Abstract

THE belly is benign” takes its place among other cringe-causing statements in the emergency medicine lexicon (such as “Remember that older gentleman you sent home last night?”). What should accompany such abominable proclamations is the trailing caveat “but he’s intoxicated…is head injured…has a fractured femur…has a seat-belt mark…has a cervical cord injury…” and so forth. Worse, though, is the failure even to suspect that abdominal trauma is a possibility in the well-appearing victim.

The diagnostic approach to blunt abdominal injury has shifted in the past four decades. Prior to the advent of diagnostic peritoneal lavage (DPL) in 1964, clinical examination was the primary modality. However, its limited accuracy led to a considerable number of unneeded laparotomies and, more disturbingly, failure to operate in a timely manner on those in need. DPL was the mainstay from its inception until the 1980s, when computed tomography (CT) became routinely available. Over the past decade, ultrasound (US) has found its way into the mix, mostly as a noninvasive replacement for DPL to search for intraperitoneal blood. Today, these four tools are used in various combinations for differing clinical scenarios in EDs across the country.

Current practice emphasizes cost-effective and efficient approaches. This may include a strategy of simply observing patients with reliable and negative examinations unless and until they develop indications for specific diagnostic studies.¹ Decision trees vary widely among institutions according to the reliability and availability of the various technologies as well as the experience and preference of emergency physicians, trauma surgeons, and radiologists at the respective sites.^2,3 What is clear is that pragmatic thinking, attention to detail, and effective clinical algorithms will help the emergency physician detect occult injury and manage the traumatized victim. This issue of Emergency
Medicine Practice outlines just such an approach.

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