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<< Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking
Special Circumstances
Missed Injuries
Missed injury is common in trauma management. As many as 25% of seriously injured trauma patients have at least one injury that is overlooked during the initial evaluation.105,106 Missed injuries are most common in patients who have altered mental status, those who are intubated, and those who need an immediate operation.107,108
While the most frequently missed injuries are orthopedic,109-111 missed abdominal injury is far more lethal. In fact, missed intraabdominal injury is the most common preventable cause of trauma deaths.112
Distracting injury is so called as the patient, the physician, or both are…well…distracted. Distracting injury is one of those concepts all of us understand but none of us can quantify. However, it must be appreciated, as it is well known to cause missed abdominal as well as cervical spine pathology. In a recent prospective study, 7% of patients with no abdominal pain or tenderness but with distracting extraabdominal injury were found to have intraabdominal injury.113
Patients with altered mental status are also at high risk for undetected/unsuspected abdominal injury. Nearly 10% of patients suspected of “isolated” head injury may have intraabdominal pathology.114 In a different retrospective study of comatose but normotensive trauma victims, the use of clinical signs alone resulted in more missed injuries than did using an objective test (in this study, DPL).27 The authors suggested that all unconscious blunt trauma patients undergo objective testing of the abdomen to avoid missing life-threatening injuries.
Multi-System Injury
In patients with more than one critically injured bodily system, a rigid management algorithm does not and should not exist. In these situations, the decisionmaking needs to be fluid and responsive to the minuteto-minute changes of the patient.
It is correct that active and substantive intraperitoneal hemorrhage in an unstable patient demands immediate attention—specifically, life-saving laparotomy. However, a patient can have a minor splenic injury with evidence of hemorrhage on US, DPL, CT, or some combination of tests, yet other demands (such as an unstable pelvic fracture) will be greater at that point in time. Likewise, certain intraperitoneal injuries such as a perforated jejunum require operation, but a delay of at least eight hours is acceptable while more pressing concerns are addressed.
In summary, the key point is that an unstable patient with a significant hemoperitoneum must undergo laparotomy or face imminent exsanguination.
Pelvic Fracture
An unstable patient with a significant pelvic fracture and bloody peritoneal aspirate or positive US finding must proceed to emergency laparotomy. (See “Clinical Pathway: Management Of Combined Pelvic Fracture And Abdominal Trauma”.) This is due to the fact that approximately 85% of such patients will have active intraperitoneal hemorrhage at laparotomy. Some unstable patients with severe pelvic fracture will demonstrate a negative US, a negative peritoneal aspirate, or both. Barring other non-abdominal sources, the presumed origin of shock is the retroperitoneum. Therefore, the patient would then proceed to angiography for possible embolization to staunch hemorrhage.
Before proceeding to angiography, a pelvic stabilizing device is indicated to reduce pelvic volume, stabilize displaced fracture segments, and tamponade venous bleed. The PASG, vacuum splint, or even a tightly wrapped sheet about the pelvis when necessary can serve in this capacity.16 The placement of an external fixator, typically by an orthopedist, is advised by some.115 However, this requires a much more laborious application, and there are no prospective, randomized trials to support its use.
In a patient with pelvic fracture and apparent hemodynamic stability, a CT of the abdomen is usually warranted. If an ultrasound was performed and demonstrated some measure of fluid, CT can help decipher the need for laparotomy. If DPL effluent returns with a positive RBC count only (but a negative aspirate), CT should again be used to establish whether significant intraperitoneal injury exists, as the RBC count alone in this circumstance can be falsely positive.
Closed-Head Injury
Patients with surgically correctable injuries of both the head and the abdomen are rare, although the literature is divided regarding which injury is more common in the comatose hypotensive patient.116,117 The presence or absence of lateralizing findings (such as a unilateral blown pupil or asymetric posturing) is key. Generally speaking, patients with severe closed-head injury but without lateralizing findings do not require craniotomy.117 Should lateralizing features and blunt abdominal injury coexist, the clinician is faced with the choice of rapid pre-laparotomy CT scan of the head vs. preemptive burr holes in the ED or during laparotomy. (See “Clinical Pathway: Management Of Combined Head And Abdominal Trauma”.) Neurosurgeons prefer the former approach whenever possible, but hemodynamic instability may compel the latter. The emergency physician sorting this out must measure the timeliness of CT availability, when the neurosurgeon is expected to arrive, and, most importantly, the severity and direction of hemodynamic changes.
