Abdominal Trauma

BY KEVIN T. COLLOPY, BA, FP-C, CCEMT-P, NREMT-P, WEMT AND GREG FRIESE, MS, NREMT-P

Tulisan di http://www.emsworld.com/article/10319768/abdominal-trauma Created: March 1, 2010 Diakses 28 juni 2012

INCIDENCE AND EPIDEMIOLOGY Blunt and penetrating abdominal trauma are major causes of morbidity and mortality in the United States, particularly because it can be very difficult to recognize clear symptoms early.1 In blunt force abdominal trauma, the spleen and liver are the most commonly injured organs, with a mortality rate of roughly 8.5%.2 Nearly three-quarters of all blunt abdominal trauma injuries involve vehicles.3 Almost two-thirds of injuries occur in males, with a peak incidence in patients between ages 14 and 30. Penetrating abdominal trauma has a slightly higher mortality rate, depending on the mechanism of injury. It ranges up to about 12%, and is responsible for more than a third of urban trauma center admissions and 12% of rural trauma center admissions. Gunshot and stab wounds combine to cause 95% of penetrating abdominal injuries. Penetrating abdominal injuries have a significantly higher morbidity rate than blunt trauma, with the most serious morbidities arising from wound site infections and development of intra-abdominal abscesses.4 Pediatric patients warrant special mention because their abdominal anatomy differs from adults. Fewer than 10% of pediatric injuries are considered abdominal trauma in nature; however, more than 80% of pediatric abdominal injuries are caused by blunt force trauma.2 Be suspicious of pediatric abdominal injuries, as many are caused by abuse. Due to the unique pediatric anatomy, discussed later in this article, organ injury rates differ from adults.

ANATOMIC REVIEW The abdomen holds and protects major organs of the digestive, reproductive, genitourinary, vascular and endocrine systems, and can be defined as the space between the diaphragm pelvic bony structures on the superior and inferior aspects, respectively; the flanks along the lateral walls; the abdominal muscles anteriorly; and the vertebrae and back muscles along the posterior cavity wall. Four regions divide the abdominal cavity. The intrathoracic region, which includes the spleen, stomach, diaphragm and a portion of the liver, runs from the base of the 12th ribs to the diaphragm. The ribs make complete assessment of this cavity difficult, but not impossible. Beginning at the superior aspects of the iliac crests, the pelvic abdominal region is the space within the pelvic bones and contains the bladder, rectum, small intestine and female reproductive system. Connective tissues separate out the retroperitoneal region, which contains the kidneys, ureters, pancreas, aorta and inferior vena cava. Finally, the remaining space is the true abdominal region, which contains the large and small intestines, part of the liver, a gravid uterus, distended bladder and engorged stomach. The peritoneum is the connective tissue membrane holding in the contents of

the true abdominal region. Traditionally, the true abdominal region is divided into four quadrants: right upper, right lower, left upper and left lower. Organs are defined as either solid or hollow. Solid organs include the spleen, liver and pancreas, and generally bleed when injured. Hollow organs, including the stomach, intestines, bladder and gallbladder, spill their contents into the abdominal cavity (also called peritoneal cavity) when injured. With the exception of the gallbladder and bladder, hollow organs leak digestive enzymes and bacteria into the peritoneal cavity, which can lead to infections and peritonitisinflammation of the peritoneum. The bladder and gallbladder do not contain acids, bacteria or digestive juices, thus do not produce infection as readily or peritonitis as rapidly. Because the hollow organs within the abdomen expand and contract throughout digestion and waste production, many open spaces can be found throughout the abdominal cavities. These open spaces allow for organs such as the stomach and bladder to stretch and the intestines to contract and expand during peristalsis. Unfortunately, during trauma, these same open spaces allow for significant quantities of blood to collect in the abdominal regions before obvious physical signs appear. Pediatric patients have many unique abdominal anatomical differences worth mentioning. There is significantly less protection, as the muscle walls are thinner and there is less fat. Ribs protecting the thoracic abdomen have an increased flexibility compared to adult ribs and, while this protects the ribs from damage, it more easily allows the ribs to injure the abdominal organs. Solid organs within the pediatric abdomen have a larger surface area relative to adult organs, thus a greater area is exposed for potential injury. The organ attachments are also more elastic, which increases the chances of tearing and shearing injuries. In the pediatric patient, the bladder also extends to the umbilicus, increasing its chance for injury. MECHANISMS OF INJURY Traumatic injuries to the abdomen are defined as either blunt force or penetrating. Blunt force trauma occurs when an object strikes the abdomen or the abdomen strikes against an object. A common example of this occurs during an automobile accident. During blunt trauma, the abdominal organs can be injured at three distinct times. Initial injury can occur during a rapid change in organ momentum and speed. When organs or adjacent structures suddenly decelerate at different speeds (often due to connective tissues), shearing forces can result in organs tearing at their bases or at the juncture between two organs. Solid and hollow organs and the vasculature are all at risk for shearing forces. Next, organs can be crushed as a blunt object presses against them, or as organs are compressed against rigid structures in the body. The spleen, kidneys and liver are all particularly vulnerable to crushing. Finally, external compression from blunt trauma causes a rise of pressure inside an organ, particularly hollow organs. As a result, hollow organs rupture, spilling their contents into the abdominal cavity. Penetrating trauma occurs when an object physically enters through the skin and wall of the abdominal cavity. The most common mechanism for penetrating trauma is gunfire, followed by stabbing. Other causes include impalement and animal bites. As an object enters the abdominal cavity, it injures the organs in two ways. First, the object physically damages organ tissues as it penetrates. While passing through organ tissue, the object

sends a wave of pressure in all directions, stretching the organs, which can injure adjacent organs, not just the impacted organ. Organs stretch because of their elastic nature and can cause both a temporary and permanent cavity. The greater the speed of a penetrating object, the more kinetic energy is transmitted to the organs, increasing the chance for ricochet off bony objects and for fragmentation. ASSESSMENT During the care of any trauma patient, begin an initial assessment following the ABCDE mnemonic. An abdominal assessment becomes a key component of the secondary assessment and requires adequate time to complete thoroughly. However, it is imperative to not develop tunnel vision, looking for abdominal trauma findings and ignoring the remainder of the assessment. While evaluating the abdomen as part of the entire body, prioritize injuries in order of importance and severity. Complete a thorough history and SAMPLE history while examining the patient. EMS is often the only reliable source for this information. Obtain as much information about the mechanism as possible without delaying transport. Key information for blunt force trauma includes: mechanism, time of injury, speed, location of impact, need for extrication and use of protective equipment. When managing penetrating trauma, determine: the object, distance traveled to the patient, speed, on-scene external blood loss and time of injury. The distance the object traveled to the patient is actually extremely important, as the chance for serious injury decreases if the distance exceeds 10 feet (3 meters). When completing a focused abdominal assessment, be organized, efficient and thorough. Initial abdominal examinations only identify injury about 65% of the time; repeated exams are needed when there is a high index of suspicion for abdominal trauma. When there are indicators of abdominal trauma ( Table 1), repeat an abdominal exam as time permits to look for the most reliable signs of internal injuries: pain and tenderness, and peritoneal irritation. The most reliable sign of an intra-abdominal injury is shock without an otherwise identifiable cause.5 Begin an abdominal examination by exposing the entire abdomen from the nipple line to the groin. The standard sequence for an abdominal assessment is: inspection, auscultation, percussion and palpation. Inspect the abdomen for abrasions, bruising, bleeding and other signs of external injury. Look for identifiable patterns like seat belt demarcation. Lap belt impression is a strong indicator of injury. 3Identify any patterns that indicate internal injury, such as lap or shoulder belt demarcation, or a steering wheel impression. Two bruising patterns worth noting are Cullen's sign and Grey-Turner's sign, both of which indicate retroperitoneal hemorrhage. While both appear late, they may be seen on longer transports. Cullen's sign is bruising around the umbilicus. Grey-Turner's sign is bruising along the flank and is indicative of blunt force hemorrhage, aortic leaking, and pancreas or kidney bleeding. Expose the genitalia to look for swelling, bruising and blood accumulation. The labia and scrotum are both locations where blood can easily and rapidly pool which indicates free blood in the abdominal and pelvic cavities. Protruding or exposed abdominal organs is an evisceration that ensures the need for surgery. Identify any impaled objects or entrance wounds from a penetrating object. When practical, estimate the depth. Do not routinely remove impaled objects from the abdomen. When incontinence

is present, look for hematuria or blood in the urine. Its presence indicates bladder and/or kidney injury; however, the absence of hematuria is not a good indicator of the absence of abdominal injury. A recent study found that hematuria is only present in 60% of traumatic abdominal injuries.6 Auscultation for bowel sounds is difficult in an emergency department, much less the back of a moving ambulance. Due to the length of time required, this skill is often omitted during prehospital care. However, do listen carefully to lung sounds. On occasion, there may be bowel sounds in the thoracic cavity, which suggests a diaphragmatic rupture. Percussion is an often underused prehospital assessment skill. Place one hand lightly against the patient's abdomen and tap the fingers of your other hand against the first. This triggers slight movement of the peritoneum. When there is peritoneal irritation, percussion causes tenderness.

