How do you diagnose and manage suspected bleeding in a patient with abdominal injury?

Diagnosing and Managing Bleeding in Abdominal Injury

For patients with suspected abdominal bleeding following trauma, immediate FAST (Focused Abdominal Sonography for Trauma) should be performed, followed by CT scan in hemodynamically stable patients or immediate surgical intervention in unstable patients with positive FAST findings. 1

Initial Assessment for Abdominal Bleeding

Hemodynamic Status Evaluation

• Assess vital signs to determine the class of hemorrhage 1:
  • Class I (up to 15% blood volume loss): HR <100, normal BP
  • Class II (15-30% loss): HR 100-120, normal BP, decreased pulse pressure
  • Class III (30-40% loss): HR 120-140, decreased BP, decreased pulse pressure
  • Class IV (>40% loss): HR >140, decreased BP, decreased pulse pressure

Primary Diagnostic Tools

1. FAST Examination (first-line diagnostic tool)

   • Recommended for all patients with suspected torso trauma 1
   • High specificity (96-100%) but variable sensitivity (42-71%) 1, 2
   • Examines for free fluid in:
     • Perihepatic space
     • Perisplenic space
     • Pelvis
     • Pericardium

2. CT Scan with IV Contrast

   • Gold standard for definitive diagnosis 1
   • Recommended for all hemodynamically stable patients 1
   • Can identify specific organ injuries and active extravasation
   • Should be whole-body CT for trauma patients 1

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients (SBP <90 mmHg)

1. Positive FAST: Immediate surgical intervention 1

   • Do not delay for additional imaging
   • Proceed to operating room for exploratory laparotomy

2. Negative FAST but persistent instability:

   • Consider other sources of bleeding (chest, pelvis, external)
   • If no other source identified, repeat FAST or consider DPL (diagnostic peritoneal lavage) 1
   • Consider immediate laparotomy if clinical suspicion remains high despite negative imaging

Hemodynamically Stable Patients

1. Positive FAST: Proceed to contrast-enhanced CT scan 1

   • Characterizes specific injuries
   • Identifies active bleeding
   • Guides management decisions (operative vs. non-operative)

2. Negative FAST:

   • If high clinical suspicion or significant mechanism: Proceed to CT scan 1
   • If minimal symptoms and low suspicion: Serial clinical examinations and repeat FAST

Special Considerations

Pelvic Fractures with Abdominal Trauma

• High association between unstable pelvic fractures and intra-abdominal injuries 1
• Consider angiography in patients with:
  • Active arterial extravasation on CT
  • High-volume blood transfusions
  • Injury Severity Score ≥16 1

Pharmacological Management

• For ongoing bleeding despite surgical control, consider tranexamic acid 3
  • Acts by inhibiting fibrinolysis and stabilizing clot formation 4
  • Caution in patients with renal impairment (dose adjustment required) 4

Pitfalls and Caveats

1. False Negative FAST Results

   • FAST has limited sensitivity (42-71%) 1, 2
   • A negative FAST does not exclude significant injury
   • Serial examinations are crucial in high-risk patients

2. Delayed Hollow Organ Injuries

   • CT has lower sensitivity for hollow viscus injuries 5
   • Serial clinical examinations and laboratory tests are essential
   • Consider repeat imaging if clinical status changes

3. Abdominal Compartment Syndrome

   • Monitor for increased intra-abdominal pressure in severely injured patients 5
   • Risk factors: severe bleeding, massive fluid resuscitation
   • Consider decompressive laparotomy for pressures >20 mmHg with organ dysfunction

4. Pediatric Considerations

   • FAST has lower sensitivity in children (42-55%) 2
   • Higher threshold for CT scanning due to radiation concerns
   • Consider complete abdominal ultrasound rather than limited FAST views 2

By following this structured approach based on hemodynamic status and initial FAST results, clinicians can rapidly identify and appropriately manage abdominal bleeding in trauma patients, significantly improving outcomes in terms of morbidity and mortality.