How to treat a blunt trauma injury?

Management of Blunt Trauma Injury

Begin with primary survey, E-FAST ultrasound, physical examination, blood chemistry, vital signs, followed by contrast-enhanced abdominal CT scan in hemodynamically stable patients. 1

Initial Assessment and Hemodynamic Status

Hemodynamically Unstable Patients (SBP <90 mmHg)

• Bedside ultrasound (E-FAST) should be the initial diagnostic modality performed to identify the need for emergent laparotomy 1
• Proceed directly to operating room if positive findings of free fluid or solid organ injury 1
• Do not delay for CT scanning in unstable patients—transport to radiology suite is contraindicated 1

Hemodynamically Stable Patients

• Complete primary and secondary survey with focused physical examination 1
• Obtain blood chemistry, complete blood count, and vital signs 1
• Perform contrast-enhanced abdominal CT scan as the definitive diagnostic modality 1
• E-FAST can be performed concurrently but should not replace CT in stable patients 1

Specific Injury Patterns and High-Risk Mechanisms

Seatbelt Sign or Handlebar Injury

• The presence of a seatbelt sign mandates CT scan with high index of suspicion for bowel injury 1
• Admit for observation with serial clinical examinations every 8 hours even if initial CT is non-specific 1
• These high-risk mechanisms frequently cause delayed presentation of bowel injuries 1

CT Findings Requiring Action

Highly Specific Signs (proceed to laparotomy):

• Free intraperitoneal air without pneumothorax (32% sensitivity, 99% specificity) 1
• Bowel wall discontinuity (22% sensitivity, 99% specificity) 1
• Intravenous contrast extravasation in mesentery (23% sensitivity, 100% specificity) 1
• Oral contrast extravasation (10% sensitivity, 100% specificity) 1

Highly Sensitive Signs (require close observation):

• Free peritoneal fluid without solid organ injury (53% sensitivity, 81% specificity) 1
• Bowel wall thickening (35% sensitivity, 95% specificity) 1
• Mesenteric stranding (34% sensitivity, 92% specificity) 1

Non-Operative Management Protocol

Observation Requirements

• Minimum 48 hours of serial clinical examinations performed by consistent specialists or consultants 1
• Vital sign monitoring continuously 1
• Serial inflammatory markers (CRP, procalcitonin) every 24 hours 1
• Repeat CT scan after 6 hours if initial CT shows equivocal signs 1
• Repeat CT if evolving clinical signs develop suspicious for bowel injury 1

Clinical Adjuncts for Unconscious Patients

• Monitor trends in white blood cell count, lactate, and quick SOFA score—these become progressively more accurate over time rather than initial values 1
• Do not rely on initial laboratory values alone; serial trending is crucial 1
• Tolerance to enteral feeding may serve as negative predictor of bowel injury, but failure to tolerate feeding should raise immediate concern (15% of ICU patients who failed feeding had GI injury) 1

Solid Organ Injuries (Spleen, Liver, Kidney)

Non-Operative Management Criteria

• Hemodynamic stability after initial resuscitation 1
• Absence of peritonitis 1
• No other injuries requiring laparotomy 1
• Success rate approaches 90% in high-volume centers with appropriate resources 1

Risk Factors for NOM Failure

• Age >55 years (not absolute contraindication but requires intensive monitoring) 1
• High Injury Severity Score 1
• AAST-OIS grade IV-V injuries (failure rate up to 54.6%) 1
• Arterial blush on CT scan warrants consideration for angiography/embolization as first-line intervention 1

Contraindications to NOM

• Unresponsive hemodynamic instability 1
• Peritonitis 1
• Hollow organ injuries 1
• Bowel evisceration 1

Surgical Intervention

Indications for Laparotomy

• Hemodynamic instability unresponsive to resuscitation 1
• Peritonitis on examination 1
• Highly specific CT findings as listed above 1
• Failed non-operative management with clinical deterioration 1

Bowel Injury Repair Principles

• Primary repair of small bowel injuries is preferred when possible 1
• Primary anastomosis of colon injuries is safe in selected patients based on physiology, concomitant injuries, and resilience to potential anastomotic leak 1
• Diverting stomas remain recommended in high-risk patients with high-risk colon anastomoses 1

Critical Pitfalls to Avoid

• Do not discharge patients with high-risk mechanisms (seatbelt sign, handlebar injury) based on negative initial CT alone—bowel injuries are frequently missed initially 1
• Delay in diagnosis of bowel injury significantly increases morbidity and mortality—maintain high index of suspicion 1
• Do not over-rely on procalcitonin and CRP as sole decision-making tools—they are supportive biomarkers that help exclude injury but can lead to unnecessary laparotomy if weighted too heavily 1
• Do not perform single clinical examination—serial examinations over 48 hours are mandatory for safe observation 1
• In unconscious patients, do not start enteral feeding to "test" for bowel injury—wait until probability is low, but if feeding fails, immediately investigate for GI injury 1