From the Guidelines
The management of blunt trauma to the abdomen should begin with a primary survey following ATLS principles, focusing on airway, breathing, and circulation, with immediate attention to life-threatening hemorrhage, as recommended by the most recent guidelines 1.
Initial Assessment
The initial assessment should include a physical examination, laboratory tests (complete blood count, liver function tests, amylase, lipase, urinalysis), and imaging studies.
- FAST (Focused Assessment with Sonography for Trauma) ultrasound is the initial imaging modality to detect free fluid.
- CT scan with IV contrast is the gold standard for detailed assessment of organ injuries.
Management Decisions
Management decisions depend on hemodynamic status and specific organ injuries.
- Non-operative management is appropriate for many solid organ injuries (liver, spleen, kidney) in stable patients, involving close monitoring in an ICU setting with serial hemoglobin measurements and vital sign checks.
- Fluid resuscitation typically begins with crystalloids (normal saline or lactated Ringer's) at 1-2 liters, followed by blood products if needed.
- Pain control with intravenous opioids (morphine 2-4mg IV or fentanyl 25-50mcg IV) is important.
- Prophylactic antibiotics (cefazolin 1g IV q8h) are indicated for penetrating injuries or when surgery is planned.
Specific Considerations
- For hemodynamically unstable patients with suspected intra-abdominal bleeding, immediate surgical exploration is indicated.
- Patients require frequent reassessment as initially occult injuries may become apparent over time, and deterioration may necessitate a change in management strategy from conservative to surgical intervention, as supported by recent studies 1.
- The use of angioembolization may be considered in selected cases, particularly in patients with ongoing bleeding or hemodynamic instability, as recommended by recent guidelines 1.
From the Research
Management of Blunt Trauma to the Abdomen
The management of blunt trauma to the abdomen involves a combination of diagnostic modalities and treatment approaches. The following are key aspects of management:
- Initial evaluation: The initial management of the patient with blunt abdominal trauma should parallel the primary survey of airway, breathing, and circulation 2.
- Diagnostic modalities:
- Diagnostic peritoneal lavage (DPL) is a cornerstone of triage in patients with life-threatening blunt abdominal trauma 2.
- Computed tomography (CT) is useful as a complementary diagnostic tool in selected patients and is the critical test for guiding nonoperative management of known intraperitoneal trauma 2.
- Abdominal ultrasonography, especially focused assessment with sonography for trauma (FAST), is not sensitive enough for evaluation of abdominal injury, but can be used as an initial diagnostic tool in the emergency room 3.
- Treatment approaches:
- Hemodynamically unstable patients with evidence of free intraperitoneal fluid should undergo laparotomy 3.
- Hemodynamically stable patients should undergo a CT-scan of the abdomen to prove or exclude an abdominal injury 3.
- Nonoperative management is the procedure of choice for solid organ injury in patients with blunt abdominal trauma, but missed bowel and mesenteric injuries are possible due to difficult diagnosis 4.
- Algorithm for diagnosis: A proposed algorithm for the diagnosis of bowel and mesenteric injuries includes abdominal ultrasonography, computed tomography, and diagnostic peritoneal lavage 4.
Diagnostic Challenges
- Clinical examination is often unreliable, even if the patient is awake, and the frequent co-existence of head injury exacerbates this problem 5.
- Abdominal ultrasound, especially if only focusing on free fluid, is not sensitive enough for evaluation of abdominal injury 3.
- The risk of overlooking a significant gastrointestinal tract injury on CT scan is minimal provided that unexplained free fluid, bowel wall thickening or enhancement, mesenteric fat streaking, and bowel dilatation are taken as evidence of injury 6.