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<< Blunt Abdominal Trauma: Priorities, Procedures, And Pragmatic Thinking
Special Populations
Pediatrics
As with adults, motor vehicle crashes cause most of the morbidity and mortality in cases of pediatric trauma; auto/pedestrian accidents and falls out of cars represent a large subset of these. Handle-bar injuries and lap-belt-only restraints are much more likely to be seen in children and can lead to pancreaticoduodenal and small bowel injury.21 Child abuse is both common and terribly harmful. Abdominal injuries are second only to head injuries as a cause of death in abused children.
A child’s abdomen has poorly developed musculature and a relatively small anteroposterior diameter. These facts amplify the vulnerability of intraperitoneal organs to compressive forces. The rib cage is very compliant in children, and while less prone to fractures, it provides limited protection against upper quadrant solid visceral injury. Solid organ injuries predominate in children and are responsible for twothirds to 90% of intraperitoneal pathology.
As in adults, most hematologic and serum chemical studies do not have adequate positive or negative predictive value to warrant their routine use.125 Perhaps the most valuable lab test for intraabdominal injury in children is the urinalysis. In one retrospective study of 285 injured children, the physical examination combined with urinalysis showing more than 5 RBC/hpf had a sensitivity of 100%, and a specificity of 64% in detecting intraabdominal injury.125
Microscopic hematuria portends a reasonable likelihood of injury to the liver, spleen, or kidneys. It may also be a reflection of a previously unknown coagulopathy or intraabdominal anomaly (e.g., Wilms’ tumor). The threshold at which consideration should be given to further diagnostics, notably CT, varies from 20-50 RBC/hpf.126
The important diagnostic tests used in adults with abdominal trauma (CT, US, and DPL) have somewhat different roles in children. Ultrasound has been found to have comparable ability to screen for intraperitoneal hemorrhage as in adults.127,128
However, DPL is used differently in the injured child. It has an important role in the hypotensive child with multi-system blunt trauma in whom US is unavailable or equivocal. However, children with stable hemodynamics and hemoglobin who have blood discovered in their abdomen are much more likely to be managed without laparotomy than adults. Therefore, DPL is generally not indicated if the child can be stabilized with blood and fluids.
CT, with its ability to discern specific organ pathology both in the peritoneal and retroperitoneal spaces, remains a mainstay diagnostic test. The important caveat that applies to CT in adults applies to children as well; false-negative rates for hollow visceral and pancreatic injury are substantial, at 26% and 15%, respectively.129,130
Some authors believe that serial physical examinations are more important than CT in the diagnosis of pediatric bowel injury. In one retrospective study, all children with major intestinal injury had suggestive signs on presentation or shortly thereafter.131 These signs included seat-belt ecchymoses or diffuse abdominal tenderness. The abdominal CT was insensitive in making the diagnosis and detected only one in 13 bowel injuries. Another study confirmed that the initial and serial physical examinations are more reliable than diagnostic testing in children with small bowel injuries.132
Geriatrics
The diagnostic approach to the elderly patient is unchanged. However, it is critical to bear two facts in mind. These patients are far more likely to have significant comorbid disease and to be on medications that alter their presentation, including vital signs, as well as their ability to tolerate these injuries. In addition, this group has increased morbidity and mortality for virtually any injury sustained when compared with younger cohorts.133 As such, management and disposition decisions should lean well toward the conservative end of the spectrum. At least one study suggests that an elevated base deficit (more negative than -6) during the first hour of care can help predict severe injury or death in the elderly trauma victim.134
Pregnancy
Trauma is frequent during pregnancy. Women are more subject to falls after 20 weeks of gestation compared with nonpregnant patients, and the incidence of physical abuse is 4%-17% during pregnancy.135
Certain physiologic changes affect the approach to abdominal trauma. The systolic and diastolic blood pressures decline 2-4 mmHg and 5-15 mmHg, respectively, in the first and second trimester and then normalize in the third trimester; in addition, an increase in pulse of 10-15 bpm can be anticipated throughout. The clinical diagnosis of shock is impaired during pregnancy due to the significant cardiovascular changes. A pregnant woman may lose 30%-35% of her blood volume—1.5 liters—prior to demonstrating any physiologic signs of shock.136 In addition, stretching of the peritoneum decreases the ability of the physician to detect hemoperitoneum. In an early series, 50% of pregnant women with massive hemoperitoneum had no peritoneal signs.137
The management of shock also changes in pregnancy. The “supine hypotensive syndrome” may occur after 20 weeks’ gestation. This syndrome is caused by uterine pressure on the inferior vena cava, resulting in a drop in cardiac output of up to 28% and systolic blood pressure of 30 mmHg.138 One of the first interventions by prehospital care providers and ED personnel alike is to “unload” the vena cava by pushing the uterus to the left. Alternatively, towels placed under the right side of a backboard will cause the uterus to fall to the side, accomplishing the same purpose.
