From the Guidelines
The management of blunt trauma to the abdomen should begin with the ATLS protocol, prioritizing airway, breathing, and circulation, followed by a primary survey and secondary survey to identify life-threatening injuries, as recommended by the most recent guidelines 1.
Initial Assessment and Resuscitation
The initial assessment includes a primary survey to identify life-threatening injuries, followed by a secondary survey with a thorough physical examination. Hemodynamically unstable patients require immediate resuscitation with two large-bore IV lines for fluid administration, typically starting with 1-2 liters of crystalloid solution.
- Laboratory tests should include complete blood count, metabolic panel, coagulation studies, and type and cross-match.
- Diagnostic imaging is crucial, with FAST (Focused Assessment with Sonography for Trauma) ultrasound as the initial bedside tool to detect free fluid.
Diagnostic Imaging and Management Decisions
- CT scan with IV contrast is the gold standard for stable patients, providing detailed information about solid organ injuries and active bleeding.
- Management decisions depend on hemodynamic status and injury severity.
- Unstable patients with positive FAST scans typically require immediate exploratory laparotomy.
- Stable patients with solid organ injuries (liver, spleen, kidney) can often be managed non-operatively with close monitoring in an ICU setting, serial hemoglobin checks every 6 hours initially, bed rest, and analgesia.
Non-Operative Management and Surgical Intervention
- Grade I-III splenic and hepatic injuries have high success rates with non-operative management, while higher-grade injuries may require surgical intervention or angioembolization.
- Hollow viscus injuries typically require surgical repair.
- Pain management should include multimodal analgesia with scheduled acetaminophen, NSAIDs if not contraindicated, and judicious opioid use.
- Prophylactic antibiotics are indicated only for penetrating injuries or when surgery is performed, as supported by recent studies 1.
Specific Considerations
- The presence of a seatbelt sign should prompt a CT scan and a high index of suspicion for bowel injury, as recommended by recent guidelines 1.
- In patients not clinically evaluable, the diagnosis of hollow viscus injuries relies on injury pattern, vital signs, inflammatory markers trends, and follow-up CT, as suggested by recent studies 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.