positive
results that may lead to unnecessary laparotomy. Achieve appropriate hemostasis prior
to entering the peritoneum and placing the catheter. False-positive DPL results can
occur if an infraumbilical approach is used in a patient with a pelvic fracture. A pelvic
x-ray film should be obtained prior to performing DPL if a pelvic fracture is
suggested. Before DPL is attempted, the urinary bladder and stomach should be
decompressed.
DPL has been shown in some studies to have a diagnostic accuracy of 98-100%, a
sensitivity of 98-100%, and a specificity of 90-96%. It has some advantages,
including high sensitivity, rapidity, and immediate interpretation. The main limitations
of DPL include its potential for iatrogenic abdominal injury and its high sensitivity,
which can lead to nontherapeutic laparotomies.
With the availability of fast, noninvasive, and better imaging modalities (eg, FAST,
CT scanning), the role of DPL is now limited to the evaluation of unstable trauma
patients in whom FAST results are negative or inconclusive. In some contexts, DPL
may be complemented with a CT scan if the patient has positive lavage results but
stabilizes.

Prehospital Care
Prehospital care focuses on rapidly evaluating life-threatening problems, initiating
resuscitative measures, and initiating prompt transport to a definitive care site.[33, 34]
The injured patient is at risk for progressive deterioration from continued bleeding
and requires rapid transport to a trauma center or the closest appropriate facility, with
appropriate stabilization procedures performed en route. Hence, securing the airway,
placing large-bore intravenous (IV) lines, and administering IV fluid must take place
en route, unless transport is delayed.
A study by Nirula et al demonstrates the importance of field triage protocols that
allow immediate transport to definitive care sites for very severely injured patients.[35]
In the study, the odds of death were 3.8 times greater for patients initially triaged to a
nontrauma center. Such responses require preplanning within a mature trauma system
and mandate appropriate prehospital training and protocols.
Use endotracheal intubation to secure the airway of any patient who is unable to
maintain the airway or who has potential airway threats. Secure the airway in
conjunction with in-line cervical immobilization in any patient who may have
suffered cervical trauma. Provide artificial ventilation by using a high fraction of
inspired oxygen (FIO2) for patients who exhibit compromised breathing respirations.
Maintain oxygen saturation (SaO2) at more than 90-92%.
External hemorrhage rarely is associated with blunt abdominal trauma. If external
bleeding is present, control it with direct pressure. Note any signs of inadequate

systemic perfusion. Consider intraperitoneal hemorrhage whenever evidence of


hemorrhagic shock is found in the absence of external hemorrhage.
Initiate volume resuscitation with crystalloid solution; however, never delay patient
transport while IV lines are inserted. En route, administer a fluid bolus of lactated
Ringer or normal saline solution to patients with evidence of shock.[36, 37]
Titrate IV fluid therapy to the patients clinical response. Because overaggressive
volume resuscitation may lead to recurrent or increased hemorrhage, IV fluids should
be titrated to a systolic blood pressure of 90-100 mm Hg. This practice should provide
the mean blood pressure necessary to maintain perfusion of the vital organs.
Acquire expeditious and complete spinal immobilization on patients with multisystem
injuries and on patients with a mechanism of injury that has potential for spinal cord
trauma. In the rural setting, the pneumatic antishock garment may have a role for
treating shock resulting from a severe pelvic fracture.
Promptly notify the destination hospital so that that facility can activate its trauma
team and prepare for the patient.

Emergency Department Care


Upon the patients arrival in the emergency department (ED) or trauma center, a rapid
primary survey should be performed to identify immediate life-threatening problems.
The first priority is reassessment of the airway. Protection of the cervical spine with
in-line immobilization is absolutely mandatory. If intubation is indicated, attempt
nasotracheal (ie, if no contraindications) or endotracheal intubation. If possible,
perform and record a brief neurologic examination prior to neuromuscular blockade
and intubation. If intubation is unsuccessful, perform cricothyroidotomy.
After an airway has been established, adequate ventilatory exchange is assessed by
auscultation of both lung fields. Patients who display apnea or hypoventilation require
respiratory support, as do those patients with tachypnea. Provide all patients with
supplemental oxygen from a device capable of delivering a high fraction of inspired
oxygen (FIO2) (eg, a nonrebreather mask).
Clinical diagnosis of a tension pneumothorax is treated with needle decompression
followed by chest thoracostomy tube placement. Other mechanical factors that can
interfere with ventilation include sucking chest wounds, a hemothorax, and
pulmonary contusion. Treat these aggressively and expediently.
The next priority in the primary survey is an assessment of the circulatory status of
the patient. Circulatory collapse in a patient with blunt abdominal trauma is usually
caused by hypovolemia from hemorrhage. Identification of hypovolemia and signs of
shock necessitate vigorous resuscitation and attempts to identify the source of blood
loss.