Palpate the abdomen for masses, tenderness and deformity. There is a difference between pain, which is always present, and tenderness, which causes discomfort when pressure is applied. Palpate the inferior ribs. Rib pain or tenderness suggests fracture and indicates spleen injury on the left side and liver injury on the right. On the anterior abdomen, palpate each abdominal quadrant. A full or doughy sensation indicates free blood. Rigidity and guarding both present quickly following an injury with intestinal leakage and suggest developing peritonitis. Peritonitis tends to be diffuse across the entire abdomen. Isolated flank or upper quadrant rigidity and guarding can also be caused by inferior rib fractures. Pelvic fractures can cause isolated lower quadrant rigidity. Palpate the pelvis for stability. Any abnormal bone movement is considered a positive finding for a pelvis fracture. Stop the pelvic assessment at that point and manage the fracture aggressively. Remember, after completing an abdominal assessment, complete the rest of the secondary assessment and prioritize injuries in order of their severity and life-threat. Serious abdominal findings do not warrant ignoring the rest of the examination, as other equally or more life-threatening injuries may be discovered. Once all injuries have been identified, begin efficient management. MANAGEMENT The primary goal of trauma care remains airway stabilization, breathing protection, circulation support and cervical spine stabilization. Throughout the care of a patient experiencing major trauma, work to rapidly identify severe life-threatening conditions, including the potential for severe internal bleeding. This is a critical step in determining appropriate transport destinations, including bypassing the local hospital for a level 1 or 2 trauma center. Whenever patients show evidence of major trauma, including abdominal trauma that may require surgical intervention, rapidly transport the patient directly to the highest level available trauma center. Patients are better off going to a more distant trauma center than directly to a local emergency department that will need to transfer them. Consider early activation of air medical transport whenever dispatch information or physical

findings warrant transport directly to a trauma center. It may be in the patient's best interest to meet a helicopter down the road rather than transporting to a small rural emergency department. Most deaths from penetrating abdominal trauma occur secondary to exsanguination. As soon as penetrating abdominal trauma is recognized, expedite transport to a trauma center. Following the ABCDE mnemonic, begin routine trauma care with high-flow supplemental oxygen and secure the airway. Perform endotracheal intubation when necessary, utilizing rapid sequence intubation when authorized. Consider the use of oral and nasal pharyngeal airways as needed. At a minimum provide supplemental oxygen. Provide cardiovascular hemodynamic support by establishing IV access and administering crystalloid fluids to prevent hypotension. When possible, establish IVs during transport rather than on scene. Avoid overly aggressive fluid resuscitation; provide fluid boluses to maintain a systolic blood pressure between 90-100 mmHg, or a mean arterial pressure of 65 mmHg. Blood pressures in this range maintain vital organ perfusion. Too much IV fluid can dilute the blood and actually worsen bleeding, and is particularly harmful in penetrating abdominal injuries.1 ALS providers, when trained and authorized, should place a nasogastric or an oral-gastric (NG/OG) tube. Placing an NG/OG tube protects the intestines by emptying the stomach and permits stomach content evaluation for blood. Impaled objects in the abdomen often tamponade internal hemorrhage, and removing them may trigger significant internal bleeding. Stabilize impaled objects in place with bulky dressings, remembering that any bump against the object moves the distal end in the organ and worsens damage. Only remove an impaled object in the abdomen when it cannot be secured or stabilized in place for transport and only after consultation with on-line medical direction. Abdominal eviscerations are a surgical emergency. The protruding organ requires careful cleaning and evaluation prior to reinsertion. Do not attempt to reinsert the organs in the prehospital setting. Cover any protruding abdominal contents with a sterile dressing moistened with sterile saline and place an occlusive dressing over the top. Open wounds left by penetrating objects likely need to be cleaned as well. When there is severe bleeding at the wound site, control it with well-aimed pressure directly on the bleeding source. Once bleeding is controlled, cover the wound with a sterile dressing.

Suspected pelvic fractures can rapidly produce massive internal hemorrhage. Don't wait for symptoms of shock to appear prior to management. Apply MAST pants or a pelvic binding wrap at the level of the greater trochantor. Pain management is an essential component to good trauma care. Simple pain management techniques include oxygen administration, splinting, speaking in a calm, reassuring voice, and placing the patient in his

position of comfort. When spinal immobilization is required, flexing the patient's knees toward the chest helps relax the abdominal muscles. Consider administering analgesic drugs such as morphine sulfate or fentanyl. Both drugs are safe and effective analgesics and have a rapid onset. Painful injuries often produce significant anxiety. Anxiolytics help to calm the patient, provide some amnesic effects and reduce the quantity of analgesia needed. Consider administering an anxiolytic like a benzodiazepine. Benzodiazepines work to reduce the action of GABA, a neurotransmitter in the brain, which provides central nervous depression, including the pain-sensing portions of the brain. Versed is often considered the sedative of choice for this, as it provides immediate effect and has a short half-life. TRANSFER OF CARE Upon arriving in the emergency department, deliver a clear and concise report stating the mechanism of injury, assessment findings, interventions, current vital signs and any hypotension. Make sure the ED staff is aware of all drugs given, the doses, and how much IV fluid was administered. As part of the emergency department's assessment, the physician will likely select one of three tests to look for blood in the abdomen. The traditional test has been a diagnostic peritoneal lavage (DPL), with a needle inserted inferior to the umbilicus and introduced into the abdominal cavity where fluid is withdrawn and tested for blood. Any blood is considered a positive test and the patient is sent for surgery. The DPL is a very invasive procedure and is not frequently used. Development of the FAST exam outdated the DPL. First used in 1996, the Focused Assessment with Sonography for Trauma (FAST) can detect as little as 30 mL of blood and looks at four different views of the abdominal cavity. Using ultrasound, the FAST exam looks at the pericardic, perihepatic, perisplenic and peripelvic spaces for the presence of fluid in the abdominal cavity. FAST is very accurate and can help eliminate unnecessary CT scans. The gold standard in diagnosing solid organ injuries is the computed tomography, or CT, scan. Unlike the FAST exam, which can only identify the presence of blood, the CT scan identifies the bleeding source as well. Unfortunately, the CT scan is not available at all facilities, is very expensive to perform, and requires contrast dye administration. Once physicians have completed their assessments and testing, they will determine who needs surgical intervention and who doesn't. Patients with deep penetrating injuries nearly always require surgery; small penetrating wounds that do not go through the muscle wall often do not require surgical care. Trauma teams use these different tools to identify specific organ injuries and determine their best course of long- term care. EMS providers can benefit patients and improve their hospital care by identifying the mechanism of injury and looking for signs and symptoms specific to abdominal traumatic injuries. Table 1: Indicators Suggestive of Abdominal Trauma

Mechanism of injury consistent with abdominal compression Bent steering wheel

Safety belt impressions Shock without an obvious cause Soft tissue injury to the lower thorax, back, flank or abdomen Significant tenderness on palpation or coughing Involuntary guarding5

Blunt Abdominal Trauma

Author: John Udeani, MD, FAAEM; Chief Editor: John Geibel, MD, DSc, MA
Updated: Oct 25, 2011 accessed June 28, 2012

Background
The care of the trauma patient is demanding and requires speed and efficiency. Evaluating patients who have sustained blunt abdominal trauma remains one of the most challenging and resource-intensive aspects of acute trauma care.[1, 2] Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Identification of serious intra-abdominal pathology is often challenging. Many injuries may not manifest during the initial assessment and treatment period. Missed intra-abdominal injuries and concealed hemorrhage are frequent causes of increased morbidity and mortality, especially in patients who survive the initial phase after an injury. Physical examination findings are notoriously unreliable. One reason is that mechanisms of injury often result in other associated injuries that may divert the physicians attention from potentially life-threatening intra-abdominal pathology. Other common reasons are an altered mental state and drug and alcohol intoxication. Coordinating a trauma resuscitation demands a thorough understanding of the pathophysiology of trauma and shock, excellent clinical and diagnostic acumen, skill with complex procedures, compassion, and the ability to think rationally in a chaotic milieu. Blunt abdominal trauma usually results from motor vehicle collisions (MVCs), assaults, recreational accidents, or falls. The most commonly injured organs are the spleen, liver, retroperitoneum, small bowel, kidneys (see the image below), bladder, colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often than women.

Blunt abdominal trauma. Right kidney injury with blood in perirenal space. Injury resulted from high-speed motor vehicle collision

For more information, see the following:

Pediatric Abdominal Trauma Penetrating Abdominal Trauma Focused Assessment with Sonography in Trauma (FAST) Abdominal Vascular Injuries

Anatomy
The abdomen can be arbitrarily divided into 4 areas. The first is the intrathoracic abdomen, which is the portion of the upper abdomen that lies beneath the rib cage. Its contents include the diaphragm, liver, spleen, and stomach. The rib cage makes this area inaccessible to palpation and complete examination. The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents include the urinary bladder, urethra, rectum, small intestine, and, in females, ovaries, fallopian tubes, and uterus. Injury to these structures may be extraperitoneal in nature and therefore difficult to diagnose. The third is the retroperitoneal abdomen, which contains the kidneys, ureters, pancreas, aorta, and vena cava. Injuries to these structures are very difficult to diagnose on the basis of physical examination findings. Evaluation of the structures in this region may require computed tomography (CT) scanning, angiography, and intravenous pyelography (IVP). The fourth is the true abdomen, which contains the small and large intestines, the uterus (if gravid), and the bladder (when distended). Perforation of these organs is associated with significant physical findings and usually manifests with pain and tenderness from peritonitis. Plain x-ray films are helpful if free air is present. Additionally, diagnostic peritoneal lavage (DPL) is a useful adjunct.

