Blunt Abdominal Trauma


Article Author:
Maria O'Rourke


Article Editor:
Bracken Burns


Editors In Chief:
Jeanie Skibiski
Kathrin Allen
Brian Cornelius


Managing Editors:
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Scott Dulebohn
Sobhan Daneshfar
William Gossman
Pritesh Sheth
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Richard Ciresi
Hajira Basit
Phillip Hynes


Updated:
12/26/2018 7:52:03 AM

Introduction

Abdominal trauma caused by blunt force is a common presentation in the emergency room seen in adults and children. [1][2]

Etiology

The chief cause of blunt abdominal trauma in the United States is motor vehicle accidents. Other rare causes include falls from heights, bicycle injuries, injuries sustained during sporting activities, and industrial accidents. In children, the most common causes are due to motor vehicle injuries and bicycle accidents.[3][4]

Epidemiology

Blunt trauma to the abdomen can occur in people of all ages and is associated with a high morbidity. Each year thousands of patients with blunt abdominal injury are seen in emergency departments, and this substantially increases the cost of healthcare.[5] [6]

Pathophysiology

Blunt abdominal trauma can cause damage to the internal organs, resulting in internal bleeding, cause contusions, or injuries to the bowel, spleen, liver,  and intestines. Patients can also present with extra-abdominal injuries such as extremity injuries. [7][8]

History and Physical

Because the presentation is often not straightforward, the diagnosis can be difficult and often time-consuming. Besides pain, the patient may present with bleeding per rectum, unstable vital signs, and the presence of peritonitis. The physical exam may reveal marks from a lap belt, ecchymosis, abdominal distention, absent bowel sounds and tenderness to palpation. If peritonitis is present, abdominal rigidity, guarding and rebound tenderness may be present. The mechanism of injury, motor vehicle speed, associated deaths at the scene, uses of alcohol or other substance of abuse must be taken into account so as not to miss an injury.

Evaluation

The evaluation of any trauma patient begins with evaluating the airway, accessing the breathing, and managing the circulation. The diagnosis of intra-abdominal injury following blunt trauma depends primarily on the hemodynamic status of the patient. If the patient is hemodynamically stable, CT scan is the ideal test to look for solid organ injury in the abdomen and pelvis. For unstable patients, one may perform an ultrasound (Extended Focused Assessment with Sonography for Trauma (EFAST)) or diagnostic peritoneal lavage, both of which are associated with a high rate of false negatives and false positives.[3][9][10]

All indications for trauma ultrasound include blunt or penetrating trauma to the torso where there is a suspicion of intraperitoneal hemorrhage, pericardial tamponade, and hemothorax.

The Extended Focused Assessment with Sonography for Trauma (EFAST) exam includes the following views:

1. RUQ (right upper quadrant)

  • One should evaluate for free fluid in Morison's pouch or the hepatorenal space, the lower pole of the kidney and the space below the diaphragm on the right. In the supine patient, the hepatorenal space is the most dependent area and the least obstructed for fluid flow. Fluid in the abdomen can move freely to the right pericolic gutter into this space.

2. Perisplenic space LUQ (left upper quadrant)

  • One should visualize the diaphragm and the entire spleen
  • Check above the diaphragm for signs of free fluid in the left hemithorax. On the left, fluid flows preferentially into the subphrenic area and not into the splenorenal area,  which is important because the subphrenic area may be difficult to visualize due to bowel gas and splenic flexure gas.

3. Pelvis (bladder)

  • One should visualize interface w/ the rectum, prostate, or uterus.
  • Additionally, a second image can be viewed in a longitudinal plane.
  • Fluid in the pelvic region flows to the microvesicular area in the male patient and the pouch of Douglas in the female patient because these areas are the most dependent areas of the pelvis.

4. Cardiac view: Subcostal or any other cardiac view. See below

5. Normal Lung: Lung sliding back and forth is normally secondary to the normal anatomy of the parietal and visceral pleural movement.  As well,  the pleura moves with respect to the ribs+Comet tail artifacts.