Effective volume resuscitation is accomplished by controlling external hemorrhage


and infusing warmed crystalloid solution via 2 large-bore (eg, 18-gauge) peripheral
IV lines. Use central lines (preferably femoral by using a large-bore line such as a
Cordis catheter) and cutdowns (eg, saphenous, brachial) for patients in whom
percutaneous peripheral access cannot be established. Administer a rapid bolus of
crystalloid.
Hemodynamic instability despite the administration of 2 L of fluid to adult patients
indicates ongoing blood loss and is an indication for immediate blood transfusion.
Administer type O, Rh-negative blood if cross-matched or type-specific blood is not
available.
The CONTROL trial, the only prospective randomized trial of factor VII in trauma
patients, evaluated the efficacy and safety of recombinant factor VIIa as an adjunct to
direct hemostasis in major trauma. Results showed a small decrease in blood
utilization but no mortality benefit. Currently available data do not support empiric
use of factor VIIa for civilian trauma patients.[38]
The primary survey is completed with a brief neurologic assessment of the patient
using elements of the Glasgow Coma Scale. The patient is undressed and draped in
clean, dry, warm sheets.
After the primary survey and initial resuscitation have begun, complete the secondary
survey, as described earlier (see Physical Examination). Perform a thorough head-totoe examination, paying attention to evidence of the mechanism of injury and
potentially injured areas. Before the placement of a nasogastric tube and Foley
catheter, perform appropriate head, neck, pelvic, perineum, and rectal examinations.
Log-roll the patient to examine the back and palpate the entire spinal column.
On the basis of the injury mechanism and the findings from physical examination,
obtain initial trauma radiographic studies. In general, trauma suite views include
lateral cervical spine, anterior portable chest, and pelvis radiographs. In-line spinal
immobilization must be continued until spinal fractures have been ruled out.
Additional radiographs are indicated for other findings in the secondary survey.
Bedside ultrasonography using a trauma examination protocol (eg, FAST) can be used
to determine the presence of intraperitoneal hemorrhage (see the images below). If
findings are negative or equivocal, DPL may be performed in hemodynamically
unstable patients.

Ultrasound image of right flank. Clear hypoechoic


stripe exists between right kidney and liver in Morison pouch.

Ultrasound image of left flank in same patient, with


thin hypoechoic stripe above spleen and wider hypoechoic stripe in splenorenal
recess.
Depending on patient stability, injury mechanism, and likelihood of intra-abdominal
injury, further investigation may be warranted for patients who are hemodynamically
stable after the initial assessment and resuscitation and who have negative or
equivocal FAST or DPL results. Further investigation includes contrast-enhanced CT
scans of the abdomen and pelvis or serial examinations and ultrasonography.

Approach Considerations
Treatment of blunt abdominal trauma begins at the scene of the injury and is
continued upon the patients arrival at the emergency department (ED) or trauma
center. Management may involve nonoperative measures or surgical treatment, as
appropriate.
Indications for laparotomy in a patient with blunt abdominal injury include the
following:

Signs of peritonitis

Uncontrolled shock or hemorrhage

Clinical deterioration during observation

Hemoperitoneum findings after focused assessment with sonography for


trauma (FAST) or diagnostic peritoneal lavage (DPL) examinations

Finally, surgical intervention is indicated in patients with evidence of peritonitis based


on physical examination findings.
Operative treatment is not indicated in every patient with positive FAST scan results.
Hemodynamically stable patients with positive FAST findings may require a
computed tomography (CT) scan to better define the nature and extent of their
injuries. Operating on every patient with positive FAST scan findings may result in an
unacceptably high laparotomy rate.
Resuscitative thoracotomy is not recommended in patients with blunt
thoracoabdominal trauma who have pulseless electrical activity upon arrival in the
emergency department (ED). The survival rate in this situation is virtually 0%. These

patients may be allowed a thoracotomy in the ED only if they have signs of life upon
arrival.

