eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Abdominal Trauma, Blunt: Differential Diagnoses & Workup

Author: Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
Coauthor(s): Jeffrey P Salomone, MD, FACS, NREMT-P, Associate Professor of Surgery, Emory University School of Medicine; Deputy Chief of Surgery, Grady Memorial Hospital
Contributor Information and Disclosures

Updated: Oct 2, 2009

Differential Diagnoses

Abdominal Trauma, Penetrating
Trauma, Lower Genitourinary
Domestic Violence
Trauma, Upper Genitourinary
Pregnancy, Trauma
Shock, Hemorrhagic
Shock, Hypovolemic

Workup

Laboratory Studies

  • In recent years, laboratory evaluation of trauma victims has been a matter of significant discussion. Commonly recommended studies include serum glucose, complete blood count (CBC), serum chemistries, serum amylase, urinalysis, coagulation studies, blood type and match, arterial blood gas (ABG), blood ethanol, urine drug screens, and a urine pregnancy test (for females of childbearing age).
  • Complete blood count
    • Normal hemoglobin and hematocrit results do not rule out significant hemorrhage. Patients bleed whole blood. Until blood volume is replaced with crystalloid solution or hormonal effects (eg, adrenocorticotropic hormone [ACTH], aldosterone, antidiuretic hormone [ADH]) and transcapillary refill occurs, anemia may not develop. Do not withhold transfusion in patients who have relatively normal hematocrit results (ie, >30%) but have evidence of clinical shock, serious injuries (eg, open-book pelvic fracture), or significant ongoing blood loss.
    • Use platelet transfusions to treat patients with thrombocytopenia (ie, platelet count <50,000/mL) and ongoing hemorrhage.
    • Bedside diagnostic testing with rapid hemoglobin or hematocrit machines may quickly identify patients who have physiologically significant volume deficits and hemodilution. Reported hemoglobin from ABGs also may be useful in identifying anemia.
    • Some studies have correlated a low initial hematocrit (ie, <30%) with significant injuries.
  • Serum chemistries
    • Recently, the usefulness of routine serum chemistries of trauma patients has been questioned. Most trauma victims are younger than 40 years and rarely are taking medications that may alter electrolytes (eg, diuretics, potassium replacements).
    • The more prudent choice when attempting to limit cost involves selective ordering of these studies. Base the selections on the patient's medications, presence of concurrent nausea or vomiting, presence of dysrhythmias, or history of renal failure or other chronic medical problems associated with electrolyte imbalance.
    • If blood gas measurements are not routinely obtained, serum chemistries that measure serum glucose and carbon dioxide levels are indicated.
    • Rapid bedside blood-glucose determination, obtained with a finger-stick measuring device, is important for patients with altered mental status.
  • Liver function studies
    • LFTs may be useful in the patient with blunt abdominal trauma; however, test findings may be elevated for several reasons (eg, alcohol abuse).5
    • One study has shown that an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) level more than 130 U corresponds with significant hepatic injury.6
    • Lactate dehydrogenase (LDH) and bilirubin levels are not specific indicators of hepatic trauma.
  • Amylase measurement
    • Controversy surrounds the role of amylase determination in the presence of blunt abdominal trauma.
    • An initial amylase determination has been shown in multiple studies to be neither sensitive nor specific for pancreatic injury; however, an abnormally elevated amylase level 3-6 hours after trauma has a much greater accuracy.
    • Although some pancreatic injuries may be missed with a CT scan performed soon after trauma, virtually all are identified if the scan is repeated in 36-48 hours.
  • Urinalysis
    • Indications for diagnostic urinalysis include significant trauma to the abdomen and/or flank, gross hematuria, microscopic hematuria in the setting of hypotension, and a significant deceleration mechanism.7
    • Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP) or CT scanning with intravenous contrast.
    • Gross hematuria indicates a workup that includes cystography and IVP or CT scanning of the abdomen with contrast.
  • Obtain a serum or urine pregnancy test on all females of childbearing age.
  • Coagulation profile
    • The cost-effectiveness of routine prothrombin time (PT)/activated partial thromboplastin time (aPTT) determination upon admission is questionable.
    • Obtain PT/aPTT in patients who have a history of blood dyscrasias (eg, hemophilia), who have synthetic problems (eg, cirrhosis), or who take anticoagulant medications (eg, warfarin, heparin).
  • Blood type, screen, and crossmatch
    • Screen and type blood from all trauma patients with suspected blunt abdominal injury. If an injury is identified, this practice greatly reduces the time required for crossmatch.
    • Perform an initial crossmatch on a minimum of 4-6 units for those patients with clear evidence of abdominal injury and hemodynamic instability.
    • Until crossmatched blood is available, utilize O-negative or type-specific blood.
  • Arterial blood gas measurement
    • ABG level may provide important information in major trauma victims. In addition to information about oxygenation (eg, PO2, SaO2) and ventilation (PCO2), this test provides valuable information regarding oxygen delivery by calculation of the A-a gradient.
    • Upon initial hospital admission, suspect metabolic acidemia to result from the lactic acidosis that accompanies shock.
    • A moderate base deficit (ie, more than -5 mEq) indicates the need for aggressive resuscitation and determination of the etiology.
    • Attempt to improve systemic oxygen delivery by ensuring an adequate SaO2 (ie, >90%) and by acquiring volume resuscitation with crystalloid solutions and, if indicated, blood.
    • ABGs report total hemoglobin more rapidly than CBCs.
  • Drug and alcohol screens
    • Perform drug and alcohol screens on trauma patients who have alterations in their level of consciousness.
    • Breath or blood testing may quantify alcohol level.

