From the Guidelines
The management of blunt trauma abdomen should follow a systematic approach, beginning with primary survey and resuscitation according to ATLS principles, and may involve non-operative management (NOM) for hemodynamically stable patients with liver injuries, as recommended by the World Society of Emergency Surgery (WSES) guidelines 1. The initial assessment includes airway management, ensuring adequate breathing, and establishing circulatory support with two large-bore IV lines for fluid resuscitation using crystalloids like normal saline or Ringer's lactate.
- Diagnostic evaluation involves physical examination, FAST ultrasound to detect free fluid, and CT scan with IV contrast for hemodynamically stable patients.
- Laboratory tests including CBC, comprehensive metabolic panel, coagulation studies, urinalysis, and type and cross-match should be obtained.
- For unstable patients with positive FAST or peritoneal signs, immediate surgical exploration is indicated.
- Stable patients with positive imaging findings may be managed non-operatively with close monitoring of vital signs, serial physical examinations, and hemoglobin checks every 6 hours for the first 24 hours.
- Specific organ injuries require tailored approaches:
- Liver injuries often need observation and possible angioembolization, as recommended by the WSES guidelines 1.
- Splenic injuries may require splenectomy or splenic artery embolization.
- Bowel injuries typically require surgical repair.
- Renal injuries are often managed conservatively unless there's significant hemorrhage or urinary extravasation.
- Pain management with opioids like morphine (2-4mg IV every 4 hours) or hydromorphone (0.5-1mg IV every 4 hours) should be provided, along with DVT prophylaxis using enoxaparin 40mg subcutaneously daily for patients on bed rest. This approach balances the need for prompt intervention in life-threatening situations with conservative management when appropriate to minimize unnecessary surgeries, as supported by recent clinical policies from the American College of Emergency Physicians 1.
From the Research
Management Approach for Blunt Trauma to the Abdomen
The management of blunt trauma to the abdomen involves a series of diagnostic and therapeutic steps to identify and treat potential injuries. The following are key aspects of this approach:
- Initial Assessment: The initial management of the patient with blunt abdominal trauma should parallel the primary survey of airway, breathing, and circulation 2.
- Diagnostic Tools:
- Clinical Examination: Clinical examination is not reliable for evaluation of abdominal injury 3.
- Abdominal Ultrasound: Abdominal ultrasound, especially if only focusing on free fluid (FAST), is not sensitive enough 3. However, it can be used as an initial screening tool to detect free intraperitoneal fluid 4, 5.
- CT-Scan: CT-scan of the abdomen is the gold-standard in diagnosing abdominal injury 3 and is useful in detecting bowel or mesenteric injuries 5.
- Diagnostic Peritoneal Lavage (DPL): DPL has a high sensitivity but is only used in exceptional cases 3.
- Indications for Laparotomy:
- Hemodynamic Instability: Patients with continuing hemodynamical instability after abdominal trauma and evidence of free intraperitonial fluid should undergo laparotomy 3.
- Peritonitis: Patients with features of peritonitis should undergo laparotomy 6.
- Other Indications: Laparotomy may also be indicated for vascular thrombosis of end arteries supplying solid organs, internal or external herniation through a mesenteric tear or anterior abdominal wall musculature, respectively 6.
- Non-Operative Management: Computed tomography is useful as a complementary diagnostic tool in selected patients and is the critical test for guiding nonoperative management of known intraperitoneal trauma 2.