eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Abdominal Trauma, Blunt: Treatment & Medication

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

Treatment

Prehospital Care

  • Focus prehospital care on rapidly evaluating life-threatening problems, initiating resuscitative measures, and initiating prompt transport to the closest appropriate hospital, which typically is a trauma center.
  • Use endotracheal intubation to secure the airway of any patient who is unable to maintain the airway or who has potential airway threats. Secure the airway in conjunction with in-line cervical immobilization in any patient who may have suffered cervical trauma. Provide artificial ventilation by using a high fraction of inspired oxygen (FIO2) for patients who exhibit compromised breathing respirations. Maintain oxygenation at more than 90-92% saturation.
  • External hemorrhage rarely is associated with blunt abdominal trauma. If present, control the hemorrhage with direct pressure. Note any signs of inadequate systemic perfusion. Consider intraperitoneal hemorrhage whenever evidence of hemorrhagic shock is found in the absence of external hemorrhage. Initiate volume resuscitation with crystalloid solution; however, never delay patient transport while intravenous lines are inserted. En route, administer a fluid bolus of lactated Ringer or normal saline solution to patients with evidence of shock.18,19
  • Titrate intravenous fluid therapy to the patient's clinical response. Because overaggressive volume resuscitation may lead to recurrent or increased hemorrhage, titrate intravenous fluids to a systolic blood pressure of 90-100 mm Hg. This practice should provide the mean blood pressure necessary to maintain perfusion of the vital organs.
  • Acquire expeditious and complete spinal immobilization on patients with multisystem injuries and on patients with a mechanism of injury that has potential for spinal cord trauma. In the rural setting, the pneumatic antishock garment may have a role for treating shock resulting from a severe pelvic fracture.
  • Transport patients who meet physiologic or anatomic criteria to the closest trauma center. Promptly notify the destination hospital in order for that facility to activate its trauma team and prepare for the patient.

Emergency Department Care

  • Perform a rapid primary survey to identify immediate life-threatening problems. Focus close attention on whether the patient can maintain the airway or if a potential threat is present. Secure the airway by orotracheal intubation, which is performed with concurrent in-line manual immobilization of the cervical spine. If intubation is required, and if possible, perform and record a brief neurologic examination prior to neuromuscular blockade and intubation.
  • Patients who display apnea or hypoventilation require respiratory support, as do those patients with tachypnea. Provide all patients with supplemental oxygen from a device capable of delivering a high FIO2 (eg, nonrebreather mask). Decreased or absent breath sounds raise the possibility of hemothorax or pneumothorax; therefore, consider needle decompression or tube thoracostomy, even prior to obtaining a chest radiograph.
  • Identification of hypovolemia and signs of shock necessitate vigorous resuscitation and attempts to identify the source of blood loss. Initiate at least 2 large-bore (eg, 18-guage) peripheral intravenous lines. Use central lines (preferably femoral by using a large-bore line such as a Cordis catheter) and cutdowns (eg, saphenous, brachial) for patients in whom percutaneous peripheral access cannot be established. Administer a rapid bolus of crystalloid.
  • Perform physical examination that consists of a complete head-to-toe secondary survey, with attention paid to evidence of the mechanism of injury and potentially injured areas. Before the placement of a nasogastric tube and Foley catheter, perform appropriate head, neck, pelvic, perineum, and rectal examinations.
  • Based on mechanism and physical examination, obtain initial trauma radiographic studies. In general, trauma suite views include a lateral cervical spine, anterior portable chest, and pelvis radiograph. In-line spinal immobilization must be continued until spinal fractures have been ruled out. Additional radiographs are indicated for other findings in the secondary survey.
  • After the primary survey and initial resuscitation have begun, complete the secondary survey to identify all potential and present injuries. "Log-roll" the patient to examine the back and palpate the entire spinal column. Investigate for any signs of injury. Perform a rectal examination.
  • If signs of shock persist after an initial 2-3 liters of crystalloid infusion, administer blood products. Type O Rh-negative blood typically is given to women of childbearing age. Type O-positive blood may be given safely to all other patients including men and postmenopausal women. As soon as available, use type-specific or crossmatched blood.
  • Bedside ultrasonography using a trauma examination protocol (eg, FAST) can be used to determine the presence of intraperitoneal hemorrhage (see Media files 1-2). If findings are negative or equivocal, a DPL may be performed in hemodynamically unstable patients.
Ultrasound image of right flank. A clear hypoecho...

Ultrasound image of right flank. A clear hypoechoic stripe exists between the right kidney and the liver in the area known as the Morison pouch.

[ CLOSE WINDOW ]
Ultrasound image of right flank. A clear hypoecho...