Imaging Studies

  • Focused abdominal sonogram for trauma
    • Bedside ultrasonography in the form of focused abdominal sonogram for trauma (FAST) has been used in the evaluation of trauma patients in Europe for more than 10 years and is increasingly gaining acceptance in the United States. FAST's diagnostic accuracy generally is equal to that of diagnostic peritoneal lavage (DPL). Studies in the United States over the last few years have demonstrated the value of bedside sonography as a noninvasive approach for rapid evaluation of hemoperitoneum. The studies demonstrate a degree of operator dependence; however, some studies have shown that with a structured learning session, even novice operators can identify free intra-abdominal fluid, especially if greater than 500 mL of fluid is present.
    • In the patient with isolated blunt abdominal trauma and multisystem injuries, bedside ultrasonography performed by an experienced sonographer can rapidly identify free intraperitoneal fluid. The sensitivity for solid organ encapsulated injury is moderate in most studies. Hollow viscus injury rarely is identified; however, free fluid may be visualized in these cases. For patients with persistent pain or tenderness or for those developing peritoneal signs, consider FAST as a complementary measure to CT scan, DPL, or exploration.
    • FAST evaluation of the abdomen consists of visualization of the pericardium (from a subxiphoid view), the splenorenal and the hepatorenal spaces (ie, Morison pouch), the paracolic gutters, and the pouch of Douglas in the pelvis. The Morison pouch view has been shown to be the most sensitive, regardless of the etiology of the fluid.
    • Free fluid, generally assumed to be blood in the setting of abdominal trauma, appears as a black stripe. Free fluid in a hemodynamically unstable patient indicates the need for emergent laparotomy; however, CT scan may further evaluate the stable patient with free fluid.
    • Sensitivity and specificity of these studies range from 85-95%.8,9,10,11,12
  • CT scanning
    • Although expensive and potentially time-consuming, CT scan often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention.13,14,15,16
    • Transport only hemodynamically stable patients to the CT scanner. When performing CT scan, closely and carefully monitor vital signs for clinical evidence of decompensation.
    • CT scanning may miss injuries to the diaphragm and perforations of the GI tract, especially when CT scanning is performed soon after the injury. Pancreatic injuries may not be identified on initial CT scans but generally are found on follow-up examinations performed on high-risk patients. For selected patients, endoscopic retrograde cholangiopancreatography (ERCP) may complement CT scanning to rule out a ductal injury.
    • The primary advantage of CT scanning is its high specificity and use for guiding nonoperative management of solid organ injuries.
    • Drawbacks of CT scanning relate to the need to transport the patient from the trauma resuscitation area and the additional time required to perform CT scanning compared to FAST or DPL. The best CT imagery requires both oral and intravenous contrast.
    • Some controversy has arisen over the use of oral contrast and whether the additional information it provides negates the drawbacks of increased time to administration and risk of aspiration. The value of oral contrast in diagnosing bowel injury has been debated, but no definitive answer exists at this time.

