From the Guidelines
The most appropriate initial method to diagnose small bowel injury in a conscious, stable trauma patient with seatbelt injury is serial abdominal examination. This approach involves repeated physical assessments of the abdomen over time to detect evolving signs of peritonitis or worsening tenderness, which may indicate small bowel injury 1. Serial examination is particularly valuable in stable patients because small bowel injuries may not present with immediate symptoms or radiological findings. The development of increasing abdominal tenderness, guarding, rigidity, or other peritoneal signs during observation suggests bowel perforation requiring surgical intervention.
Some key points to consider in the diagnosis of small bowel injury include:
- The clinical assessment for a patient with suspected intestinal injury begins with the primary survey to assess life-threatening injuries 1.
- Patients who are haemodynamically decompensated with a positive Focused Assessment with Sonography for Trauma (FAST) should proceed directly to a trauma laparotomy to stop major abdominal bleeding and, if applicable, other sources of bleeding 1.
- Intra-abdominal free fluid on FAST is non-specific for intestinal injury and should not be relied upon in these settings to diagnose bowel trauma 1.
- Intra venous contrast enhanced computed tomography (CT) scan may identify intra-abdominal injuries, but bowel injury remains one of the most common abdomino-pelvic injury missed on initial CT at 20% of bowel injuries missed 1.
- Observation in patients with high-risk mechanism, and quick sequential organ failure assessment (qSOFA) score, demonstrate a higher sensitivity for sepsis or septic shock and may play a crucial role during the observation of patients at a higher risk for bowel injuries based on mechanism of injury or CT findings 1.
While other diagnostic methods such as CT scanning and FAST have their own advantages, serial abdominal examination is the most appropriate initial method for diagnosing small bowel injury in a conscious, stable trauma patient with seatbelt injury, as it allows for close monitoring of the patient's condition and avoids unnecessary invasive procedures. Additionally, the importance of prompt decision making in all trauma situations is highlighted by studies showing that delays to surgical treatment can be associated with increased morbidity and mortality 1.
From the Research
Diagnostic Methods for Small Bowel Injury
The most appropriate initial method to diagnose small bowel injury in a conscious stable trauma patient with seatbelt injury is:
- Serial abdominal examination [(2,3,4,5,6)]
Rationale
- Diagnostic peritoneal lavage (DPL) and Focused Assessment with Sonography for Trauma (FAST) are not reliable methods for assessing intra-abdominal injury in patients with seat belt marks 3
- Computed Tomography (CT) scan is a sensitive tool for detecting intra-abdominal injuries, but it may not be necessary as an initial method for stable patients 2
- Serial abdominal examination is a non-invasive and cost-effective method that can be used to monitor patients for signs of abdominal injury, such as increasing abdominal pain and distension [(4,5,6)]
- The presence of a seat belt sign, ecchymosis of the abdominal wall, and increasing abdominal pain and distension are associated with hollow viscus injuries (HVI) [(4,5,6)]
Considerations
- A high index of suspicion for overt or covert intra-abdominal injuries should be maintained when patients involved in road-traffic collisions attend the Emergency Department 5
- Children and pregnant women represent high-risk groups who are particularly vulnerable to injuries 5
- The recognition of seat belt marks made by a compromised occupant-restraint relationship is an important finding that allows risk stratification of the patient at the bedside 6