II. Causes: Blunt Abdominal Trauma

  1. Direct blow to the Abdomen (e.g. Contact Sports, Motor Vehicle Accident)
  2. Fall from Height
  3. Cycling handlbar injury

III. Associated Conditions

  1. Liver Laceration
  2. Splenic Rupture
  3. Renal Injury
  4. Pancreatic Injury
  5. Hollow viscus (bowel perforation) or Lumbar Spine Injury
    1. Seat Belt
    2. Deceleration injury
  6. Rectum or other bowel injury
  7. Gastrointestinal Bleeding

IV. Indications: Diagnostic Testing

  1. See precautions below
    1. Do not delay an exploratory laparoscopy that is clearly indicated
  2. Suspected occult internal bleeding with decreasing Hematocrit and no obvious source
  3. Non-diagnostic examination with higher clinical suspicion
    1. Equivocal peritoneal signs with abdominal tenderness and guarding
    2. Altered Level of Consciousness and suspected Abdominal Trauma
    3. Negative abdominal exam but high level of suspicion based on mechanism of injury
  4. Bony Fracture with associated abdominal tenderness or guarding
    1. Multiple lower Rib Fractures
    2. Lumbar transverse process Fracture
    3. Pelvic Fracture

V. Symptoms

  1. Persistent Abdominal Pain after injury
    1. Pain may be referred to the Shoulders
  2. Fever
  3. Nausea
  4. Vomiting
  5. Bright Red Blood Per Rectum

VI. Signs

  1. Localized Abdominal Pain
  2. Abdominal guarding
  3. Abdominal Rebound Tenderness
  4. Abdominal rigidity

VII. Examination

  1. Evaluate for peritonitis or hemodynamic instability
    1. Fever
    2. Hypotension
    3. Tachycardia
  2. Complete abdominal exam
  3. Rectal examination
    1. Decreased rectal tone (Spinal Injury)
    2. High riding Prostate (Urethral transection)
    3. Bloody stool on rectal exam

VIII. Imaging: First-line studies

  1. FAST Exam
  2. CT Abdomen and Pelvis
    1. Perform with IV contrast
    2. Consider oral and rectal contrast if time allows and not contraindicated
    3. Identifies Stomach and intestinal rupture

IX. Imaging: Abdominal XRay

  1. Rarely useful beyond demonstrating free air compared with CT Abdomen
  2. Evaluate with CT Abdomen and Pelvis (or UGI with gastrograffin) if red flags are positive
  3. General suspicious KUB findings
    1. Peritoneal free air mandates emergent laparoscopy
    2. Ileus
    3. Visceral displacement
    4. Lumbar compression Fracture
  4. Duodenum or pacreas injury signs
    1. Psoas shadow absent
    2. Retroperitoneal gas
    3. Linear air shadows at duodenum or overlying the right Kidney
  5. Splenic Injury signs
    1. Splenic shadow absent
    2. Gastric air bubble displaced medially
    3. Left psoas and left renal shadows obscured
    4. Left upper quadrant soft tissue density

X. Diagnostics

  1. Diagnostic Peritoneal Lavage (not recommended)
    1. Rarely performed now in United States where Ultrasound and CT Scans are readily available
    2. Typically FAST Exam followed by CT Abdomen and Pelvis is performed in Trauma

XI. Precautions

  1. Do not delay emergent exploratory laparotomy when indicated
  2. Peritoneal cavity extends well into chest
    1. Anterior superior diaphragm boundary: Nipple Line
    2. Posterior superior diaphragm boundary: 4th intercostal space
  3. Although distracting injury may theoretically hide abdominal findings on exam, it still has 90% Test Sensitivity
    1. Rostas (2015) J Trauma Acute Care Surg 78(6):1095-100 +PMID:26151507 [PubMed]
  4. Manage secondary conditions
    1. Hemorrhagic Shock
    2. Peritonitis
      1. Broad spectrum antibiotic coverage for intraabdominal infection
      2. Sepsis management including Intravenous FluidResuscitation

XII. Management: Exploratory Laparotomy Indications

  1. Unexplained shock
  2. Visceral Trauma (e.g. evisceration)
  3. Gastrointestinal Bleeding
    1. Blood in Stomach
    2. Blood aspirated via Nasogastric Tube
    3. Rectal Bleeding
  4. Peritoneal signs on examination
    1. Abdominal Distention
    2. Absent bowel sounds
    3. Peritonitis
  5. Suspicious findings on adominal XRay or CT Abdomen (e.g. Abdominal free air)
  6. Retained Foreign Body into the peritoneal cavity
    1. All abdominal gun shot wounds should be surgically explored
    2. Stabbing weapon

XIII. References

  1. (2012) ATLS Manual, 9th ed, American College of Surgeons
  2. Dreis (2020) Crit Dec Emerg Med 34(7):3-21

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