The three primary diagnostic agents can be utilized throughout pregnancy, with certain precautions. Ultrasound is presumed safe and accurate in this setting, but a large, prospective trial has not yet been conducted. With regard to CT, the fetus is most vulnerable to radiation while it is from 2-7 weeks’ gestational age. A modified abdominal CT limited to the areas above the uterus (basically the liver and spleen) incurs a safe dosage of less than 3 rads to the fetus. Including the pelvis in the scan generates an undesirable 3-9 rads. However, spiral CT reduces fetal radiation exposure 14%-30%.139 DPL is known to be accurate in pregnancy137,140 but should be performed by the open supraumbilical technique after the first trimester.86 Cut-off values for DPL effluent are identical to those of nonpregnant patients.
Maternal resuscitation is the prevailing tenet, and indications for abdominal laparotomy are unchanged. One disposition matter is key. Patients beyond 20 weeks’ gestation (i.e., in whom the fetus is viable) who sustain torso trauma of any magnitude and who appear otherwise well should undergo at least four hours of fetal monitoring. This allows early detection of placental abruption, a complication of even trivial trauma.141
Alcoholic Patients
Both acute and chronic alcohol usage increase the risk of abdominal trauma. From a physiologic perspective, alcoholics tend to have a lax abdominal wall and therefore incur greater morbidity from anteriorposterior compressive and burst forces.142 Alcoholic hepatitis and cirrhotic liver disease lead to an enlarged liver and congested spleen, respectively. As such, these are afforded less protection by the rib cage, and their increased intracapsular pressure decreases their resistance to blunt forces. Pancreatic pseudocysts are also subject to rupture from blunt trauma.143 Finally, chronic alcoholism may result in coagulopathy with resultant exacerbated hemorrhage and complicated management.
The clinical examination and major diagnostic procedures can all be affected by acute and chronic intoxication. In a recent series, intoxicated patients were nearly five times more likely to have an unsuspected injury than patients who had a negative blood alcohol level.144 If the patient’s mental status is impaired by acute intoxication or hepatic encephalopathy, the ability of the patient and the examiner to appreciate intraperitoneal and retroperitoneal manifestation is impaired. Ascites can create difficulties in the interpretationof DPL, CT, and US. If coagulopathy is present or suspected, some authorities suggest that DPL should be performed by the semi-open or fully open technique with careful attention to hemostasis. Portal hypertension in the chronic alcoholic can lead to engorgement of umbilical veins that pose additional hazard to the performance of DPL, particularly if percutaneous. Combativeness obviously is problematic for any of the procedures, but appropriate administration of butyrophenones should place the patient (and thus the treating physician) in a much better mood.
Acutely intoxicated patients with suspected minimal trauma can be observed or committed to one or more of the diagnostic tests. This is a clinical decision that rests with the understanding of the mechanism, the clinical circumstances of the patient, and the institutional resources. For example, a very busy ED with limited personnel should move more quickly toward definitive diagnostics rather than serial observations. Finally, in patients with known intraperitoneal injury as determined particularly by CT, expectant management (i.e., the deliberate observation of a patient in whom laparotomy may be unnecessary) is more hazardous than in the nonalcoholic patient.145
As with adults, motor vehicle crashes cause most of the morbidity and mortality in cases of pediatric trauma; auto/pedestrian accidents and falls out of cars represent a large subset of these. Handle-bar injuries and lap-belt-only restraints are much more likely to be seen in children and can lead to pancreaticoduodenal and small bowel injury.21 Child abuse is both common and terribly harmful. Abdominal injuries are second only to head injuries as a cause of death in abused children.