Pathophysiology
Intra-abdominal injuries secondary to blunt force are attributed to collisions between the injured person and the external environment and to acceleration or deceleration forces acting on the persons internal or gans. Blunt force injuries to the abdomen can generally be explained by 3 mechanisms. The first mechanism is deceleration. Rapid deceleration causes differential movement among adjacent structures. As a result, shear forces are created and cause hollow, solid, visceral organs and vascular pedicles to tear, especially at relatively fixed points of attachment. For example, the distal aorta is attached to the thoracic spine and decelerates much more quickly than the relatively mobile aortic arch. As a result, shear forces in the aorta may cause it to rupture. Similar situations can occur at the renal pedicles and at the cervicothoracic junction of the spinal cord. Classic deceleration injuries include hepatic tear along the ligamentum teres and intimal injuries to the renal arteries. As bowel loops travel from their mesenteric attachments, thrombosis and mesenteric tears, with resultant splanchnic vessel injuries, can result. The second mechanism involves crushing. Intra-abdominal contents are crushed between the anterior abdominal wall and the vertebral column or posterior thoracic cage. This produces a crushing effect, to which solid viscera (eg, spleen, liver, kidneys) are especially vulnerable. The third mechanism is external compression, whether from direct blows or from external compression against a fixed object (eg, lap belt, spinal column). External compressive forces result in a sudden and dramatic rise in intraabdominal pressure and culminate in rupture of a hollow viscous organ (ie, in accordance with the principles of Boyle law). The liver and spleen seem to be the most frequently injured organs, though reports vary. The small and large intestines are the next most frequently injured organs. Recent studies show an increased number of hepatic injuries, perhaps reflecting increased use of CT scanning and concomitant identification of more injuries.

Etiology
Vehicular trauma is by far the leading cause of blunt abdominal trauma in the civilian population. Auto-to-auto and auto-to-pedestrian collisions have been cited as causes in 50-75% of cases. Other common etiologies include falls and industrial or recreational accidents. Rare causes of blunt abdominal injuries include iatrogenic trauma during cardiopulmonary resuscitation, manual thrusts to clear an airway, and the Heimlich maneuver.

Epidemiology
United States statistics
By nearly every measure, injury ranks as one of the most pressing health issues in the United States. More than 150,000 people die each year as a result of injuries, such as motor vehicle crashes, fires, falls, drowning, poisoning, suicide, and homicide. Injuries are the leading cause of death and disability for US children and young adults. According to the 2000 statistics from the National Center for Injury Prevention and Control, trauma (unintentional and intentional) was the leading cause of death in persons aged 1-44 years. Further review of the data reveals that in

those aged 15-25 years, 14,113 persons died from unintentional injuries, 73% of which were related to vehicular trauma. In individuals aged 25-34 years, 57% of the 11,769 deaths reported were from motor vehicle collisions. In 2001, approximately 30 million people visited emergency departments (EDs) for the treatment of nonfatal injuries, and more than 72,000 people were disabled by injuries. Injury imposes exceptional costs, both in health care dollars and in human losses, to society. The true frequency of blunt abdominal trauma, however, is unknown. Data collected from trauma centers reflect patients who are transported to or seek care at these centers; these data may not reflect patients presenting to other facilities. The incidence of out-of-hospital deaths is unknown. One review from the National Pediatric Trauma Registry by Cooper et al reported that 8% of patients (total=25,301) had abdominal injuries. Eighty-three percent of those injuries were from blunt mechanisms. Automobile-related injuries accounted for 59% of those injuries.[3] Similar reviews from adult trauma databases reflect that blunt trauma is the leading cause of intra-abdominal injury and that MVC is the leading mode of injury. Blunt injuries account for approximately two thirds of all injuries. Hollow viscus trauma is more frequent in the presence of an associated, severe, solid organ injury, particularly to the pancreas. Approximately two thirds of patients with hollow viscus trauma are injured in MVCs.

International statistics
In 1990, approximately 5 million people died worldwide as a result of injury. The risk of death from injury varied strongly by region, age, and sex. Approximately 2 male deaths due to violence were reported for every female death. Injuries accounted for approximately 12.5% of all male deaths, compared with 7.4% of female deaths. Globally, injury accounts for 10% of all deaths; however, injuries in sub-Saharan Africa are far more destructive than in other areas. In sub-Saharan Africa, the risk of death from trauma is highest in those aged 15-60 years, and the proportion of such deaths from trauma is higher than in any other region of the world. South Africa, for instance, has a traffic death rate per unit of distance traveled that is surpassed only by those of Korea, Kenya, and Morocco. Estimates indicate that by 2020, 8.4 million people will die yearly from injury, and injuries from traffic collisions will be the third most common cause of disability worldwide and the second most common cause in the developing world. Data from the World Health Organization (WHO) indicate that falls from heights of less than 5 meters are the leading cause of injury, and automobile crashes are the next most frequent cause. These data reflect all injuries, not just blunt injuries to the abdomen. A review from Singapore described trauma as the leading cause of death in those aged 1-44 years. Traffic accidents, stab wounds, and falls from heights were the leading modes of injury. Blunt abdominal trauma accounted for 79% of cases.[4] A similar paper from India reported that blunt abdominal trauma is more frequent in males aged 21-30 years; the majority of patients were injured in automobile accidents. A German study indicated that, of patients with vertical deceleration injuries (ie, falls from heights), only 5.9% had blunt abdominal injuries.

Age-related differences in incidence

Most studies indicate that the peak incidence is in persons aged 14-30 years. A review of 19,261 patients with blunt abdominal trauma revealed equal incidence of hollow viscus injuries in both children (ie, 14 y) and adults.

Sex-related differences in incidence

According to national and international data, blunt abdominal trauma is more common in men. The male-to-female ratio is 60:40.

Prognosis
Overall prognosis for patients who sustain blunt abdominal trauma is favorable. Without statistics that indicate the number of out-of-hospital deaths and the total number of patients with blunt trauma to the abdomen, a description of the specific prognosis for patients with intra-abdominal injuries is difficult. Mortality rates for hospitalized patients are approximately 5-10%. The National Pediatric Trauma Registry reported that 9% of pediatric patients with blunt abdominal trauma died. Of these, only 22% were reported as having intra-abdominal injuries as the likely cause of death.[3]

A review from Australia of intestinal injuries in blunt trauma reported that 85% of injuries occurred from vehicular accidents. The mortality rate was 6%. In a large review of operating room deaths in which blunt trauma accounted for 61% of all injuries, abdominal trauma was the primary identified cause of death in 53.4% of cases.

Patient Education
Proper adjustment of restraints in motor vehicles is an important aspect of patient education. The following are key recommendations:

Wear lap belts in conjunction with shoulder restraints. Adjust lap belts so that they fit snugly, and place them across the lower abdomen and below the iliac crests. Wear restraints even in vehicles equipped with supplemental vehicle restraints (eg, airbags). Adjust seats and steering wheels so that the distance between the abdominal wall and the steering wheel is as wide as possible while still allowing proper control of the vehicle. Advise patients to practice defensive driving by observing speed limits and keeping a safe distance between them and other automobiles on the road. For patient education resources, see the Kidneys and Urinary System Center, as well as Blood in the Urine and Bruises.

History
Initially, evaluation and resuscitation of a trauma patient occur simultaneously. In general, do not obtain a detailed history until life-threatening injuries have been identified and therapy has been initiated. The initial assessment begins at the scene of the injury, with information provided by the patient, family, bystanders, or paramedics, or police. Important factors relevant to the care of a patient with blunt abdominal trauma, specifically those involving motor vehicles, include the following:

The extent of vehicular damage Whether prolonged extrication was required Whether the passenger space was intruded Whether a passenger died Whether the person was ejected from the vehicle The role of safety devices such as seat belts and airbags The presence of alcohol or drug use The presence of a head or spinal cord injury Whether psychiatric problems were evident Important elements of the pertinent history include the following: Allergies Medications Past medical and surgical history Time of last meal Immunization status Events leading to the incident Social history, including history of substance abuse Information from family and friends The mnemonic AMPLE (A llergies, M edications, P ast medical history, L ast meal or other intake, and E vents leading to presentation) is often useful as a means of remembering key elements of the history. A history of out-of-hospital hypotension is a predictor of more significant intra-abdominal injuries. Even if the patient is normotensive at arrival in the emergency department (ED), he or she should be considered to be at increased risk.