Procedures

  • Diagnostic peritoneal lavage

    • DPL is used as a method of rapidly determining the presence of intraperitoneal blood. DPL is particularly useful if the history and abdominal examination of a patient who is unstable and has multisystem injuries is either unreliable (eg, head injury, alcohol, drug intoxication) or equivocal (eg, lower rib fractures, pelvic fractures, confounding clinical examination). DPL also is useful for patients in whom serial abdominal examinations cannot be performed (eg, those in an angiographic suite or operating room during emergent orthopedic or neurosurgical procedures).17
    • The preferred method involves an open or semiopen technique that is performed in an infraumbilical location. In pregnant patients or in patients with particular risk for potential pelvic hematoma, perform the DPL superior to the umbilicus.
    • Following insertion of the catheter into the peritoneum, attempt to aspirate free intraperitoneal blood (at least 15-20 mL). Abdominal exploration is always indicated if approximately 10 mL of blood is aspirated upon insertion of the peritoneal catheter (grossly positive) in the unstable patient. If findings are negative, infuse 1 L of crystalloid solution (eg, lactated Ringer solution) into the peritoneum. Then, allow this fluid to drain by gravity, and ensure laboratory analysis is performed.
    • The presence of more than 100,000 RBC/mm3 or more than 500 WBC/mm3 is considered a positive finding.
    • Other results from DPL fluid that indicate the need for exploration include the presence of bile or abnormally high amylase level (indicative of intestinal perforation), food fibers, or bacteria noted on microscopic examination.
    • In some contexts, DPL may be complemented with a CT scan if the patient has positive lavage results but stabilizes.
    • The only absolute contraindication for a DPL is for the patient who requires emergent laparotomy regardless of the findings.
    • Complications of DPL include bleeding from the incision and catheter insertion, infection (ie, wound, peritoneal), and injury to intra-abdominal structures (eg, urinary bladder, small bowel, uterus). These complications may increase the possibility of false-positive studies. Additionally, infection of the incision, peritonitis from the catheter placement, laceration of the urinary bladder, or injury to other intra-abdominal organs can occur.
    • Bleeding from the incision, dissection, or catheter insertion can cause false-positive results that may lead to unnecessary laparotomy. Achieve appropriate hemostasis prior to entering the peritoneum and placing the catheter.

More on Abdominal Trauma, Blunt

Overview: Abdominal Trauma, Blunt
Differential Diagnoses & Workup: Abdominal Trauma, Blunt
Treatment & Medication: Abdominal Trauma, Blunt
Follow-up: Abdominal Trauma, Blunt
Multimedia: Abdominal Trauma, Blunt
References
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Further Reading

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Keywords

intra-abdominal trauma, intra-abdominal injury, blunt abdominal injury, motor vehicle collision, motor vehicle accident, MVA, blunt trauma

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Contributor Information and Disclosures

Author

Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey P Salomone, MD, FACS, NREMT-P, Associate Professor of Surgery, Emory University School of Medicine; Deputy Chief of Surgery, Grady Memorial Hospital
Jeffrey P Salomone, MD, FACS, NREMT-P is a member of the following medical societies: American College of Surgeons, American Medical Association, Medical Association of Georgia, National Association of EMS Physicians, and Society of Critical Care Medicine
Disclosure: Schering plough Consulting fee Consulting; Merck Honoraria Speaking and teaching; NAEMT-PreHospital Trauma Life Support None Editing PHTLS textbook; all royalties paid to NAEMT; Ortho-McNeil Consulting fee Consulting

Medical Editor

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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