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Overview of Abdominal Trauma
Diagnosis of Abdominal Trauma
Clinical evaluation Often CT or ultrasonography As for all patients experiencing significant trauma, clinicians do a thorough, organized trauma evaluation simultaneous with resuscitation (see Approach to the Trauma Patient ). Although many intra-abdominal injuries heal without specific treatment, the clinician's primary goal is to identify injuries requiring intervention. Because many intra-abdominal injuries heal without specific treatment, the clinician's primary goal is to identify injuries requiring intervention. Following clinical evaluation, a few patients clearly require exploratory laparotomy rather than testing, including those with Peritonitis Hemodynamic instability due to penetrating abdominal trauma Gunshot wounds (most) Evisceration Conversely, a few patients are at very low risk and may be discharged or observed briefly without any testing other than visual inspection of the urine for gross blood. These patients typically have isolated blunt abdominal trauma and a minor mechanism of injury, normal sensorium, and no tenderness or peritoneal signs; they should be instructed to return immediately if pain worsens. Patients with isolated anterior abdominal stab wounds that have not penetrated the fascia can also be observed briefly and discharged ( Diagnosis reference ). However, most patients do not have such clear-cut positive or negative manifestations and thus require testing to evaluate for intra-abdominal injury. Testing options include Imaging studies (ultrasonography, CT) Procedures (wound exploration, diagnostic peritoneal lavage) In addition, patients usually should have a chest x-ray to look for free air under the diaphragm (indicating perforation of a hollow viscus) and an elevated hemidiaphragm (suggesting diaphragmatic rupture). Pelvis x-ray is done in patients with pelvic tenderness or significant deceleration and an unreliable clinical examination. Laboratory testing is secondary. Urinalysis to detect hematuria (gross or microscopic) is helpful, and for patients with apparently serious injuries, a complete blood count (CBC) is valuable to establish baseline hematocrit (Hct). Pancreatic and liver enzyme levels are not sufficiently sensitive or specific for significant organ injury to be recommended. The blood bank should do a Pretransfusion Testing in case blood transfusions are possible; The method chosen to detect intra-abdominal injury varies by mechanism of injury and the clinical examination. Blindly probing wounds with a blunt instrument (eg, cotton swab, fingertip) should not be done. If the peritoneumhasbeen violated, probing may introduce infection or cause further damage. (including impalements) to the anterior abdomen (between the 2 anterior axillary lines) in hemodynamically stable patients without peritoneal signs can be explored locally. Typically, local anesthesia is given and the wound is opened enough to allow complete visualization of the entire tract. If the anterior fascia is penetrated, patients are admitted for serial clinical examinations; exploratory laparotomy is done if peritoneal signs or hemodynamic instability develop. If the fascia is not violated, the wound is cleansed and repaired and the patient discharged. Alternatively, some centers do CT, or less commonly, How To Do Diagnostic Peritoneal Lavage (DPL) (DPL), to evaluate patients with fascial penetration. CT is recommended for stab wounds to the flank (between the anterior and posterior axillary lines) or back (between the 2 posterior axillary lines) because injuries to the retroperitoneal structures underlying these areas can be missed when serial abdominal examinations and/or DPL are done. Forgunshot wounds,most clinicians do exploratory laparotomy unless the wound is clearly grazing or tangential and peritonitis and hypotension are absent. However, some centers that use nonoperative management of select patients with only solid organ (typically liver) injury do CT of stable patients with gunshot wounds. Local wound exploration is typically not done for gunshot wounds. Most patients with multiple trauma and distracting injuries and/or altered sensorium should have testing of the abdomen as should patients with findings on examination. Typically, clinicians use ultrasonography or CT, or sometimes both. (sometimes termed focused assessment with sonography in trauma [FAST]) can be done during the initial assessment without moving the patient to the radiology suite. The FAST images the pericardium, right and left upper quadrants, and pelvis; its primary aim is to find abnormal pericardial fluid or intraperitoneal free fluid. An How To Do E-FAST Examination (E-FAST) adds images of the chest aimed at detecting CTis typically done with IV but not an oral contrast agent; this test is very sensitive for free fluid and solid organ injury but less so for small viscus perforations (albeit better than ultrasonography), and it can simultaneously detect injury to the spine or pelvis. However, CT exposes patients to radiation, which is a particular concern in children and in patients who may require repeat studies (eg, stable patients with small amounts of free fluid), and requires patient transport away from the resuscitation area. Choice between ultrasonography and CT is based on patient status. If the patient needs CT to assess another body region (eg, cervical spine, pelvis), CT is probably the reasonable choice to evaluate the abdomen. Some clinicians do a FAST scan during the resuscitation phase and proceed to laparotomy if a large amount of free fluid is seen (in hypotensive patients). If FAST results are negative or weakly positive, clinicians do CT if there is still concern about the abdomen after the patient is stabilized. Reasons for such concern include increasing abdominal pain or anticipated inability to monitor the patient clinically (eg, patients who require heavy sedation or who will be undergoing lengthy surgical procedures). How To Do Diagnostic Peritoneal Lavage (DPL) (DPL), Patients with sudden worsening of abdominal pain in the days following injury should be suspected of having a ruptured solid organ hematoma or a delayed hollow viscus perforation, particularly if they have tachycardia and/or hypotension. Steadily worsening pain within the first day suggests hollow viscus perforation or, if after several days, abscess formation, particularly if accompanied by fever and leukocytosis. In both cases, imaging with ultrasonography or CT is usually done in stable patients, followed by operative repair. Following severe abdominal trauma, Abdominal compartment syndrome should be suspected in patients with decreased urine output, ventilatory insufficiency, and/or hypotension, particularly if the abdomen is tense or distended (however, physical findings are not very sensitive). Because such manifestations can also be signs of decompensation due to the underlying injuries, a high degree of suspicion is required in at-risk patients. Diagnosis requires measuring intra-abdominal pressure, typically with a pressure transducer connected to the bladder catheter; values > 20 mm Hg are diagnostic of intra-abdominal hypertension and are concerning. When patients with such a reading also have signs of organ dysfunction (eg, hypotension, hypoxia/hypercarbia, decreased urine output, increased intracranial pressure), surgical decompression is done. Typically the abdomen is left open with the wound covered by a vacuum pack dressing or other temporary device. Como JJ, Bokhari F, Chiu WC, et al: Practice management guidelines for selective nonoperative management of penetrating abdominal trauma.J Trauma68(3):721-733, 2010. doi: 10.1097/TA.0b013e3181cf7d07 