A child’s abdomen has poorly developed musculature and a relatively small anteroposterior diameter. These facts amplify the vulnerability of intraperitoneal organs to compressive forces. The rib cage is very compliant in children, and while less prone to fractures, it provides limited protection against upper quadrant solid visceral injury. Solid organ injuries predominate in children and are responsible for twothirds to 90% of intraperitoneal pathology.
As in adults, most hematologic and serum chemical studies do not have adequate positive or negative predictive value to warrant their routine use.125 Perhaps the most valuable lab test for intraabdominal injury in children is the urinalysis. In one retrospective study of 285 injured children, the physical examination combined with urinalysis showing more than 5 RBC/hpf had a sensitivity of 100%, and a specificity of 64% in detecting intraabdominal injury.125
Microscopic hematuria portends a reasonable likelihood of injury to the liver, spleen, or kidneys. It may also be a reflection of a previously unknown coagulopathy or intraabdominal anomaly (e.g., Wilms’ tumor). The threshold at which consideration should be given to further diagnostics, notably CT, varies from 20-50 RBC/hpf.126
The important diagnostic tests used in adults with abdominal trauma (CT, US, and DPL) have somewhat different roles in children. Ultrasound has been found to have comparable ability to screen for intraperitoneal hemorrhage as in adults.127,128
However, DPL is used differently in the injured child. It has an important role in the hypotensive child with multi-system blunt trauma in whom US is unavailable or equivocal. However, children with stable hemodynamics and hemoglobin who have blood discovered in their abdomen are much more likely to be managed without laparotomy than adults. Therefore, DPL is generally not indicated if the child can be stabilized with blood and fluids.
CT, with its ability to discern specific organ pathology both in the peritoneal and retroperitoneal spaces, remains a mainstay diagnostic test. The important caveat that applies to CT in adults applies to children as well; false-negative rates for hollow visceral and pancreatic injury are substantial, at 26% and 15%, respectively.129,130
Some authors believe that serial physical examinations are more important than CT in the diagnosis of pediatric bowel injury. In one retrospective study, all children with major intestinal injury had suggestive signs on presentation or shortly thereafter.131 These signs included seat-belt ecchymoses or diffuse abdominal tenderness. The abdominal CT was insensitive in making the diagnosis and detected only one in 13 bowel injuries. Another study confirmed that the initial and serial physical examinations are more reliable than diagnostic testing in children with small bowel injuries.132
Geriatrics
The diagnostic approach to the elderly patient is unchanged. However, it is critical to bear two facts in mind. These patients are far more likely to have significant comorbid disease and to be on medications that alter their presentation, including vital signs, as well as their ability to tolerate these injuries. In addition, this group has increased morbidity and mortality for virtually any injury sustained when compared with younger cohorts.133 As such, management and disposition decisions should lean well toward the conservative end of the spectrum. At least one study suggests that an elevated base deficit (more negative than -6) during the first hour of care can help predict severe injury or death in the elderly trauma victim.134
Pregnancy
Trauma is frequent during pregnancy. Women are more subject to falls after 20 weeks of gestation compared with nonpregnant patients, and the incidence of physical abuse is 4%-17% during pregnancy.135
Certain physiologic changes affect the approach to abdominal trauma. The systolic and diastolic blood pressures decline 2-4 mmHg and 5-15 mmHg, respectively, in the first and second trimester and then normalize in the third trimester; in addition, an increase in pulse of 10-15 bpm can be anticipated throughout. The clinical diagnosis of shock is impaired during pregnancy due to the significant cardiovascular changes. A pregnant woman may lose 30%-35% of her blood volume—1.5 liters—prior to demonstrating any physiologic signs of shock.136 In addition, stretching of the peritoneum decreases the ability of the physician to detect hemoperitoneum. In an early series, 50% of pregnant women with massive hemoperitoneum had no peritoneal signs.137
The management of shock also changes in pregnancy. The “supine hypotensive syndrome” may occur after 20 weeks’ gestation. This syndrome is caused by uterine pressure on the inferior vena cava, resulting in a drop in cardiac output of up to 28% and systolic blood pressure of 30 mmHg.138 One of the first interventions by prehospital care providers and ED personnel alike is to “unload” the vena cava by pushing the uterus to the left. Alternatively, towels placed under the right side of a backboard will cause the uterus to fall to the side, accomplishing the same purpose.