Ultrasound image of right flank. A clear hypoechoic stripe exists between the right kidney and the liver in the area known as the Morison pouch.


Ultrasound image of the left flank in the same pa...

Ultrasound image of the left flank in the same patient, with a thin hypoechoic stripe above the spleen and a wider hypoechoic stripe in the splenorenal recess.

[ CLOSE WINDOW ]
Ultrasound image of the left flank in the same pa...

Ultrasound image of the left flank in the same patient, with a thin hypoechoic stripe above the spleen and a wider hypoechoic stripe in the splenorenal recess.

  • Based on stability, mechanism, and suspicion of intra-abdominal injury, further investigation may be warranted for patients who are hemodynamically stable after the initial assessment and resuscitation and who have negative or equivocal bedside ultrasonography and/or DPL results. Further investigation includes contrast-enhanced CT scans of the abdomen and pelvis or serial examinations and ultrasonography.

Consultations

  • The best outcomes from trauma are obtained by involving consultants who possess specific expertise and training in managing trauma patients. Consider evaluation by a trauma surgeon for all patients with evidence of blunt abdominal trauma. Clearly, patients who have hemodynamic instability or significant abnormalities found during physical examinations and diagnostic procedures require involvement of a trauma surgeon.
  • Specific physical examination findings indicate timely surgical evaluation as follows:
    • History of blunt abdominal trauma, shock, or abnormal vital signs (eg, tachycardia, hypotension)
    • Evidence of shock without obvious external blood loss
    • Evidence of peritonitis (eg, marked tenderness, involuntary guarding, percussion tenderness)
    • Findings consistent with potential intra-abdominal injury (eg, lap belt signs, lower rib fractures, lumbar spine fractures)
    • Altered levels of consciousness or sensation, whether due to drugs, alcohol, or head/spinal injury
    • Patients who require other prolonged operative intervention (eg, orthopedic procedures)
  • Specific findings on diagnostic studies, such as evidence of free fluid or solid organ injury on sonograms or CT scan, indicate timely involvement of a trauma surgeon. Although a trend toward nonoperative management of hepatic, splenic, and renal injuries in patients who are hemodynamically normal has occurred, a trained trauma surgeon must oversee this care. Other specific findings that indicate timely trauma surgeon involvement are as follows:
    • Positive findings on DPL
    • Evidence of extravasated contrast or extraluminal air on an upper GI series (eg, duodenal rupture), plain abdominal radiography, or cystography
    • Serious pelvic fractures
    • Evidence of bladder rupture on contrast cystogram or gross hematuria
    • Elevated findings on liver function studies

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
[ CLOSE WINDOW ]

References

  1. American College of Surgeons Committee on Trauma. Abdominal Trauma. In: ATLS Student Course Manual. 8th. American College of Surgeons; 2008.

  2. Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg. Jan 1994;29(1):33-8. [Medline].

  3. Ong CL, Png DJ, Chan ST. Abdominal trauma--a review. Singapore Med J. Jun 1994;35(3):269-70. [Medline].

  4. [Best Evidence] Hankin AD, Baren JM. Should the digital rectal examination be a part of the trauma secondary survey?. Ann Emerg Med. Feb 2009;53(2):208-12. [Medline].

  5. Ritchie AH, Williscroft DM. Elevated liver enzymes as a predictor of liver injury in stable blunt abdominal trauma patients: case report and systematic review of the literature. Can J Rural Med. 2006;11(4):283-7. [Medline].

  6. Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF, Malangoni MA. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. Jul 1997;63(7):598-604. [Medline].

  7. Knudson MM, McAninch JW, Gomez R, Lee P, Stubbs HA. Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg. Nov 1992;164(5):482-5; discussion 485-6. [Medline].

  8. Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. Nov 2004;22(7):601-4. [Medline].

  9. Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. Jun 1997;42(6):1086-90. [Medline].

  10. Kornezos I, Chatziioannou A, Kokkonouzis I, Nebotakis P, Moschouris H, Yiarmenitis S. Findings and limitations of focused ultrasound as a possible screening test in stable adult patients with blunt abdominal trauma: a Greek study. Eur Radiol. Aug 7 2009;[Medline].

  11. Kendall JL, Faragher J, Hewitt GJ, Burcham G, Haukoos JS. Emergency Department Ultrasound Is not a Sensitive Detector of Solid Organ Injury. West J Emerg Med. Feb 2009;10(1):1-5. [Medline].

  12. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. Sep 1995;39(3):492-8; discussion 498-500. [Medline].

  13. Brasel KJ, Olson CJ, Stafford RE, Johnson TJ. Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma. J Trauma. May 1998;44(5):889-92. [Medline].

  14. Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. Jan 2004;43(1):120-8. [Medline].