Nonoperative Management
Nonoperative management (NOM) strategies based on CT scan diagnosis and the
hemodynamic stability of the patient are now being used in adults for the treatment of
solid organ injuries, primarily those to the liver and spleen. In blunt abdominal
trauma, including severe solid organ injuries, selective nonoperative management has
become the standard of care.
Angiography is a valuable modality in nonoperative management of abdominal solid
organ injuries from blunt trauma in adults. It is used aggressively for nonoperative
control of hemorrhage, thereby obviating nontherapeutic cost-inefficient laparotomies.
Splenic artery embolotherapy (SAE), although not standard of care, is another
nonoperative management modality for adult blunt splenic injury. Requarth et al
conducted a metaanalysis comparing outcomes data for observational management
versus SAE by splenic injury grade cohort. Results show the failure rate of
observational management increases with splenic injury grade, whereas the failure
rate of SAE does not change significantly from splenic injury grades 1 to 5. In grade 4
and 5 injuries, SAE is associated with significantly higher salvage rates. The SAE
success rate noted may in part be due to the fact that SAE was introduced later in the
experience surveyed, and the improved NOM failure rate may be due to other factors
that came into play as the experience proceeded.[39]
The trend toward simply observing hemodynamically stable patients with injuries
involving the spleen, liver, or kidneys is becoming more popular. In a study of
pediatric patients, those with blunt abdominal trauma who were hemodynamically
stable after fluid replacement of less than 40 mL/kg, had proven evidence of solid
organ injuries, and remained stable were admitted to the pediatric intensive care unit
(ICU) under surgical management. No deaths and no immediate or long-term
complications were reported in this group.
If the decision has been made to observe the patient, closely monitor vital signs and
frequently repeat the physical examination. An increased temperature or respiratory
rate can indicate a perforated viscus or the formation of an abscess. Pulse and blood
pressure can also change with sepsis or intra-abdominal bleeding. Physical
examination findings reflecting peritonitis are an indication for surgical intervention.

Surgical Management
Resuscitative thoracotomy
Resuscitative thoracotomy in the ED is only occasionally life-saving. It is an
aggressive, desperate measure intended to save a patient whose death is thought to be
imminent or otherwise inevitable. Survival with good neurologic recovery is more
likely for patients with penetrating trauma than for patients with blunt trauma.
Thoracotomy may have a role in selected patients with penetrating injuries to the

neck, chest, or extremities and those with signs of life within 5 minutes of arrival in
the ED.
A resuscitative thoracotomy is seldom of benefit for patients with cardiac arrest
secondary to blunt or head injury or for those without vital signs at the scene of the
accident. Patients with blunt thoracoabdominal trauma with pulseless electrical
activity upon arrival in the ED have a survival rate of virtually 0% and are poor
candidates for resuscitative thoracotomy. Patients with blunt trauma may be allowed a
thoracotomy in the ED only if they have signs of life upon arrival.
In a patient with hemoperitoneum from blunt thoracoabdominal trauma, the goals of a
resuscitative thoracotomy in the ED are (1) to cross-clamp the aorta, diverting
available blood to the coronaries and cerebral vessels during resuscitation; (2) to
evacuate pericardial tamponade; (3) to directly control thoracic hemorrhage; and (4)
to open the chest for cardiac massage.

Laparotomy and definitive repair


Indications for laparotomy in a patient with blunt abdominal injury include signs of
peritonitis, uncontrolled shock or hemorrhage, clinical deterioration during
observation, and hemoperitoneum findings after FAST or DPL examinations (see
Workup).
When laparotomy is indicated, broad-spectrum antibiotics are given. A midline
incision is usually preferred. When the abdomen is opened, hemorrhage control is
accomplished by removing blood and clots, packing all 4 quadrants, and clamping
vascular structures. Obvious hollow viscus injuries (HVIs) are sutured. After intraabdominal injuries have been repaired and hemorrhage has been controlled by
packing, a thorough exploration of the abdomen is then performed to evaluate the
entire contents of the abdomen.
After intraperitoneal injuries are controlled, the retroperitoneum and pelvis must be
inspected. Do not explore pelvic hematomas. Use external fixation of pelvic fractures
to reduce or stop blood loss in this region. Explore large or expanding midline
retroperitoneal hematomas, with the anticipation of damage to the large vascular
structures, pancreas, or duodenum. Do not explore small or stable perinephric
hematomas.
After the source of bleeding has been stopped, further stabilizing the patient with fluid
resuscitation and appropriate warming is important. After such measures are
complete, perform a thorough exploratory laparotomy with appropriate repair of all
injured structures.
A study by Crookes et al suggests that the true morbidity of a negative laparotomy
may not be as high as previously believed.[40] They conclude that in blunt abdominal
trauma patients, exploratory laparotomy to establish a diagnosis does not result in
increased morbidity in a 30-day period, compared with no laparotomy. In other words,
it is safer to undergo laparotomy with negative findings than to delay treatment of an
injury.