Physical Examination
Primary survey
Resuscitation is performed concomitantly and continues as the physical examination is completed. Priorities in resuscitation and diagnosis are established on the basis of hemodynamic stability and the degree of injury. The goal of the primary survey, as directed by the Advanced Trauma Life Support (ATLS) protocol, is to identify and expediently treat life-threatening injuries. The protocol includes the following:

Airway, with cervical spine precautions Breathing Circulation Disability Exposure It is imperative for all personnel involved in the direct care of a trauma patient to exercise universal precautions against body fluid exposure. The incidence of infectious diseases (eg, HIV, hepatitis) is significantly higher in trauma patients than in the general public, with some centers reporting rates as high as 19%. Even in medical centers with relatively low rates of communicable diseases, safely determining who is infected with such pathogens is impossible. The standard barrier precautions include a hat, eye shield, face mask, gown, gloves, and shoe covers. Unannounced trauma arrival is probably the most common situation that leads to a breach in barrier precautions. Personnel must be instructed to adhere to these guidelines at all times, even if it means a 30-second delay in patient care.

Secondary survey
After an appropriate primary survey and initiation of resuscitation, attention should be focused on the secondary survey of the abdomen. The secondary survey is the identification of all injuries via a head-to-toe examination. For life-threatening injuries that necessitate emergency surgery, a comprehensive secondary survey should be delayed until the patient has been stabilized. At the other end of the spectrum are victims of blunt trauma who have a benign abdomen upon initial presentation. Many injuries initially are occult and manifest over time. Frequent serial examinations, in conjunction with the appropriate diagnostic studies, such as abdominal computed tomography (CT) and bedside ultrasonography, are essential in any patient with a significant mechanism of injury. The evaluation of a patient with blunt abdominal trauma must be accomplished with the entire patient in mind, with all injuries prioritized accordingly. This implies that injuries involving the head, the respiratory system, or the cardiovascular system may take precedence over an abdominal injury. The abdomen should neither be ignored nor be the sole focus of the treating clinician and surgeon. In an unstable patient, the question of abdominal involvement must be expediently addressed. This is accomplished by identifying free intra-abdominal fluid with diagnostic peritoneal lavage (DPL) or focused assessment with sonography for trauma (FAST). The objective is rapid identification of those patients who need a laparotomy. The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate. Associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult. Lower rib fractures, pelvic fractures, and abdominal wall contusions may mimic the signs of peritonitis. In a collected series of 955 patients, Powell et al reported that clinical evaluation alone has an accuracy rate of only 65% for detecting the presence or absence of intraperitoneal blood.[5] In general, accuracy increases if the patient is reevaluated repeatedly and at frequent intervals. However, repeated examinations may not be feasible in patients who need general anesthesia and surgery for other injuries. The greatest compromise of the physical examination occurs in the setting of neurologic dysfunction, which may be caused by head injury or substance abuse. The most reliable signs and symptoms in alert patients are pain, tenderness, gastrointestinal hemorrhage, hypovolemia, and evidence of peritoneal irritation. However, large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings. Bradycardia may indicate the presence of free intraperitoneal blood in a patient with blunt abdominal injuries. The respiratory pattern should be observed because abdominal breathing may indicate spinal cord injury. A sensory examination of the chest and abdomen should be performed to evaluate the potential for spinal cord injury. Spinal cord injury may interfere with the accurate assessment of the abdomen by causing decreased or absent pain perception. The abdominal examination must be systematic. The abdomen is inspected for abrasions or ecchymosis. Particular attention should be paid to injury patterns that predict the potential for intra-abdominal trauma (eg, lap belt abrasions, steering wheelshaped contusions). In most studies, lap belt marks have been correlated with rupture of the small intestine and an increased incidence of other intra-abdominal injuries. Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign) indicates retroperitoneal hemorrhage, but this is usually delayed for several hours to days.

Visual inspection for abdominal distention, which may be due to pneumoperitoneum, gastric dilatation secondary to assisted ventilation or swallowing of air, or ileus produced by peritoneal irritation, is important. Auscultation of bowel sounds in the thorax may indicate the presence of a diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula. Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound tenderness, which suggests peritoneal injury. Such signs appearing soon after an injury suggest leakage of intestinal content. Peritonitis due to intra-abdominal hemorrhage may take several hours to develop. Fullness and doughy consistency on palpation may indicate intra-abdominal hemorrhage. Crepitation or instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries associated with lower rib injuries. Tenderness on percussion constitutes a peritoneal sign. Tenderness mandates further evaluation and probably surgical consultation. Rectal and bimanual vaginal pelvic examinations should be performed. [6] A rectal examination should be done to search for evidence of bony penetration resulting from a pelvic fracture, and the stool should be evaluated for gross or occult blood. The evaluation of rectal tone is important for determining the patients neurologic status, and palpation of a high-riding prostate suggests urethral injury. The genitals and perineum should be examined for soft tissue injuries, bleeding, and hematoma. Pelvic instability indicates the potential for lower urinary tract injury, as well as pelvic and retroperitoneal hematoma. Open pelvic fractures are associated with a mortality rate exceeding 50%. A nasogastric tube should be placed routinely (in the absence of contraindications, eg, basilar skull fracture) to decompress the stomach and to assess for the presence of blood. If the patient has evidence of a maxillofacial injury, an orogastric tube is preferred. As the assessment continues, a Foley catheter is placed and a sample of urine is sent for analysis for microscopic hematuria. If injury to the urethra or bladder is suggested because of an associated pelvic fracture, then a retrograde urethrogram is performed before catheterization. With respect to the primary and secondary surveys, pediatric patients are assessed and treated at least initiallyas adults. However, there are obvious anatomic and clinical differences between children and adults that must be kept in mind, including the following:

A pediatric patients physiologic response to injury is different. Effective communication with a child is not always possible. Physical examination findings become more important in children. A pediatric patients blood volume is smaller, predisposing to rapid exsanguinations. Technical procedures in pediatric patients tend to be more time consuming and challenging. A childs relatively large body surface area contributes to rapid heat loss. Perhaps the most significant difference between pediatric and adult blunt trauma is that, for the most part, pediatric patients can be resuscitated and treated nonoperatively. Some pediatric surgeons often transfuse up to 40 mL/kg of blood products in an effort to stabilize a pediatric patient. Obviously, if this fails and the child continues to be unstable, laparotomy is indicated.

Tertiary survey
The concept of the tertiary trauma survey was first introduced by Enderson et al to assist in the diagnosis of any injuries that may have been missed during the primary and secondary surveys.[7] The tertiary survey involves a repetition of the primary and secondary surveys and a revision of all laboratory and radiographic studies. In 1 study, a tertiary trauma survey detected 56% of injuries missed during the initial assessment within 24 hours of admission. [8]

Diagnostic Considerations
Identification of intra-abdominal injuries can be challenging. Common pitfalls in diagnosis include the following:

Failure to suspect intra-abdominal injury from appropriate mechanisms Failure to evaluate abdominal/flank/costal margin pain after blunt abdominal injury

Failure to obtain timely surgical consultation and operative intervention Failure to recognize intra-abdominal hemorrhage and delay operation for additional diagnostic testing in the face of hemodynamic compromise

Differential Diagnoses

Domestic Violence Hemorrhagic Stroke Hypovolemic Shock Lower Genitourinary Trauma Penetrating Abdominal Trauma in Emergency Medicine Pregnancy Trauma Upper Genitourinary Trauma

Approach Considerations
In recent years, laboratory evaluation of trauma patients has been a matter of significant discussion. Commonly recommended studies include serum glucose, complete blood count (CBC), serum chemistries, serum amylase, urinalysis, coagulation studies, blood typing and cross-matching, arterial blood gases (ABGs), blood ethanol, urine drug screens, and a urine pregnancy test (for females of childbearing age). Serum electrolyte values, creatinine level, and glucose values are often obtained for reference, but typically they have little or no value in the initial management period. Aggressive radiographic and surgical investigation is indicated in patients with persistent hyperamylasemia or hyperlipasemia, conditions that suggest significant intra-abdominal injury. All patients should have their tetanus immunization history reviewed. If it is not current, prophylaxis should be given. The most important initial concern in the evaluation of a patient with blunt abdominal trauma is an assessment of hemodynamic stability. In the hemodynamically unstable patient, a rapid evaluation must be made regarding the presence of hemoperitoneum. This can be accomplished by means of diagnostic peritoneal lavage (DPL) or the focused assessment with sonography for trauma (FAST). Radiographic studies of the abdomen are indicated in stable patients when the physical examination findings are inconclusive. Go to Focused Assessment with Sonography in Trauma (FAST) for complete information on this topic.