Pneumothorax: With a pneumothorax, there is NO lung sliding back and forth. you will note the pleura and ribs move together. There will be NO comet tail artifacts.

CARDIAC

Subxiphoid four-chamber 

Both the anterior and posterior pericardium should be visualized for anterior or posterior fluid in the pericardium.

  • Parasternal views should be attempted if the subxiphoid view is not adequate.
  • Both the anterior and posterior pericardium should be visualized.

Parasternal long axis (PSLA)

  • Both the anterior and posterior pericardium should be visualized.
  • In the ideal plane, the mitral and aortic valves will be visible, as well as a long view of the left ventricle.

Parasternal short axis (PSSA)

  • The left ventricle will appear as a ring, with the right ventricle more anterior.

Apical Four-chamber

  • Though rarely useful in the emergency department, this view allows easy comparison of left and right ventricles.
  • All four chambers should be visible in this plan.

Treatment / Management

Treatment of patients with blunt abdominal injury requires the routine ABCs (Airway, Breathing, and Circulation). Once the airway is protected, it is mandatory to protect the cervical spine. After the primary survey is complete, patients who are hypotensive require aggressive fluid resuscitation. If hemodynamic instability persists, blood should be typed and crossed, but in the meantime, immediate transfusion with O negative blood can be done (O+ for males and women past childbearing years).  All patients with blunt abdominal trauma who have signs of peritonitis, frank bleeding, or worsening of clinical signs require an immediate laparotomy. Non-surgical treatment in patients with blunt abdominal injury depends on the clinical features, hemodynamic stability and results of the CT scan. Advances in angiography can now help control hemorrhage with the use of embolization therapy, which is more cost effective than laparotomy. In general, the prognosis of patients with blunt abdominal trauma is good. [11][12][13]

Complications

  • Inadequate resuscitation
  • Missed abdominal injuries
  • Delays in diagnosis and treatment
  • Intraabdominal sepsis
  • Delayed splenic rupture

Consultations

Trauma surgeon

Radiologist

Deterrence and Patient Education

  • Wearing seat belts
  • Not texting while driving
  • Not drinking and driving
  • Not using the mobile phone while driving

Pearls and Other Issues

Mortality rates have substantially decreased in the last two decades as trauma centers have streamlined the approach to diagnosis and management. Mortality rates do vary from 2% to 10% and are most common in people with multiple organ injuries who present with shock and frank hemorrhage.

According to the Centers for Disease Control, traumatic injury is the leading cause of death in people younger than the age of 44. Many traumatic injuries can be prevented, beginning with awareness and education. Blunt abdominal trauma is in the top three categories of preventable injuries. These include older adults falls and preventable motor vehicle accidents in teens.

Enhancing Healthcare Team Outcomes

Blunt abdominal trauma results in thousands of admission each year, resulting in great costs to the healthcare system. while the actual injury is managed by a team of healthcare professionals, there is also focus on preventing such injuries. The nurses not only are responsible for monitoring these patients but they also have an important role in patient education. To prevent blunt abdominal trauma, the public has to be educated on wearing a safety belt. These safety devices have to be worn even if the motor vehicle comes fitted with airbags. More important, the public has to be educated about defensive driving and maintaining a safe distance from other automobiles on the road. Plus, the public should be told about the consequences of drinking and driving. Finally, the nurse and the pharmacist should educate the public on avoiding distractions in the car like eating, texting or using a mobile phone.[14][15] (Level V)

Outcomes

In the past two decades, the outcomes of blunt abdominal trauma have improved. However, there are very few papers published on long-term data and hence the eventual outcome of these patients remains unknown. For patients with minor blunt trauma, the outcomes are good but for those who suffer multiple organ injuries, the in-hospital mortality can vary from 3-10%. The ready availability of CT scans has also allowed physicians to closely monitor these patients without performing unnecessary surgeries.[16][17][18] (Level II)

 

 


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Blunt Abdominal Trauma - Questions

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Which is false about blunt injuries to the abdomen?