It must be stressed, however, that in this digital era with high-resolution imaging the
need to take a patient for exploratory laparotomy only to establish a diagnosis may be
unnecessary and expensive if, for instance, the CT is negative and the patient is
hemodynamically stable.
Patients who had gross enteric contamination of the peritoneal cavity are given
appropriate antibiotics for 5-7 days.
If a pelvic hematoma was found and the patient continues to lose blood after external
fixation of a pelvic fracture, arteriography with embolization can be used to stop the
small percentage of arterial bleeding found in pelvic fractures.
In adults, splenic artery embolization has been shown to improve nonoperative splenic
salvage rates. A retrospective review showed that this procedure may be useful in the
adolescent population as well, particularly in patients with high-grade injuries or with
evidence of splenic vascular injury, although this is not the standard of care.[41]

Consultations
The best outcomes from trauma are obtained by involving consultants who possess
specific expertise and training in managing trauma patients. Consider evaluation by a
trauma surgeon for all patients with evidence of blunt abdominal trauma. Clearly,
hemodynamic instability or the identification of significant abnormalities during
physical examination or a diagnostic procedure necessitates the involvement of a
trauma surgeon.
Specific physical examination findings that call for timely surgical evaluation are as
follows:

History of blunt abdominal trauma, shock, or abnormal vital signs (eg,


tachycardia, hypotension)

Evidence of shock without obvious external blood loss

Evidence of peritonitis (eg, marked tenderness, involuntary guarding,


percussion tenderness)

Findings consistent with potential intra-abdominal injury (eg, lap belt signs,
lower rib fractures, lumbar spine fractures)

Altered levels of consciousness or sensation, whether due to drugs, alcohol, or


head/spinal injury

Patients who require other prolonged operative intervention (eg, orthopedic


procedures)

Specific findings on diagnostic studies that call for timely surgical evaluation include
evidence of free fluid or solid organ injury on sonograms or CT scans.

Although a trend toward nonoperative management of hepatic, splenic, and renal


injuries in patients who are hemodynamically normal has occurred, a trained trauma
surgeon must oversee this care.
Other specific findings that indicate timely trauma surgeon involvement are as
follows:

Positive findings on DPL

Evidence of extravasated contrast or extraluminal air on an upper


gastrointestinal series (eg, duodenal rupture), plain abdominal radiography, or
cystography

Serious pelvic fractures

Evidence of bladder rupture on contrast cystogram or gross hematuria

Elevated findings on liver function studies

If consultants with expertise in managing blunt abdominal injuries are unavailable,


arrange patient transfer to the nearest appropriate trauma center as soon as injury is
identified. Lengthy diagnostic workup is counterproductive once it is recognized that
a patient cannot be managed at the initial facility. Physician-to-physician consultation
must occur before transport to ensure that the receiving facility has the resources
necessary to care for the patient.

Long-Term Monitoring
Before discharge, provide patients with detailed instructions that describe signs of
undiagnosed injury. Increased abdominal pain or distention, nausea or vomiting,
weakness, lightheadedness or fainting, or new bleeding in urine or feces mandates
immediate return and further evaluation. Ensure that close follow-up care and repeat
examinations are available for all patients.

Medication Summary
Judiciously prescribe pain medications to patients who are discharged. To prevent
masked or delayed presentations, ensure that a close follow-up for reevaluation is
available to all patients who are provided pain medications. With the potential for
hemorrhage, nonsteroidal anti-inflammatory drugs (NSAIDs) probably should be
avoided. Acetaminophen with or without small quantities of mild narcotic analgesics
may be all that should be prescribed initially. Minimize use of analgesics in patients
who are admitted for observation.
Patients who undergo laparotomy may require routine perioperative antibiotics.
Patients with repaired hollow organ injury may require additional antibiotics.

