eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Abdominal Trauma, Blunt

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

Introduction

Background

Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Identification of serious intra-abdominal pathology is often challenging. Many injuries may not manifest during the initial assessment and treatment period. Mechanisms of injury often result in other associated injuries that may divert the physician's attention from potentially life-threatening intra-abdominal pathology.1

Pathophysiology

Injury to intra-abdominal structures can be classified into 2 primary mechanisms of injury–compression forces and deceleration forces.

Compression or concussive forces may result from direct blows or external compression against a fixed object (eg, lap belt, spinal column). Most commonly, these crushing forces cause tears and subcapsular hematomas to the solid viscera. These forces also may deform hollow organs and transiently increase intraluminal pressure, resulting in rupture. This transient pressure increase is a common mechanism of blunt trauma to the small bowel.

Deceleration forces cause stretching and linear shearing between relatively fixed and free objects. These longitudinal shearing forces tend to rupture supporting structures at the junction between free and fixed segments. Classic deceleration injuries include hepatic tear along the ligamentum teres and intimal injuries to the renal arteries. As bowel loops travel from their mesenteric attachments, thrombosis and mesenteric tears, with resultant splanchnic vessel injuries, can result.

The liver and spleen seem to be the most frequently injured organs, although reports vary. Small and large intestines are the next most injured organs, respectively. Recent studies show an increased number of hepatic injuries, perhaps reflecting increased use of CT scanning and concomitant identification of more injuries.

Frequency

United States

True frequency is unknown. Data collected from trauma centers reflect patients who are transported to or seek care at these centers. These data may not reflect patients presenting to other facilities. Incidence of out-of-hospital deaths is unknown.

  • One review from the National Pediatric Trauma Registry by Cooper et al reported that 8% of patients (total=25,301) had abdominal injuries. Eighty-three percent of those injuries were from blunt mechanisms. Automobile-related injuries accounted for 59% of those injuries.2
  • Similar reviews from adult trauma databases reflect that blunt trauma is the leading cause of intra-abdominal injury and that motor vehicle collisions are the leading mode of injury. Blunt injuries account for approximately two thirds of all injuries.
  • Hollow viscus trauma is more frequent in the presence of an associated, severe, solid organ injury, particularly to the pancreas. Approximately two thirds of patients with hollow viscus trauma are injured in motor vehicle collisions.

International

Data from the World Health Organization indicate that falls from heights of less than 5 meters are the leading cause of injury, and automobile crashes are the next most frequent cause. These data reflect all injuries, not just blunt injuries to the abdomen.

  • A review from Singapore described trauma as the leading cause of death in those aged 1-44 years. Traffic accidents, stab wounds, and falls from heights were the leading modes of injury. Blunt abdominal trauma accounted for 79% of cases.3
  • A similar paper from India reported that blunt abdominal trauma is more frequent in males aged 21-30 years; the majority of patients were injured in automobile accidents.
  • A German study indicated that, of patients with vertical deceleration injuries (ie, falls from heights), only 5.9% had blunt abdominal injuries.

Mortality/Morbidity

  • The National Pediatric Trauma Registry reported that 9% of pediatric patients with blunt abdominal trauma died. Of these, only 22% were reported as having intra-abdominal injuries as the likely cause of death.2
  • A review from Australia of intestinal injuries in blunt trauma reported that 85% of injuries occurred from vehicular accidents. The mortality rate was 6%.
  • In a large review of operating room deaths in which blunt trauma accounted for 61% of all injuries, abdominal trauma was the primary identified cause of death in 53.4% of cases.

Sex

The male-to-female ratio is 60:40, according to national and international data.

Age

Most studies indicate that peak incidence occurs in persons aged 14-30 years. A review of 19,261 patients with blunt abdominal trauma revealed equal incidence of hollow viscus injuries in both children (ie, ≤14 y) and adults.

Clinical

History

  • Initially, evaluation and resuscitation occur simultaneously.
  • In general, do not obtain a detailed history until life-threatening injuries have been identified and therapy has been initiated. However, to better predict injury patterns and to identify potential pitfalls, ascertain the mechanism of injury from bystanders, paramedics, or police.
  • AMPLE is often useful as a mnemonic for remembering key elements of the history.
    • A llergies
    • M edications
    • P ast medical history
    • L ast meal or other intake
    • E vents leading to presentation
  • A history of out-of-hospital hypotension is a predictor of more significant intra-abdominal injuries. Even if normotensive upon ED arrival, consider the patient as having an increased risk.

Physical

  • Initial examination
    • After appropriate primary survey and initiation of resuscitation, focus attention on secondary survey of the abdomen.
    • For life-threatening injuries that require emergent surgery, delay comprehensive secondary survey until the patient has been stabilized.
    • At the other end of the spectrum are victims of blunt trauma who have a benign abdomen upon initial presentation. Many injuries initially are occult and manifest over time. Frequent serial examinations, in conjunction with the appropriate diagnostic studies, such as abdominal CT scan and bedside ultrasonography, are essential in any patient with significant mechanism of injury.
  • Inspection
    • Examine the abdomen to determine the presence of external signs of injury. Note patterns of abrasion and/or ecchymotic areas.
    • Note injury patterns that predict the potential for intra-abdominal trauma (eg, lap belt abrasions, steering wheel–shaped contusions). In most studies, lap belt marks have been correlated with rupture of the small intestine and an increased incidence of other intra-abdominal injuries.
    • Observe the respiratory pattern because abdominal breathing may indicate spinal cord injury. Note abdominal distention and any discoloration.
    • Bradycardia may indicate the presence of free intraperitoneal blood in a patient with blunt abdominal injuries.
    • The Cullen sign (ie, periumbilical ecchymosis) may indicate retroperitoneal hemorrhage; however, this symptom usually takes several hours to develop. Flank bruising and swelling may raise suspicion for a retroperitoneal injury.
    • Inspect genitals and perineum for soft tissue injuries, bleeding, and hematoma.
  • Auscultation
    • Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula.
    • During auscultation, gently palpate the abdomen while noting the patient's reactions.
  • Palpation
    • Carefully palpate the entire abdomen while assessing the patient's response. Note abnormal masses, tenderness, and deformities.
    • Fullness and doughy consistency may indicate intra-abdominal hemorrhage. Crepitation or instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries associated with lower rib injuries.
    • Pelvic instability indicates the potential for lower urinary tract injury as well as pelvic and retroperitoneal hematoma. Open pelvic fractures are associated with a mortality rate exceeding 50%.
    • Perform rectal and bimanual vaginal pelvic examinations to identify potential bleeding and injury.4
    • Perform a sensory examination of the chest and abdomen to evaluate the potential for spinal cord injury. Spinal cord injury may interfere with the accurate assessment of the abdomen by causing decreased or absent pain perception.
    • Abdominal distention may result from gastric dilation secondary to assisted ventilation or swallowing of air.
    • Signs of peritonitis (eg, involuntary guarding, rigidity) soon after an injury suggest leakage of intestinal content. Peritonitis due to intra-abdominal hemorrhage may take several hours to develop.
  • Percussion
    • Percussion tenderness constitutes a peritoneal sign.
    • Tenderness mandates further evaluation and probably surgical consultation.

Causes

  • The most common causes of blunt abdominal trauma are from motor vehicle accidents and automobile-pedestrian accidents.
  • Other common etiologies include falls and industrial or recreational accidents.

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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