Blood Studies
Complete blood count
The presence of massive hemorrhage is usually obvious from hemodynamic parameters, and an abnormal hematocrit value merely confirms the diagnosis. Normal hemoglobin and hematocrit results do not rule out significant hemorrhage. Patients bleed whole blood. Until blood volume is replaced with crystalloid solution or hormonal effects (eg, adrenocorticotropic hormone [ACTH], aldosterone, antidiuretic hormone [ADH]) and transcapillary refill occurs, anemia may not develop. Bedside diagnostic testing with rapid hemoglobin or hematocrit machines may quickly identify patients who have physiologically significant volume deficits and hemodilution. Reported hemoglobin from ABG measurements also may be useful in identifying anemia. Some studies have correlated a low initial hematocrit (ie, < 30%) with significant injuries. Do not withhold transfusion in patients who have relatively normal hematocrit results (ie, >30%) but have evidence of clinical shock, serious injuries (eg, open-book pelvic fracture), or significant ongoing blood loss. Hemodynamic instability in an adult despite the administration of 2 L of fluid indicates ongoing blood loss and is an indication for immediate blood transfusion. Use platelet transfusions to treat patients with thrombocytopenia (ie, platelet count < 50,000/L) and ongoing hemorrhage. An elevated white blood cell (WBC) count on admission is nonspecific and does not predict the presence of a hollow viscus injury (HVI). The diagnostic value of serial WBC counts for predicting HVI within the first 24 hours after trauma is very limited.[9]

Serum electrolyte measurements

Recently, the usefulness of routine serum chemistries of trauma patients has been questioned. Most trauma victims are younger than 40 years and rarely are taking medications that may alter electrolytes (eg, diuretics, potassium replacements). The more prudent choice when attempting to limit cost involves selective ordering of these studies. Selection should be based on the patients medications, the presence of concurrent nausea or vomiting, the presence of dysrhyt hmias, or a history of renal failure or other chronic medical problems associated with electrolyte imbalance.

Serum glucose and carbon dioxide measurements

If blood gas measurements are not routinely obtained, serum chemistries that measure serum glucose and carbon dioxide levels are indicated. Rapid bedside blood-glucose determination, obtained with a finger-stick measuring device, is important for patients with altered mental status.

Liver function tests

Liver function tests (LFTs) may be useful in the patient with blunt abdominal trauma; however, test findings may be elevated for several reasons (eg, alcohol abuse).[10] One study has shown that an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) level more than 130 U corresponds with significant hepatic injury. [11] Lactate dehydrogenase (LDH) and bilirubin levels are not specific indicators of hepatic trauma.

Serum amylase or lipase measurements

The serum lipase or amylase level is neither sensitive nor specific as a marker for major pancreatic or enteric injury. Normal levels do not exclude a major pancreatic injury. Elevated levels may be caused by injuries to the head and face or by an assortment of nontraumatic causes (eg, alcohol, narcotics, various other drugs). Amylase or lipase levels may be elevated because of pancreatic ischemia caused by the systemic hypotension that accompanies trauma. However, persistent hyperamylasemia or hyperlipasemia (eg, abnormal elevation 3-6 hours after trauma) should raise the suggestion of significant intra-abdominal injury and is an indication for aggressive radiographic and surgical investigation.

Coagulation profile
The cost-effectiveness of routine prothrombin time (PT)/activated partial thromboplastin time (aPTT) determination upon admission is questionable. PT or aPTT should be measured in patients who have a history of blood dyscrasias (eg, hemophilia), who have synthetic problems (eg, cirrhosis), or who take anticoagulant medications (eg, warfarin, heparin).

Blood typing, screening, and cross-matching

Blood from all trauma patients with suspected blunt abdominal injury should be screened and typed. If an injury is identified, this practice greatly reduces the time required for cross-matching. An initial cross-match should be performed on a minimum of 4-6 units for those patients with clear evidence of abdominal injury and hemodynamic instability. Until cross-matched blood is available, O-negative or type-specific blood should be used.

Arterial blood gas measurements

ABG values may provide important information in major trauma victims. In addition to information about oxygenation (eg, partial pressure of oxygen [PO2] and arterial oxygen saturation [SaO2]) and ventilation (partial pressure of carbon dioxide [PCO2]), this test provides valuable information regarding oxygen delivery through calculation of the alveolararterial (A-a) gradient. ABG determinations also report total hemoglobin more rapidly than CBCs. Upon initial hospital admission, suspect metabolic acidemia to result from the lactic acidosis that accompanies shock. A moderate base deficit (ie, more than 5 mEq) indicates the need for aggressive resuscitation and determination of the etiology. Attempt to improve systemic oxygen delivery by ensuring an adequate SaO 2 (ie, >90%) and by acquiring volume resuscitation with crystalloid solutions and, if indicated, blood.

Drug and alcohol screening

Perform drug and alcohol screens on trauma patients who have alterations in their level of consciousness. Breath or blood testing may quantify alcohol level.

Urine Studies
Indications for diagnostic urinalysis include significant trauma to the abdomen and/or flank, gross hematuria, microscopic hematuria in the setting of hypotension, and a significant deceleration mechanism. [12] Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP) or computed tomography (CT) scanning with intravenous (IV) contrast. Gross hematuria indicates a workup that includes cystography and IVP or CT scanning of the abdomen with contrast. Perform a urine toxicologic screen as appropriate. Obtain a serum or urine pregnancy test on all females of childbearing age.

Plain Radiography
Although their overall value in the evaluation of patients with blunt abdominal trauma is limited, plain films can demonstrate numerous findings. The chest radiograph may aid in the diagnosis of abdominal injuries such as ruptured hemidiaphragm (eg, a nasogastric tube seen in the chest) or pneumoperitoneum. The pelvic or chest radiograph can demonstrate fractures of the thoracolumbar spine. The presence of transverse fractures of the vertebral bodies (ie, Chance fractures) suggests a higher likelihood of blunt injuries to the bowel. In addition, free intraperitoneal air, or trapped retroperitoneal air from duodenal perforation, may be seen.

Ultrasonography
The use of diagnostic ultrasonography to evaluate a patient with blunt trauma for abdominal injuries has been advocated since the 1970s. European and Asian investigators have extensive experience with this technology and are leaders in the use of ultrasound for the diagnosis of blunt abdominal trauma. The first American report of physician-performed abdominal ultrasonography in the evaluation of blunt abdominal trauma was published in 1992 by Tso and colleagues. [13] Since then, numerous articles have been published in the United States advocating the use of ultrasound (ie, FAST) in the evaluation of the patient with blunt abdominal trauma. Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum. In fact, in many medical centers, the FAST examination has virtually replaced DPL as the procedure of choice in the evaluation of hemodynamically unstable trauma patients. The FAST examination is based on the assumption that all clinically significant abdominal injuries are associated with hemoperitoneum. However, the detection of free intraperitoneal fluid is based on factors such as the body habitus, injury location, presence of clotted blood, position of the patient, and amount of free fluid present. In a patient with isolated blunt abdominal trauma and multisystem injuries, FAST performed by an experienced sonographer can rapidly identify free intraperitoneal fluid (generally appearing as a black stripe). The sensitivity for solid organ encapsulated injury is moderate in most studies. Hollow viscus injury (HVI) rarely is identified; however, free fluid may be visualized. For patients with persistent pain or tenderness or those developing peritoneal signs, FAST may be considered as a complementary measure to CT scanning, DPL, or exploration. The minimum threshold for detecting hemoperitoneum is unknown and remains a subject of interest. Kawaguchi and colleagues found that 70 mL of blood could be detected,[14] whereas Tiling et al found that 30 mL is the minimum requirement for detection with ultrasonography.[15] They also concluded that a small anechoic stripe in the Morison pouch represents approximately 250 mL of fluid, whereas 0.5-cm and 1-cm stripes represent approximately 500 mL and 1 L of free fluid, respectively. The current FAST examination protocol consists of 4 acoustic windows with the patient supine. These windows are pericardiac, perihepatic, perisplenic, and pelvic (known as the 4 P s). An examination is interpreted as positive if free fluid is found in any of the 4 acoustic windows and as negative if no fluid is seen. An examination is deemed indeterminate if any of the windows cannot be adequately assessed. The pericardial window is obtained via a subcostal or transthoracic approach. It provides a 4-chamber view of the heart and can detect the presence of hemopericardium, which is demonstrated by the separation of the visceral and

parietal pericardial layers. The perihepatic window yields views of portions of the liver, diaphragm, and right kidney. It reveals fluid in the Morison pouch (see the images below), the subphrenic space, and the right pleural space.

Blunt abdominal trauma. Normal Morison pouch (ie, no free fluid).

Blunt abdominal trauma. Free fluid in Morison pouch

The perisplenic window provides views of the spleen and the left kidney and reveals fluid in the splenorenal recess (see the images below), the left pleural space, and the subphrenic space. The pelvic window makes use of the bladder as a sonographic window and thus is best accomplished while the patient has a full bladder. In males, free fluid is seen as an anechoic area (sonographically black) in the rectovesicular pouch or cephalad to the bladder. In females, fluid accumulates in the Douglas pouch, posterior to the uterus.

Blunt abdominal trauma. Normal splenorenal recess.

Blunt abdominal trauma. Free fluid in splenorenal recess.