Analgesics

Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes
pulmonary toilet, and prevents exacerbations in tachycardia and hypertension.
View full drug information

Morphine sulfate (Duramorph, Astramorph, MS Contin, Avinza,


Kadian)

Morphine is the drug of choice for narcotic analgesia due to its reliable and
predictable effects, safety profile, and ease of reversibility with naloxone. Like
fentanyl, morphine sulfate is easily titrated to desired level of pain control.
Morphine sulfate administered intravenously may be dosed in a number of ways. It is
commonly titrated until the desired effect is obtained.
View full drug information

Fentanyl citrate (Fentora, Abastral, Duragesic)

A synthetic opioid analgesic that is primarily a mu receptor agonist, fentanyl is 50-100


times more potent than morphine. It has a short duration of action (1-2 h) and minimal
cardiovascular effects, such as hypotension. Respiratory depression is uncommon, but
this effect lasts longer than its analgesic effect. Fentanyl is frequently used in patientcontrolled analgesia for relief of pain. Unlike morphine, fentanyl is not commonly
associated with histamine release.
View full drug information

Acetaminophen and hydrocodone (Vicodin, Lortab, Norco)

This drug combination is indicated for relief of moderate to severe pain.


View full drug information

Hydromorphone (Dilaudid)

Hydromorphone is a potent semisynthetic opiate agonist similar in structure to


morphine. It is approximately 7-8 times as potent as morphine on mg-to-mg basis,
with a shorter or similar duration of action.

Acetaminophen with codeine (Tylenol-3)

This combination is a mild narcotic analgesic. Provide the family with a small supply
for use when pain severity is greater than can be managed with acetaminophen alone.
Counsel parents to use for severe pain only, not as the first medication for each
symptom.

Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely
pathogens in the context of the clinical setting.
View full drug information

Cefazolin

Cefazolin is a first-generation semisynthetic cephalosporin, which, by binding to 1 or


more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits
bacterial replication. It has a poor capacity to cross the blood-brain barrier. Cefazolin
is primarily active against skin flora, including S aureus. Regimens for intravenous
and intramuscular dosing are similar. It is typically used alone for skin and skinstructure coverage.
View full drug information

Cephalexin (Keflex)

This is a first-generation cephalosporin that inhibits bacterial replication by inhibiting


bacterial cell wall synthesis. It is bactericidal and is effective against rapidly growing
organisms forming cell walls.
Resistance occurs by the alteration of penicillin-binding proteins. Cephalexin is
effective for treatment of infections caused by streptococcal or staphylococcal
organisms, including penicillinase-producing staphylococci. It may use to initiate
therapy when streptococcal or staphylococcal infection is suspected.
It is used orally when outpatient management is indicated.
View full drug information

Cefotaxime (Claforan)

Cefotaxime is a third-generation cephalosporin with a broad gram-negative spectrum,


lower efficacy against gram-positive organisms, and higher efficacy against resistant
organisms. It acts by arresting bacterial cell wall synthesis by binding to one or more
penicillin-binding proteins, which, in turn, inhibits bacterial growth. Cefotaxime is
used for septicemia and treatment of gynecologic infections caused by susceptible
organisms, but it has a lower efficacy against gram-positive organisms.
View full drug information

Ceftazidime (Fortaz, Tazicef)

Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative


activity, including against Pseudomonas; it has low efficacy against gram-positive
organisms and high efficacy against resistant organisms. This agent arrests bacterial
growth by binding to one or more penicillin-binding proteins, which, in turn, inhibits
the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall
synthesis, thus inhibiting cell wall biosynthesis.
The condition of the patient, severity of infection, and susceptibility of the
microorganism should determine the proper dose and route of administration.
View full drug information

Ceftriaxone (Rocephin)

Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative


activity, low efficacy against gram-positive organisms, and high efficacy against
resistant organisms. It is considered the drug of choice for parenteral agents in
community-acquired pneumonia. Bactericidal activity results from the inhibition of
cell wall synthesis by binding to one or more penicillin-binding proteins. This agent
exerts its antimicrobial effect by interfering with the synthesis of peptidoglycan, a
major structural component of the bacterial cell wall. Bacteria eventually lyse due to
ongoing activity of cell wall autolytic enzymes, while the cell wall assembly is
arrested.
Ceftriaxone is highly stable in the presence of beta-lactamases, both penicillinase and
cephalosporinase, and of gram-negative and gram-positive bacteria. Approximately
33-67% of the dose is excreted unchanged in urine, and the remainder is secreted in
bile and, ultimately, in feces as microbiologically inactive compounds. This agent
reversibly binds to human plasma proteins, and binding has been reported to decrease
from 95% bound at plasma concentrations of less than 25 mcg/mL to 85% bound at
300 mcg/mL.
View full drug information

Erythromycin (E.E.S., Ery-Tab, Erythrocin, PCE, EryPed)

Erythromycin covers most potential etiologic agents, including Mycoplasma species.