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Which is false about seat belts and injury?



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Which of the following diagnostic studies is the most accurate for immediately establishing the presence of intraperitoneal injury after a MVA?



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Which of the following abdominal visceral injuries is more common in adults than children?



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A 17-year-old female is punched in the left upper quadrant by her boyfriend and presents to the emergency department with severe pain and nausea. Her vital signs are stable. What is the criterion standard for evaluating patients with blunt abdominal trauma?



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A patient falls while skiing. The skiing poles injure her mid abdomen. On arrival in the emergency room, she is in severe pain. Examination reveals ecchymosis and rebound tenderness. It is suspected that she may have a pancreatic injury. Her blood pressure is 110/70 mm Hg, and her heart rate is 99 beats per minute. What is the diagnostic test of choice for this patient?



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Which hollow organ is most frequently injured in blunt trauma?



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A patient is involved in a motor vehicle accident. He is brought to the emergency department in obvious distress. His vitals show a temperature of 97.5 degrees Fahrenheit, a respiration rate of 23 breaths per minute, a pulse rate of 140 beats per minute, and a blood pressure of 80/30 mm Hg. His jugular venous pulse is diminished and neck veins are collapsed. Bilateral breath sounds are present, heart sounds are normal, and the trachea is central. He is semiconscious and his pupils are bilaterally reactive. He localizes pain. There is no obvious head injury. Abdominal examination shows distention with tenderness in all four quadrants with muscle guarding and rigidity. After initial resuscitation of the airway, breathing, and circulation, what is the next step in the management of this patient?



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A young child suffers a seat belt injury in an auto accident. Examination reveals ecchymoses on the lower abdominal wall. Which organ has most likely suffered an injury?



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What is the most commonly used diagnostic study for immediately establishing the presence of an intraperitoneal injury after a motor vehicle accident?



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In a patient with an inflammatory abdominal aortic aneurysm, the biggest concern during surgery is prevention of damage to which of the following structures?



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When attempting control of the supraceliac portion of the abdominal aorta, what structure(s) must be transected?



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A 33-year-old just finished eating dinner and got involved in a serious motor vehicle accident. A CT scan reveals gastric perforation. Which of the following is most appropriate for the management of this patient?



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A 6-year-old child was a restrained passenger in a motor vehicle accident. In the emergency department, he is alert and hemodynamically stable. Ecchymoses are noted across the lower abdominal wall. The child is at greatest risk for which of the following?



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After a motor vehicle accident, a patient has abdominal pain and a lap-belt hematoma. Which structure is least likely to be injured?



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When comparing diagnostic peritoneal lavage (DPL) to computerized axial tomography (CT) in the evaluation of blunt abdominal trauma, which of the following is false?



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An 11-year-old boy was a restrained passenger in a motor vehicle accident. He is brought to the emergency department with abdominal pain. He denies hitting his head or loss of consciousness. His vital signs are normal. He has no neck pain, neck tenderness, or airway problems. His abdomen shows ecchymosis from the lap belt, and there is diffuse tenderness. Hematocrit is 28 percent. Rupture of the spleen is suspected. Select the next step in management.



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A young man is an unrestrained driver in a motor vehicle accident. He was transported by paramedics to the emergency room with 2 lines. He has received 2500 mL of lactated Ringer solution. A contusion and curvilinear abrasion is noted at the mid upper abdomen. Vital signs show a heart rate of 120 bpm, blood pressure of 80/65 mm Hg, respirations 20, and pulse oximetry 99% on 100% oxygen. Ultrasonography shows a sonolucent area between the right kidney and the liver. Neurologic exam is normal. What is the next best step in management?



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A patient sustains blunt trauma to the abdomen. Vital signs in the emergency department are blood pressure 90/40 mmHg, heart rate 118 beats/min, and respirations 19. Which of the following would be the most appropriate for evaluating this patient for possible hemoperitoneum?