The three primary diagnostic agents can be utilized throughout pregnancy, with certain precautions. Ultrasound is presumed safe and accurate in this setting, but a large, prospective trial has not yet been conducted. With regard to CT, the fetus is most vulnerable to radiation while it is from 2-7 weeks’ gestational age. A modified abdominal CT limited to the areas above the uterus (basically the liver and spleen) incurs a safe dosage of less than 3 rads to the fetus. Including the pelvis in the scan generates an undesirable 3-9 rads. However, spiral CT reduces fetal radiation exposure 14%-30%.139 DPL is known to be accurate in pregnancy137,140 but should be performed by the open supraumbilical technique after the first trimester.86 Cut-off values for DPL effluent are identical to those of nonpregnant patients.
Maternal resuscitation is the prevailing tenet, and indications for abdominal laparotomy are unchanged. One disposition matter is key. Patients beyond 20 weeks’ gestation (i.e., in whom the fetus is viable) who sustain torso trauma of any magnitude and who appear otherwise well should undergo at least four hours of fetal monitoring. This allows early detection of placental abruption, a complication of even trivial trauma.141
Alcoholic Patients
“Bacchus has drowned more men than Neptune.”
—Thomas Fuller38
—Thomas Fuller38
Both acute and chronic alcohol usage increase the risk of abdominal trauma. From a physiologic perspective, alcoholics tend to have a lax abdominal wall and therefore incur greater morbidity from anteriorposterior compressive and burst forces.142 Alcoholic hepatitis and cirrhotic liver disease lead to an enlarged liver and congested spleen, respectively. As such, these are afforded less protection by the rib cage, and their increased intracapsular pressure decreases their resistance to blunt forces. Pancreatic pseudocysts are also subject to rupture from blunt trauma.143 Finally, chronic alcoholism may result in coagulopathy with resultant exacerbated hemorrhage and complicated management.
The clinical examination and major diagnostic procedures can all be affected by acute and chronic intoxication. In a recent series, intoxicated patients were nearly five times more likely to have an unsuspected injury than patients who had a negative blood alcohol level.144 If the patient’s mental status is impaired by acute intoxication or hepatic encephalopathy, the ability of the patient and the examiner to appreciate intraperitoneal and retroperitoneal manifestation is impaired. Ascites can create difficulties in the interpretationof DPL, CT, and US. If coagulopathy is present or suspected, some authorities suggest that DPL should be performed by the semi-open or fully open technique with careful attention to hemostasis. Portal hypertension in the chronic alcoholic can lead to engorgement of umbilical veins that pose additional hazard to the performance of DPL, particularly if percutaneous. Combativeness obviously is problematic for any of the procedures, but appropriate administration of butyrophenones should place the patient (and thus the treating physician) in a much better mood.
Acutely intoxicated patients with suspected minimal trauma can be observed or committed to one or more of the diagnostic tests. This is a clinical decision that rests with the understanding of the mechanism, the clinical circumstances of the patient, and the institutional resources. For example, a very busy ED with limited personnel should move more quickly toward definitive diagnostics rather than serial observations. Finally, in patients with known intraperitoneal injury as determined particularly by CT, expectant management (i.e., the deliberate observation of a patient in whom laparotomy may be unnecessary) is more hazardous than in the nonalcoholic patient.145
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