FASTs diagnostic accuracy generally is equal to that of DPL. Studies in the United States have demonstrated the value of bedside sonography as a noninvasive approach for rapid evaluation of hemoperitoneum. The studies demonstrate a degree of operator dependence; however, some studies have shown that with a structured learning session, even novice operators can identify free intra-abdominal fluid, especially if more than 500 mL of fluid is present. Sensitivity and specificity of these studies range from 85% to 95%.[16, 17, 18, 19, 20] As noted, FAST relies on hemoperitoneum to identify patients with injury. Chiu and colleagues, in their study of 772 patients with blunt trauma undergoing FAST scans, reported 52 patients had an abdominal injury. [21] Of the 52 patients, 15 (29%) had no hemoperitoneum on FAST or CT scan results. These findings suggest that the reliance on hemoperitoneum as the sole indicator of abdominal visceral injury limits the utility of FAST as a diagnostic screening tool in stable patients with blunt abdominal trauma. Rozycki et al studied 1540 patients and reported that ultrasonography was the most sensitive and specific modality for the evaluation of hypotensive patients with blunt abdominal trauma (sensitivity and specificity, 100%). [20] Hemodynamically stable patients with positive FAST results may require a CT scan to better define the nature and extent of their injuries. Taking every patient with a positive FAST result to the operating room may result in an unacceptably high laparotomy rate. Hemodynamically stable patients with negative FAST results require close observation, serial abdominal examinations, and a follow-up FAST examination. However, strongly consider performing a CT scan, especially if the patient is intoxicated or has other associated injuries. Hemodynamically unstable patients with negative FAST results are a diagnostic challenge. Options include DPL, exploratory laparotomy, and, possibly, a CT scan after aggressive resuscitation. Go to Focused Assessment with Sonography in Trauma (FAST) for complete information on this topic.

Computed Tomography
Although expensive and potentially time-consuming, CT scanning often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention. [22, 23, 24, 25] CT remains the criterion standard for the detection of solid organ injuries (see the image below). In addition, a CT scan of the abdomen can reveal other associated injuries, notably vertebral and pelvic fractures and injuries in the thoracic cavity.

Blunt abdominal trauma with liver laceration.

CT scanning, unlike DPL or FAST, has the capability to determine the source of hemorrhage (see the image below). In addition, many retroperitoneal injuries go unnoticed with DPL and FAST examinations.

Blunt abdominal trauma with splenic injury and hemoperitoneum.

Transport only hemodynamically stable patients to the CT scanner. When performing CT scans, closely and carefully monitor vital signs for clinical evidence of decompensation. Preliminary evidence suggests that a flat vena cava on CT scan is a marker for underresuscitation and may be correlated with higher mortality and hemodynamic decompensation.[26] CT scans provide excellent imaging of the pancreas, duodenum, and genitourinary system. The images can help quantitate the amount of blood in the abdomen and can reveal individual organs with precision. The primary advantage of CT scanning is its high specificity and use for guiding nonoperative management of solid organ injuries. Drawbacks of CT scanning relate to the need to transport the patient from the trauma resuscitation area and the additional time required to perform CT scanning compared to FAST or DPL. In addition, CT scanning may miss injuries to the diaphragm and perforations of the gastrointestinal (GI) tract, especially when performed soon after the injury. Although some pancreatic injuries may be missed with a CT scan performed soon after trauma, virtually all are identified if the scan is repeated in 36-48 hours. For selected patients, endoscopic retrograde cholangiopancreatography (ERCP) may complement CT scanning to rule out a ductal injury. Finally, CT scanning is relatively expensive and time consuming and requires oral or intravenous (IV) contrast, which may cause adverse reactions. The best CT imagery requires both oral and IV contrast. Some controversy has arisen over the use of oral contrast and whether the additional information it provides negates the drawbacks of increased time to administration and risk of aspiration. The value of oral contrast in diagnosing bowel injury has been debated, but no definitive answer exists at this time.

Diagnostic Laparoscopy
The introduction of minimally invasive surgery has revolutionized many surgical diagnostic protocols. In the late 1980s and early 1990s, there was considerable interest in the use of laparoscopy for evaluation and management of blunt and penetrating abdominal trauma. Subsequent studies, however, revealed major limitations to this approach and cautioned against its widespread use. The most important limitation is inability to reliably identify hollow viscus and retroperitoneal injuries, even in the hands of experienced laparoscopists. Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for the introduction of the laparoscope and creating other ports for retractors, clamps, and other tools necessary for visualization of the repair. Diagnostic laparoscopy has been most useful in the evaluation of possible diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on the left side.[27, 28, 29] In blunt trauma, it has no clear advantages over less invasive modalities such as DPL and CT scanning; furthermore, complications can result from trocar misplacement.

Diagnostic Peritoneal Lavage

The idea of evaluating the abdomen by analyzing its contents was first used in the diagnosis of acute abdominal conditions. In 1906, Salomon described the passage of a urethral catheter by means of a trocar inserted through the abdominal wall to obtain samples of peritoneal fluid with the aim of establishing the diagnosis of peritonitis from infectious agents (eg, pneumococcal or tuberculous organisms). This technique has since been refined and is now known as abdominal paracentesis. In 1926, Neuhof and Cohen described the sampling of peritoneal fluid in cases of acute pancreatitis and blunt abdominal trauma by passing a spinal needle through the abdominal wall. [30] In 1965, Root et al reported the use of percutaneous DPL in patients who had sustained blunt abdominal trauma. [31] DPL is used as a method of rapidly determining the presence of intraperitoneal blood. It is particularly useful if the history and abdominal examination of an unstable patient with multisystem injuries are either unreliable (eg, because of head injury, alcohol, or drug intoxication) or equivocal (eg, because of lower rib fractures, pelvic fractures, or confounding clinical examination). DPL is also useful for patients in whom serial abdominal examinations cannot be performed (eg, those in an angiographic suite or operating room during emergency orthopedic or neurosurgical procedures).[32] DPL is indicated for the following patients in the setting of blunt trauma:

Patients with a spinal cord injury Those with multiple injuries and unexplained shock Obtunded patients with a possible abdominal injury Intoxicated patients in whom abdominal injury is suggested Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure

The only absolute contraindication to DPL is the obvious need for laparotomy. Relative contraindications include morbid obesity, a history of multiple abdominal surgeries, and pregnancy. Various methods of introducing the catheter into the peritoneal space have been described. These include the open, semiopen, and closed methods. The open method requires an infraumbilical skin incision that is extended to and through the linea alba. (In pregnant patients or in patients with particular risk for potential pelvic hematoma, the incision should be placed superior to the umbilicus.) The peritoneum is opened, and the catheter is inserted under direct visualization. The semiopen method is identical, except that the peritoneum is not opened and the catheter is delivered percutaneously through the peritoneum into the peritoneal cavity. The closed technique requires the catheter to be inserted blindly through the skin, subcutaneous tissue, linea alba, and peritoneum. The closed and semiopen techniques at the infraumbilical site are preferred at most centers. The fully open method is the most technically demanding and is restricted to those situations in which the closed or semiopen technique is unsuccessful or is deemed unsafe (eg, patients with pelvic fractures, pregnancy, obesity, or prior abdominal operations). After insertion of the catheter into the peritoneum, attempt to aspirate free intraperitoneal blood (at least 15-20 mL). DPL results are considered positive in a blunt trauma patient if 10 mL of grossly bloody aspirate is obtained before infusion of the lavage fluid or if the siphoned lavage fluid contains more than 100,000 red blood cells (RBCs)/L, more than 500 white blood cells (WBCs)/L, elevated amylase content, bile, bacteria, vegetable matter, or urine. Only approximately 30 mL of blood is needed in the peritoneum to produce a microscopically positive DPL result. If findings are negative, infuse 1 L of crystalloid solution (eg, lactated Ringer solution) into the peritoneum. Then, allow this fluid to drain by gravity, and ensure that laboratory analysis is performed. Complications of DPL include bleeding from the incision and catheter insertion, infection (ie, wound, peritoneal), and injury to intra-abdominal structures (eg, urinary bladder, small bowel, uterus). These complications may increase the possibility of false-positive studies. Additionally, infection of the incision, peritonitis from the catheter placement, laceration of the urinary bladder, or injury to other intra-abdominal organs can occur. Bleeding from the incision, dissection, or catheter insertion can cause false-positive results that may lead to unnecessary laparotomy. Achieve appropriate hemostasis prior to entering the peritoneum and placing the catheter. False-positive DPL results can occur if an infraumbilical approach is used in a patient with a pelvic fracture. A pelvic x-ray film should be obtained prior to performing DPL if a pelvic fracture is suggested. Before DPL is attempted, the urinary bladder and stomach should be decompressed. DPL has been shown in some studies to have a diagnostic accuracy of 98-100%, a sensitivity of 98-100%, and a specificity of 90-96%. It has some advantages, including high sensitivity, rapidity, and immediate interpretation. The main limitations of DPL include its potential for iatrogenic abdominal injury and its high sensitivity, which can lead to nontherapeutic laparotomies. With the availability of fast, noninvasive, and better imaging modalities (eg, FAST, CT scanning), the role of DPL is now limited to the evaluation of unstable trauma patients in whom FAST results are negative or inconclusive. In some contexts, DPL may be complemented with a CT scan if the patient has positive lavage results but stabilizes.

Approach Considerations
In recent years, laboratory evaluation of trauma patients has been a matter of significant discussion. Commonly recommended studies include serum glucose, complete blood count (CBC), serum chemistries, serum amylase, urinalysis, coagulation studies, blood typing and cross-matching, arterial blood gases (ABGs), blood ethanol, urine drug screens, and a urine pregnancy test (for females of childbearing age). Serum electrolyte values, creatinine level, and glucose values are often obtained for reference, but typically they have little or no value in the initial management period. Aggressive radiographic and surgical investigation is indicated in patients with persistent hyperamylasemia or hyperlipasemia, conditions that suggest significant intra-abdominal injury. All patients should have their tetanus immunization history reviewed. If it is not current, prophylaxis should be given.

