What is the management of severe abdominal pain with tenderness after a road traffic accident?

Management of Severe Abdominal Pain with Tenderness After Road Traffic Accident

Patients with severe abdominal pain and tenderness following a road traffic accident require immediate assessment and intervention, with hemodynamically unstable patients proceeding directly to laparotomy without delay.

Initial Assessment and Triage

Immediate Evaluation

• Assess hemodynamic status using ACS/ATLS classification 1:
  • Pulse rate, blood pressure, pulse pressure
  • Respiratory rate
  • Urine output
  • Mental status

Diagnostic Approach

1. FAST (Focused Abdominal Sonography for Trauma)

   • Perform immediately to detect free intraperitoneal fluid 1, 2
   • High specificity (96-100%) but moderate sensitivity (74-76%) 2
   • Negative FAST can rule out significant hemoperitoneum (>500ml) 1, 2

2. CT Scan (if hemodynamically stable)

   • Recommended for stable patients to identify specific abdominal injuries 1
   • Contrast-enhanced thoraco-abdominal CT has high diagnostic accuracy for solid organ injuries (sensitivity 98%, specificity 98%) 1
   • Lower performance for hollow organ injuries (sensitivity 85%, specificity 96%) 1

Management Algorithm

Hemodynamically Unstable Patients

1. Immediate Surgical Intervention

   • Patients with positive FAST and persistent hemodynamic instability require immediate laparotomy 1
   • Every 10-minute delay from admission to laparotomy increases 24-hour mortality by a factor of 1.5 1
   • Delayed laparotomy increases odds of death by 1% every 3 minutes 1

2. Resuscitation Measures

   • Establish large-bore IV access
   • Initiate balanced fluid resuscitation
   • Consider blood product administration per massive transfusion protocol
   • Pain management with IV morphine 0.1-0.2 mg/kg (administer slowly) 3

Hemodynamically Stable Patients

1. Contrast-Enhanced CT Scan

   • Recommended to identify specific injuries 1
   • Allows for complete assessment of all potential hemorrhagic sources 1

2. Management Based on CT Findings

   • Large peritoneal effusion with solid organ injury: Consider non-operative management with close monitoring in ICU 1
   • Hollow viscus injury: Surgical intervention typically required 1
   • Retroperitoneal hematoma: May require angioembolization 1

Special Considerations

High-Risk Indicators

• Seatbelt sign (abdominal wall contusion) increases risk of intestinal injury significantly 4
• Patients with seatbelt sign have 64% chance of abdominal injury and 21% risk of small bowel perforation 4
• Traffic accidents are the leading cause of pelvic injury (60%), which is associated with significant hemorrhage 1

Pain Management

• IV morphine is indicated for severe pain management 3
• Starting dose: 0.1-0.2 mg/kg IV every 4 hours as needed 3
• Administer slowly to avoid respiratory depression 3
• Have naloxone and resuscitative equipment immediately available 3
• Use caution in patients with hypotension or respiratory compromise 3

Monitoring and Follow-up

• Hemodynamically stable patients with abdominal injuries require 24-hour ICU surveillance 1
• Serial abdominal examinations to detect evolving injuries
• Repeat imaging (CT scan) for patients managed non-operatively who show clinical deterioration
• Monitor for complications including delayed hollow viscus perforation, which may present days after initial trauma 5

Pitfalls to Avoid

1. Delayed Surgical Intervention: Every 10-minute delay increases mortality significantly in unstable patients 1
2. Over-reliance on FAST: Negative FAST does not rule out specific organ injuries 1, 2
3. Underestimating Seatbelt Sign: Presence of abdominal wall contusion significantly increases risk of intestinal injury 4
4. Inadequate Pain Control: Untreated pain can worsen outcomes but use caution with opioids in unstable patients 3
5. Missing Hollow Viscus Injuries: CT has lower sensitivity for these injuries compared to solid organ injuries 1