What is the next step in managing a patient with a history of abdominal trauma?

Management of Abdominal Trauma

The next step in managing a patient with abdominal trauma should be a contrast-enhanced abdominal CT scan for hemodynamically stable patients, while immediate surgical exploration is indicated for unstable patients with evidence of intraperitoneal bleeding. 1, 2

Initial Assessment Algorithm

For Hemodynamically Unstable Patients:

• Immediate surgical exploration (laparotomy) is indicated when there is:
  • Hemodynamic instability with large peritoneal effusion
  • Active peritoneal bleeding
  • Evidence of bowel perforation

Every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 and in-hospital mortality by a factor of 1.4 2. Delayed laparotomy increases the odds of death by 1% every 3 minutes in unstable patients 2.

For Hemodynamically Stable Patients:

• Contrast-enhanced abdominal CT scan with portal venous phase (70 seconds after contrast) 1
• CT allows evaluation of specific organ injuries (liver, spleen, kidneys) and detection of active bleeding 1
• Look for highly specific signs of bowel injury:
  • Extraluminal air
  • Bowel wall defects
  • Free intraperitoneal air
  • Free fluid without solid organ injury
  • Mesenteric stranding 1

Management Based on CT Findings

If CT Shows No Significant Injury:

• For patients with high-risk mechanisms (especially with seat belt sign):
  • Admission for observation for 24-48 hours
  • Serial clinical examinations every 4-8 hours
  • Laboratory tests (CBC, inflammatory markers) every 24 hours 1

If CT Shows Solid Organ Injury Without Active Bleeding:

• Non-operative management (NOM) is the standard of care for 90% of renal injuries and 70-80% of splenic and hepatic injuries 2
• Requirements for NOM:
  • Admission to a facility with 24/7 capacity for emergency laparotomy
  • Continuous monitoring for at least 24 hours in ICU
  • Clinical and biological observation for 3-5 days minimum 2
  • Monitor intra-abdominal pressure to detect abdominal compartment syndrome 2

If CT Shows Active Bleeding:

• Consider therapeutic angioembolization if immediately available 2
• This can significantly reduce the failure rate of non-operative management for splenic, hepatic, kidney, or adrenal injuries 2

If CT Shows Definitive Signs of Bowel Injury:

• Surgical exploration is recommended 1
• Laparoscopic approach may be considered for diagnostic/therapeutic purposes in stable patients when:
  • Radiologic survey suggests diaphragmatic or hollow viscus injury
  • To complete non-operative management 2

Follow-up Imaging

• Perform a follow-up abdominopelvic CT scan with intravascular contrast media:
  • Before hospital discharge for all at-risk abdominal injuries
  • When a complication is suspected
  • If clinical signs evolve during observation 2, 1

Common Pitfalls to Avoid

1. Delayed recognition of bowel injuries: Approximately 20% of bowel injuries may be missed on initial CT 1. Maintain high suspicion even with normal initial imaging, especially with seat belt signs.

2. Premature discharge: Patients with high-risk mechanisms should be observed for at least 24-48 hours, even with negative initial CT 1.

3. Inadequate monitoring: Even hemodynamically stable patients may have significant occult bleeding. Continuous monitoring is essential during the first 24 hours 2, 1.

4. Missing associated injuries: Check for Chance fractures of the lumbar spine with abdominal seat belt injuries and cervical spine injuries with neck seat belt signs 1.

5. Relying solely on biomarkers: While procalcitonin and CRP can help exclude bowel injuries, they should not be used exclusively 1.