The oral regimen may be insufficient to adequately treat Legionella species, and this
agent is less active against H influenzae. Although the standard course of treatment is
10 days, treatment until the patient has been afebrile for 3-5 days seems a more
rational approach. Erythromycin therapy may result in GI upset, causing some
clinicians to prescribe an alternative macrolide or change to a thrice-daily dosing.
Erythromycin is a macrolide that inhibits bacterial growth possibly by blocking
dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein
synthesis to arrest.
View full drug information

Amoxicillin and clavulanate (Augmentin, Augmentin XR, Amoclan)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding


proteins. The addition of clavulanate inhibits beta-lactamase producing bacteria.
It is a good alternative antibiotic for patients allergic to or intolerant of the macrolide
class. It is usually is well tolerated and provides good coverage to most infectious
agents. It is not effective against Mycoplasma and Legionella species. The half-life of
the oral dosage form is 1-1.3 hours. It has good tissue penetration but does not enter
cerebrospinal fluid.
For children older than 3 months, base the dosing protocol on the amoxicillin content.
Due to different amoxicillin/clavulanic acid ratios in the 250-mg tablet (250/125)
versus the 250-mg chewable tablet (250/62.5), do not use the 250-mg tablet until child
weighs more than 40 kg.
View full drug information

Ampicillin and sulbactam (Unasyn)

This is a drug combination of a beta-lactamase inhibitor with ampicillin. It interferes


with bacterial cell wall synthesis during active replication, causing bactericidal
activity against susceptible organisms. It is an alternative to amoxicillin when the
patient is unable to take medication orally.
It covers skin, enteric flora, and anaerobes. It is not ideal for nosocomial pathogens.
View full drug information

Piperacillin and tazobactam sodium (Zosyn)

This is an antipseudomonal penicillin plus a beta-lactamase inhibitor. It inhibits the


biosynthesis of cell wall mucopeptide and is effective during the stage of active
multiplication.
View full drug information

Ticarcillin and clavulanate (Timentin)

It inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage
of active growth.
It is an antipseudomonal penicillin plus a beta-lactamase inhibitor that provides
coverage against most gram-positives, most gram negatives, and most anaerobes.
View full drug information

Ciprofloxacin (Cipro)

Ciprofloxacin is a fluoroquinolone that inhibits bacterial DNA synthesis and,


consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are
required for replication, transcription, and translation of genetic material. Quinolones
have broad activity against gram-positive and gram-negative aerobic organisms. It is
has no activity against anaerobes. Continue treatment for at least 2 days (7-14 d
typical) after signs and symptoms have disappeared.
View full drug information

Levofloxacin (Levaquin)

Levofloxacin is rapidly becoming a popular choice in pneumonia; this agent is a


fluoroquinolone used to treat community-acquired pneumonia caused by S aureus, S
pneumoniae (including penicillin-resistant strains), H influenzae, H parainfluenzae,
Klebsiella pneumoniae, M catarrhalis, C pneumoniae, Legionella pneumophila, or M
pneumoniae. Fluoroquinolones should be used empirically in patients likely to
develop exacerbation due to resistant organisms to other antibiotics.
Levofloxacin is the L stereoisomer of the D/L parent compound ofloxacin, the D form
being inactive. It is good monotherapy with extended coverage against Pseudomonas

species and excellent activity against pneumococci. Levofloxacin acts by inhibition of


DNA gyrase activity. The oral form has a bioavailability that is reportedly 99%.
The 750-mg dose is as well tolerated as the 500-mg dose, and it is more effective.
Other fluoroquinolones with activity against S pneumoniae may be useful and include
moxifloxacin, gatifloxacin, and gemifloxacin.
View full drug information

Clindamycin (Cleocin, Cleocin Pediatric)

Clindamycin is a lincosamide semisynthetic antibiotic produced by 7(S)-chlorosubstitution of 7(R)-hydroxyl group of the parent compound lincomycin. It inhibits
bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes,
causing RNA-dependent protein synthesis to arrest. It widely distributes in the body,
without penetration of the CNS. It is protein bound and is excreted by the liver and
kidneys.
It is available in a parenteral form (ie, clindamycin phosphate) and oral form (ie,
clindamycin hydrochloride). Oral clindamycin is absorbed rapidly and almost
completely and is not appreciably altered by the presence of food in the stomach.
Appropriate serum levels are reached and sustained for at least 6 hours following an
oral dose. No significant levels are attained in cerebrospinal fluid. It is also effective
against aerobic and anaerobic streptococci (except enterococci).