The most important initial concern in the evaluation of a patient with blunt abdominal trauma is an assessment of hemodynamic stability. In the hemodynamically unstable patient, a rapid evaluation must be made regarding the presence of hemoperitoneum. This can be accomplished by means of diagnostic peritoneal lavage (DPL) or the focused assessment with sonography for trauma (FAST). Radiographic studies of the abdomen are indicated in stable patients when the physical examination findings are inconclusive. Go to Focused Assessment with Sonography in Trauma (FAST) for complete information on this topic.

Blood Studies
Complete blood count
The presence of massive hemorrhage is usually obvious from hemodynamic parameters, and an abnormal hematocrit value merely confirms the diagnosis. Normal hemoglobin and hematocrit results do not rule out significant hemorrhage. Patients bleed whole blood. Until blood volume is replaced with crystalloid solution or hormonal effects (eg, adrenocorticotropic hormone [ACTH], aldosterone, antidiuretic hormone [ADH]) and transcapillary refill occurs, anemia may not develop. Bedside diagnostic testing with rapid hemoglobin or hematocrit machines may quickly identify patients who have physiologically significant volume deficits and hemodilution. Reported hemoglobin from ABG measurements also may be useful in identifying anemia. Some studies have correlated a low initial hematocrit (ie, < 30%) with significant injuries. Do not withhold transfusion in patients who have relatively normal hematocrit results (ie, >30%) but have evidence of clinical shock, serious injuries (eg, open-book pelvic fracture), or significant ongoing blood loss. Hemodynamic instability in an adult despite the administration of 2 L of fluid indicates ongoing blood loss and is an indication for immediate blood transfusion. Use platelet transfusions to treat patients with thrombocytopenia (ie, platelet count < 50,000/L) and ongoing hemorrhage. An elevated white blood cell (WBC) count on admission is nonspecific and does not predict the presence of a hollow viscus injury (HVI). The diagnostic value of serial WBC counts for predicting HVI within the first 24 hours after trauma is very limited.[9]

Serum electrolyte measurements

Recently, the usefulness of routine serum chemistries of trauma patients has been questioned. Most trauma victims are younger than 40 years and rarely are taking medications that may alter electrolytes (eg, diuretics, potassium replacements). The more prudent choice when attempting to limit cost involves selective ordering of these studies. Selection should be based on the patients medications, the presence of concurrent nausea or vomiting , the presence of dysrhythmias, or a history of renal failure or other chronic medical problems associated with electrolyte imbalance.

Serum glucose and carbon dioxide measurements

If blood gas measurements are not routinely obtained, serum chemistries that measure serum glucose and carbon dioxide levels are indicated. Rapid bedside blood-glucose determination, obtained with a finger-stick measuring device, is important for patients with altered mental status.

Liver function tests

Liver function tests (LFTs) may be useful in the patient with blunt abdominal trauma; however, test findings may be elevated for several reasons (eg, alcohol abuse).[10] One study has shown that an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) level more than 130 U corresponds with significant hepatic injury. [11] Lactate dehydrogenase (LDH) and bilirubin levels are not specific indicators of hepatic trauma.

Serum amylase or lipase measurements

The serum lipase or amylase level is neither sensitive nor specific as a marker for major pancreatic or enteric injury. Normal levels do not exclude a major pancreatic injury. Elevated levels may be caused by injuries to the head and face or by an assortment of nontraumatic causes (eg, alcohol, narcotics, various other drugs). Amylase or lipase levels may be elevated because of pancreatic ischemia caused by the systemic hypotension that accompanies trauma.

However, persistent hyperamylasemia or hyperlipasemia (eg, abnormal elevation 3-6 hours after trauma) should raise the suggestion of significant intra-abdominal injury and is an indication for aggressive radiographic and surgical investigation.

Coagulation profile
The cost-effectiveness of routine prothrombin time (PT)/activated partial thromboplastin time (aPTT) determination upon admission is questionable. PT or aPTT should be measured in patients who have a history of blood dyscrasias (eg, hemophilia), who have synthetic problems (eg, cirrhosis), or who take anticoagulant medications (eg, warfarin, heparin).

Blood typing, screening, and cross-matching

Blood from all trauma patients with suspected blunt abdominal injury should be screened and typed. If an injury is identified, this practice greatly reduces the time required for cross-matching. An initial cross-match should be performed on a minimum of 4-6 units for those patients with clear evidence of abdominal injury and hemodynamic instability. Until cross-matched blood is available, O-negative or type-specific blood should be used.

Arterial blood gas measurements

ABG values may provide important information in major trauma victims. In addition to information about oxygenation (eg, partial pressure of oxygen [PO2] and arterial oxygen saturation [SaO2]) and ventilation (partial pressure of carbon dioxide [PCO2]), this test provides valuable information regarding oxygen delivery through calculation of the alveolararterial (A-a) gradient. ABG determinations also report total hemoglobin more rapidly than CBCs. Upon initial hospital admission, suspect metabolic acidemia to result from the lactic acidosis that accompanies shock. A moderate base deficit (ie, more than 5 mEq) indicates the need for aggressive resuscitation and determination of the etiology. Attempt to improve systemic oxygen delivery by ensuring an adequate SaO 2 (ie, >90%) and by acquiring volume resuscitation with crystalloid solutions and, if indicated, blood.

Drug and alcohol screening

Perform drug and alcohol screens on trauma patients who have alterations in their level of consciousness. Breath or blood testing may quantify alcohol level.

Urine Studies
Indications for diagnostic urinalysis include significant trauma to the abdomen and/or flank, gross hematuria, microscopic hematuria in the setting of hypotension, and a significant deceleration mechanism. [12] Obtain a contrast nephrogram by utilizing intravenous pyelography (IVP) or computed tomography (CT) scanning with intravenous (IV) contrast. Gross hematuria indicates a workup that includes cystography and IVP or CT scanning of the abdomen with contrast. Perform a urine toxicologic screen as appropriate. Obtain a serum or urine pregnancy test on all females of childbearing age.

Plain Radiography
Although their overall value in the evaluation of patients with blunt abdominal trauma is limited, plain films can demonstrate numerous findings. The chest radiograph may aid in the diagnosis of abdominal injuries such as ruptured hemidiaphragm (eg, a nasogastric tube seen in the chest) or pneumoperitoneum. The pelvic or chest radiograph can demonstrate fractures of the thoracolumbar spine. The presence of transverse fractures of the vertebral bodies (ie, Chance fractures) suggests a higher likelihood of blunt injuries to the bowel. In addition, free intraperitoneal air, or trapped retroperitoneal air from duodenal perforation, may be seen.

Ultrasonography
The use of diagnostic ultrasonography to evaluate a patient with blunt trauma for abdominal injuries has been advocated since the 1970s. European and Asian investigators have extensive experience with this technology and are leaders in the use of ultrasound for the diagnosis of blunt abdominal trauma.

The first American report of physician-performed abdominal ultrasonography in the evaluation of blunt abdominal trauma was published in 1992 by Tso and colleagues. [13] Since then, numerous articles have been published in the United States advocating the use of ultrasound (ie, FAST) in the evaluation of the patient with blunt abdominal trauma. Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum. In fact, in many medical centers, the FAST examination has virtually replaced DPL as the procedure of choice in the evaluation of hemodynamically unstable trauma patients. The FAST examination is based on the assumption that all clinically significant abdominal injuries are associated with hemoperitoneum. However, the detection of free intraperitoneal fluid is based on factors such as the body habitus, injury location, presence of clotted blood, position of the patient, and amount of free fluid present. In a patient with isolated blunt abdominal trauma and multisystem injuries, FAST performed by an experienced sonographer can rapidly identify free intraperitoneal fluid (generally appearing as a black stripe). The sensitivity for solid organ encapsulated injury is moderate in most studies. Hollow viscus injury (HVI) rarely is identified; however, free fluid may be visualized. For patients with persistent pain or tenderness or those developing peritoneal signs, FAST may be considered as a complementary measure to CT scanning, DPL, or exploration. The minimum threshold for detecting hemoperitoneum is unknown and remains a subject of interest. Kawaguchi and colleagues found that 70 mL of blood could be detected,[14] whereas Tiling et al found that 30 mL is the minimum requirement for detection with ultrasonography.[15] They also concluded that a small anechoic stripe in the Morison pouch represents approximately 250 mL of fluid, whereas 0.5-cm and 1-cm stripes represent approximately 500 mL and 1 L of free fluid, respectively. The current FAST examination protocol consists of 4 acoustic windows with the patient supine. These windows are pericardiac, perihepatic, perisplenic, and pelvic (known as the 4 P s). An examination is interpreted as positive if free fluid is found in any of the 4 acoustic windows and as negative if no fluid is seen. An examination is deemed indeterminate if any of the windows cannot be adequately assessed. The pericardial window is obtained via a subcostal or transthoracic approach. It provides a 4-chamber view of the heart and can detect the presence of hemopericardium, which is demonstrated by the separation of the visceral and parietal pericardial layers. The perihepatic window yields views of portions of the liver, diaphragm, and right kidney. It reveals fluid in the Morison pouch (see the images below), the subphrenic space, and the right pleural space.