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A 17-year-old suffers blunt abdominal injury following a motor vehicle collision. His abdominal x-ray reveals air around the kidney and he has crepitus in the right lower quadrant. What structure is most likely injured?



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Blunt Abdominal Trauma - References

References

Garside G,Khan O,Mukhtar Z,Sinha C, Paediatric duodenal injury complicated by common bile duct rupture due to blunt trauma: a multispecialist approach. BMJ case reports. 2018 Aug 29     [PubMed]
Taghavi S,Askari R, Trauma, Liver null. 2018 Jan     [PubMed]
Sarychev LP,Sarychev YV,Pustovoyt HL,Sukhomlin SA,Suprunenko SM, Management of the patients with blunt renal trauma: 20 years of clinical experience. Wiadomosci lekarskie (Warsaw, Poland : 1960). 2018     [PubMed]
Zhou H,Ma X,Sheng M,Lai C,Fu J, Evolution of intramural duodenal hematomas on magnetic resonance imaging. Pediatric radiology. 2018 Aug 14     [PubMed]
Molinelli V,Iosca S,Duka E,De Marchi G,Lucchina N,Bracchi E,Carcano G,Novario R,Fugazzola C, Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries. La Radiologia medica. 2018 Jul 23     [PubMed]
Renson A,Musser B,Schubert FD,Bjurlin MA, Seatbelt use is associated with lower risk of high-grade hepatic injury in motor vehicle crashes in a national sample. Journal of epidemiology and community health. 2018 Aug     [PubMed]
Pelletti G,Cecchetto G,Viero A,De Matteis M,Viel G,Montisci M, Traumatic fatal aortic rupture in motorcycle drivers. Forensic science international. 2017 Dec     [PubMed]
Tarchouli M,Elabsi M,Njoumi N,Essarghini M,Echarrab M,Chkoff MR, Liver trauma: What current management? Hepatobiliary     [PubMed]
So HF,Nabi H, Handlebar hernia - A rare complication from blunt trauma. International journal of surgery case reports. 2018     [PubMed]
Wortman JR,Uyeda JW,Fulwadhva UP,Sodickson AD, Dual-Energy CT for Abdominal and Pelvic Trauma. Radiographics : a review publication of the Radiological Society of North America, Inc. 2018 Mar-Apr     [PubMed]
Tsai R,Raptis D,Raptis C,Mellnick VM, Traumatic abdominal aortic injury: clinical considerations for the diagnostic radiologist. Abdominal radiology (New York). 2018 May     [PubMed]
Tomic I,Dragas M,Vasin D,Loncar Z,Fatic N,Davidovic L, Seat-belt abdominal aortic injury - treatment modalities. Annals of vascular surgery. 2018 Aug 3     [PubMed]
Inukai K,Uehara S,Furuta Y,Miura M, Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study. Emergency radiology. 2018 Jul 19     [PubMed]
Cunningham AJ,Lofberg KM,Krishnaswami S,Butler MW,Azarow KS,Hamilton NA,Fialkowski EA,Bilyeu P,Ohm E,Burns EC,Hendrickson M,Krishnan P,Gingalewski C,Jafri MA, Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study. Journal of pediatric surgery. 2017 Dec     [PubMed]
Aeberhard P,Weber M, [Sigmoid colon injuries caused by blunt abdominal trauma]. Helvetica chirurgica acta. 1979 Feb     [PubMed]
Waheed KB,Baig AA,Raza A,Ul Hassan MZ,Khattab MA,Raza U, Diagnostic accuracy of Focused Assessment with Sonography for Trauma for blunt abdominal trauma in the Eastern Region of Saudi Arabia. Saudi medical journal. 2018 Jun     [PubMed]
Margari S,Garozzo Velloni F,Tonolini M,Colombo E,Artioli D,Allievi NE,Sammartano F,Chiara O,Vanzulli A, Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study. Emergency radiology. 2018 May 12     [PubMed]
Guillen B,Cassaro S, Traumatic Open Abdomen null. 2018 Jan     [PubMed]

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