One study suggests that patients with hemoperitoneum and lateralizing signs are candidates for emergent head CT only if their blood pressure stabilizes with fluids or blood.118 However, immediate laparotomy is indicated in patients who remain hemodynamically unstable.116
Blunt Aortic Disruption
Potential blunt aortic disruption (BAD) presents even more controversies. (See “Clinical Pathway: Management Of Combined Wide Mediastinum And Abdominal Trauma”.) The injury itself is frequently lethal, and its time course is highly unpredictable. The delay to rupture may entail hours to days (and, rarely, weeks). The time-bomb metaphor is supremely apropos.
The usual indication for diagnostic evaluation is an abnormal chest x-ray. The chest film shows characteristic or suggestive findings in at least 93% of all patients with aortic injury.119 Unfortunately, many chest x-rays in acute trauma are necessarily acquired in supine anteroposterior fashion, and a significant number of patients without aortic injury may have a wide mediastinum on the supine view.120 An upright or reverse Trendelenburg inspiratory film is helpful if the patient can tolerate this position.
Even the pristine, upright, inspiratory PA film is imperfect in predicting presence or absence of this lesion. More accurate means of determination include helical chest CT, transesophageal echocardiography, and angiography. However, these tests take precious time.
In the relatively stable patient, there is good evidence to show that a normal helical (not standard) contrastenhanced CT of the chest reliably excludes aortic injury.121 The unstable patient with hemoperitoneum must proceed immediately to laparotomy. The patient can undergo mediastinal evaluation with transesophageal echocardiography during the operation.122
Angiography, once the sovereign diagnostic modality in aortic injuries, is now relegated to a subordinate role in many trauma centers.123,124
Missed injury is common in trauma management. As many as 25% of seriously injured trauma patients have at least one injury that is overlooked during the initial evaluation.105,106 Missed injuries are most common in patients who have altered mental status, those who are intubated, and those who need an immediate operation.107,108
While the most frequently missed injuries are orthopedic,109-111 missed abdominal injury is far more lethal. In fact, missed intraabdominal injury is the most common preventable cause of trauma deaths.112
Distracting injury is so called as the patient, the physician, or both are…well…distracted. Distracting injury is one of those concepts all of us understand but none of us can quantify. However, it must be appreciated, as it is well known to cause missed abdominal as well as cervical spine pathology. In a recent prospective study, 7% of patients with no abdominal pain or tenderness but with distracting extraabdominal injury were found to have intraabdominal injury.113
Patients with altered mental status are also at high risk for undetected/unsuspected abdominal injury. Nearly 10% of patients suspected of “isolated” head injury may have intraabdominal pathology.114 In a different retrospective study of comatose but normotensive trauma victims, the use of clinical signs alone resulted in more missed injuries than did using an objective test (in this study, DPL).27 The authors suggested that all unconscious blunt trauma patients undergo objective testing of the abdomen to avoid missing life-threatening injuries.
Multi-System Injury
In patients with more than one critically injured bodily system, a rigid management algorithm does not and should not exist. In these situations, the decisionmaking needs to be fluid and responsive to the minuteto-minute changes of the patient.
It is correct that active and substantive intraperitoneal hemorrhage in an unstable patient demands immediate attention—specifically, life-saving laparotomy. However, a patient can have a minor splenic injury with evidence of hemorrhage on US, DPL, CT, or some combination of tests, yet other demands (such as an unstable pelvic fracture) will be greater at that point in time. Likewise, certain intraperitoneal injuries such as a perforated jejunum require operation, but a delay of at least eight hours is acceptable while more pressing concerns are addressed.
In summary, the key point is that an unstable patient with a significant hemoperitoneum must undergo laparotomy or face imminent exsanguination.