  15. Christiano JG, Tummers M, Kennedy A. Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma. J Pediatr Surg. Jun 2009;44(6):1242-8. [Medline].

  16. Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR. Apr 2004;25(2):180-204. [Medline].

  17. Liu M, Lee CH, P'eng FK. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma. Aug 1993;35(2):267-70. [Medline].

  18. [Best Evidence] Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. Oct 17 2007;CD000567. [Medline].

  19. [Best Evidence] Bunn F, Trivedi D, Ashraf S. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev. 2008;(1):CD001319. [Medline].

  20. ACS Committee on Trauma. Abdominal trauma. In: ATLS Student Course Manual. 7th ed. 2004:131-150.

  21. Aherne NJ, Kavanagh EG, Condon ET, Coffey JC, El Sayed A, Redmond HP. Duodenal perforation after a blunt abdominal sporting injury: the importance of early diagnosis. J Trauma. Apr 2003;54(4):791-4. [Medline].

  22. Ali J, Ahmadi KA, Williams JI. Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. Can J Surg. Aug 2009;52(4):271-276. [Medline].

  23. Bellows CF, Salomone JP, Nakamura SK, Choe EU, Flint LM, Ferrara JJ. What's black and white and red (read) all over? The bedside interpretation of diagnostic peritoneal lavage fluid. Am Surg. Feb 1998;64(2):112-8. [Medline].

  24. Branney SW, Moore EE, Feldhaus KM, Wolfe RE. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma. Jul 1998;45(1):87-94; discussion 94-5. [Medline].

  25. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. Oct 1997;63(10):885-8. [Medline].

  26. Chiu WC, Cushing BM, Rodriguez A, et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma. Apr 1997;42(4):617-23; discussion 623-5. [Medline].

  27. Committees of NAEP and ACS. Trauma. In: Paturas JL, Wertz EM, eds. Basic and Advanced Prehospital Trauma Life Support. 4th ed. Mosby-Year Book; 1999.

  28. Dahmus MA, Sibai BM. Blunt abdominal trauma: are there any predictive factors for abruptio placentae or maternal-fetal distress?. Am J Obstet Gynecol. Oct 1993;169(4):1054-9. [Medline].

  29. Holmes JF, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. Oct 2009;54(4):528-33. [Medline].

  30. Holmes JF, Wisner DH, McGahan JP, Mower WR, Kuppermann N. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med. Oct 2009;54(4):575-84. [Medline].

  31. Keller MS. Blunt injury to solid abdominal organs. Semin Pediatr Surg. May 2004;13(2):106-11. [Medline].

  32. Livingston DH, Lavery RF, Passannante MR, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma. Feb 1998;44(2):273-80; discussion 280-2. [Medline].

  33. Munns J, Richardson M, Hewett P. A review of intestinal injury from blunt abdominal trauma. Aust N Z J Surg. Dec 1995;65(12):857-60. [Medline].

  34. National Association of Emergency Medical Technicians. Salomone JP, Pons PT, McSwain NE. PHTLS: Basic and Advanced Prehospital Trauma Life Support. 6th ed. MOSBY/JEMS; 2007.

  35. Rhea JT, Garza DH, Novelline RA. Controversies in emergency radiology. CT versus ultrasound in the evaluation of blunt abdominal trauma. Emerg Radiol. Jul 2004;10(6):289-95. [Medline].

  36. Rozycki GS, Shackford SR. Ultrasound, what every trauma surgeon should know. J Trauma. Jan 1996;40(1):1-4. [Medline].

  37. Sahdev P, Garramone RR Jr, Schwartz RJ, Steelman SR, Jacobs LM. Evaluation of liver function tests in screening for intra-abdominal injuries. Ann Emerg Med. Aug 1991;20(8):838-41. [Medline].

  38. Salomone JP, Ustin JS, McSwain NE, Feliciano DV. Opinions of trauma practitioners regarding prehospital interventions for critically injured patients. J Trauma. Mar 2005;58(3):509-15; discussion 515-7. [Medline].

  39. Smith JS, Wengrovitz MA, DeLong BS. Prospective validation of criteria, including age, for safe, nonsurgical management of the ruptured spleen. J Trauma. Sep 1992;33(3):363-8; discussion 368-9. [Medline].

  40. Talton DS, Craig MH, Hauser CJ, Poole GV. Major gastroenteric injuries from blunt trauma. Am Surg. Jan 1995;61(1):69-73. [Medline].

  41. Udekwu PO, Gurkin B, Oller DW. The use of computed tomography in blunt abdominal injuries. Am Surg. Jan 1996;62(1):56-9. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

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

[ CLOSE WINDOW ]

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.