Pelvic Fracture
An unstable patient with a significant pelvic fracture and bloody peritoneal aspirate or positive US finding must proceed to emergency laparotomy. (See “Clinical Pathway: Management Of Combined Pelvic Fracture And Abdominal Trauma”.) This is due to the fact that approximately 85% of such patients will have active intraperitoneal hemorrhage at laparotomy. Some unstable patients with severe pelvic fracture will demonstrate a negative US, a negative peritoneal aspirate, or both. Barring other non-abdominal sources, the presumed origin of shock is the retroperitoneum. Therefore, the patient would then proceed to angiography for possible embolization to staunch hemorrhage.
Before proceeding to angiography, a pelvic stabilizing device is indicated to reduce pelvic volume, stabilize displaced fracture segments, and tamponade venous bleed. The PASG, vacuum splint, or even a tightly wrapped sheet about the pelvis when necessary can serve in this capacity.16 The placement of an external fixator, typically by an orthopedist, is advised by some.115 However, this requires a much more laborious application, and there are no prospective, randomized trials to support its use.
In a patient with pelvic fracture and apparent hemodynamic stability, a CT of the abdomen is usually warranted. If an ultrasound was performed and demonstrated some measure of fluid, CT can help decipher the need for laparotomy. If DPL effluent returns with a positive RBC count only (but a negative aspirate), CT should again be used to establish whether significant intraperitoneal injury exists, as the RBC count alone in this circumstance can be falsely positive.
Closed-Head Injury
Patients with surgically correctable injuries of both the head and the abdomen are rare, although the literature is divided regarding which injury is more common in the comatose hypotensive patient.116,117 The presence or absence of lateralizing findings (such as a unilateral blown pupil or asymetric posturing) is key. Generally speaking, patients with severe closed-head injury but without lateralizing findings do not require craniotomy.117 Should lateralizing features and blunt abdominal injury coexist, the clinician is faced with the choice of rapid pre-laparotomy CT scan of the head vs. preemptive burr holes in the ED or during laparotomy. (See “Clinical Pathway: Management Of Combined Head And Abdominal Trauma”.) Neurosurgeons prefer the former approach whenever possible, but hemodynamic instability may compel the latter. The emergency physician sorting this out must measure the timeliness of CT availability, when the neurosurgeon is expected to arrive, and, most importantly, the severity and direction of hemodynamic changes.
One study suggests that patients with hemoperitoneum and lateralizing signs are candidates for emergent head CT only if their blood pressure stabilizes with fluids or blood.118 However, immediate laparotomy is indicated in patients who remain hemodynamically unstable.116
Blunt Aortic Disruption
Potential blunt aortic disruption (BAD) presents even more controversies. (See “Clinical Pathway: Management Of Combined Wide Mediastinum And Abdominal Trauma”.) The injury itself is frequently lethal, and its time course is highly unpredictable. The delay to rupture may entail hours to days (and, rarely, weeks). The time-bomb metaphor is supremely apropos.
The usual indication for diagnostic evaluation is an abnormal chest x-ray. The chest film shows characteristic or suggestive findings in at least 93% of all patients with aortic injury.119 Unfortunately, many chest x-rays in acute trauma are necessarily acquired in supine anteroposterior fashion, and a significant number of patients without aortic injury may have a wide mediastinum on the supine view.120 An upright or reverse Trendelenburg inspiratory film is helpful if the patient can tolerate this position.
Even the pristine, upright, inspiratory PA film is imperfect in predicting presence or absence of this lesion. More accurate means of determination include helical chest CT, transesophageal echocardiography, and angiography. However, these tests take precious time.
In the relatively stable patient, there is good evidence to show that a normal helical (not standard) contrastenhanced CT of the chest reliably excludes aortic injury.121 The unstable patient with hemoperitoneum must proceed immediately to laparotomy. The patient can undergo mediastinal evaluation with transesophageal echocardiography during the operation.122
Angiography, once the sovereign diagnostic modality in aortic injuries, is now relegated to a subordinate role in many trauma centers.123,124
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