Blunt abdominal trauma. Normal Morison pouch (ie, no free fluid).

Blunt abdominal trauma. Free fluid in Morison pouch

The perisplenic window provides views of the spleen and the left kidney and reveals fluid in the splenorenal recess (see the images below), the left pleural space, and the subphrenic space. The pelvic window makes use of the bladder as a sonographic window and thus is best accomplished while the patient has a full bladder. In males, free fluid is seen as an anechoic area (sonographically black) in the rectovesicular pouch or cephalad to the bladder. In females, fluid accumulates in the Douglas pouch, posterior to the uterus.

Blunt abdominal trauma. Normal splenorenal recess.

Blunt abdominal trauma. Free fluid in splenorenal recess.

FASTs diagnostic accuracy generally is equal to that of DPL. Studies in the United States have demonstrated the value of bedside sonography as a noninvasive approach for rapid evaluation of hemoperitoneum. The studies demonstrate a degree of operator dependence; however, some studies have shown that with a structured learning session, even novice operators can identify free intra-abdominal fluid, especially if more than 500 mL of fluid is present. Sensitivity and specificity of these studies range from 85% to 95%.[16, 17, 18, 19, 20] As noted, FAST relies on hemoperitoneum to identify patients with injury. Chiu and colleagues, in their study of 772 patients with blunt trauma undergoing FAST scans, reported 52 patients had an abdominal injury. [21] Of the 52 patients, 15 (29%) had no hemoperitoneum on FAST or CT scan results. These findings suggest that the reliance on hemoperitoneum as the sole indicator of abdominal visceral injury limits the utility of FAST as a diagnostic screening tool in stable patients with blunt abdominal trauma. Rozycki et al studied 1540 patients and reported that ultrasonography was the most sensitive and specific modality for the evaluation of hypotensive patients with blunt abdominal trauma (sensitivity and specificity, 100%). [20] Hemodynamically stable patients with positive FAST results may require a CT scan to better define the nature and extent of their injuries. Taking every patient with a positive FAST result to the operating room may result in an unacceptably high laparotomy rate. Hemodynamically stable patients with negative FAST results require close observation, serial abdominal examinations, and a follow-up FAST examination. However, strongly consider performing a CT scan, especially if the patient is intoxicated or has other associated injuries. Hemodynamically unstable patients with negative FAST results are a diagnostic challenge. Options include DPL, exploratory laparotomy, and, possibly, a CT scan after aggressive resuscitation. Go to Focused Assessment with Sonography in Trauma (FAST) for complete information on this topic.

Computed Tomography
Although expensive and potentially time-consuming, CT scanning often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention. [22, 23, 24, 25] CT remains the criterion standard for the detection of solid organ injuries (see the image below). In addition, a CT scan of the abdomen can reveal other associated injuries, notably vertebral and pelvic fractures and injuries in the thoracic cavity.

Blunt abdominal trauma with liver laceration.

CT scanning, unlike DPL or FAST, has the capability to determine the source of hemorrhage (see the image below). In addition, many retroperitoneal injuries go unnoticed with DPL and FAST examinations.

Blunt abdominal trauma with splenic injury and hemoperitoneum.

Transport only hemodynamically stable patients to the CT scanner. When performing CT scans, closely and carefully monitor vital signs for clinical evidence of decompensation. Preliminary evidence suggests that a flat vena cava on CT scan is a marker for underresuscitation and may be correlated with higher mortality and hemodynamic decompensation.[26] CT scans provide excellent imaging of the pancreas, duodenum, and genitourinary system. The images can help quantitate the amount of blood in the abdomen and can reveal individual organs with precision. The primary advantage of CT scanning is its high specificity and use for guiding nonoperative management of solid organ injuries. Drawbacks of CT scanning relate to the need to transport the patient from the trauma resuscitation area and the additional time required to perform CT scanning compared to FAST or DPL. In addition, CT scanning may miss injuries to the diaphragm and perforations of the gastrointestinal (GI) tract, especially when performed soon after the injury. Although some pancreatic injuries may be missed with a CT scan performed soon after trauma, virtually all are identified if the scan is repeated in 36-48 hours. For selected patients, endoscopic retrograde cholangiopancreatography (ERCP) may complement CT scanning to rule out a ductal injury. Finally, CT scanning is relatively expensive and time consuming and requires oral or intravenous (IV) contrast, which may cause adverse reactions. The best CT imagery requires both oral and IV contrast. Some controversy has arisen over the use of oral contrast and whether the additional information it provides negates the drawbacks of increased time to administration and risk of aspiration. The value of oral contrast in diagnosing bowel injury has been debated, but no definitive answer exists at this time.

Diagnostic Laparoscopy
The introduction of minimally invasive surgery has revolutionized many surgical diagnostic protocols. In the late 1980s and early 1990s, there was considerable interest in the use of laparoscopy for evaluation and management of blunt and penetrating abdominal trauma. Subsequent studies, however, revealed major limitations to this approach

and cautioned against its widespread use. The most important limitation is inability to reliably identify hollow viscus and retroperitoneal injuries, even in the hands of experienced laparoscopists. Diagnostic laparoscopy involves placing a subumbilical or subcostal trocar for the introduction of the laparoscope and creating other ports for retractors, clamps, and other tools necessary for visualization of the repair. Diagnostic laparoscopy has been most useful in the evaluation of possible diaphragmatic injuries, especially in penetrating thoracoabdominal injuries on the left side. [27, 28, 29] In blunt trauma, it has no clear advantages over less invasive modalities such as DPL and CT scanning; furthermore, complications can result from trocar misplacement.

Diagnostic Peritoneal Lavage

The idea of evaluating the abdomen by analyzing its contents was first used in the diagnosis of acute abdominal conditions. In 1906, Salomon described the passage of a urethral catheter by means of a trocar inserted through the abdominal wall to obtain samples of peritoneal fluid with the aim of establishing the diagnosis of peritonitis from infectious agents (eg, pneumococcal or tuberculous organisms). This technique has since been refined and is now known as abdominal paracentesis. In 1926, Neuhof and Cohen described the sampling of peritoneal fluid in cases of acute pancreatitis and blunt abdominal trauma by passing a spinal needle through the abdominal wall. [30] In 1965, Root et al reported the use of percutaneous DPL in patients who had sustained blunt abdominal trauma. [31] DPL is used as a method of rapidly determining the presence of intraperitoneal blood. It is particularly useful if the history and abdominal examination of an unstable patient with multisystem injuries are either unreliable (eg, because of head injury, alcohol, or drug intoxication) or equivocal (eg, because of lower rib fractures, pelvic fractures, or confounding clinical examination). DPL is also useful for patients in whom serial abdominal examinations cannot be performed (eg, those in an angiographic suite or operating room during emergency orthopedic or neurosurgical procedures). [32] DPL is indicated for the following patients in the setting of blunt trauma:

Patients with a spinal cord injury Those with multiple injuries and unexplained shock Obtunded patients with a possible abdominal injury Intoxicated patients in whom abdominal injury is suggested Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure The only absolute contraindication to DPL is the obvious need for laparotomy. Relative contraindications include morbid obesity, a history of multiple abdominal surgeries, and pregnancy. Various methods of introducing the catheter into the peritoneal space have been described. These include the open, semiopen, and closed methods. The open method requires an infraumbilical skin incision that is extended to and through the linea alba. (In pregnant patients or in patients with particular risk for potential pelvic hematoma, the incision should be placed superior to the umbilicus.) The peritoneum is opened, and the catheter is inserted under direct visualization. The semiopen method is identical, except that the peritoneum is not opened and the catheter is delivered percutaneously through the peritoneum into the peritoneal cavity. The closed technique requires the catheter to be inserted blindly through the skin, subcutaneous tissue, linea alba, and peritoneum. The closed and semiopen techniques at the infraumbilical site are preferred at most centers. The fully open method is the most technically demanding and is restricted to those situations in which the closed or semiopen technique is unsuccessful or is deemed unsafe (eg, patients with pelvic fractures, pregnancy, obesity, or prior abdominal operations). After insertion of the catheter into the peritoneum, attempt to aspirate free intraperitoneal blood (at least 15-20 mL). DPL results are considered positive in a blunt trauma patient if 10 mL of grossly bloody aspirate is obtained before infusion of the lavage fluid or if the siphoned lavage fluid contains more than 100,000 red blood cells (RBCs)/L, more than 500 white blood cells (WBCs)/L, elevated amylase content, bile, bacteria, vegetable matter, or urine. Only approximately 30 mL of blood is needed in the peritoneum to produce a microscopically positive DPL result. If findings are negative, infuse 1 L of crystalloid solution (eg, lactated Ringer solution) into the peritoneum. Then, allow this fluid to drain by gravity, and ensure that laboratory analysis is performed.

Complications of DPL include bleeding from the incision and catheter insertion, infection (ie, wound, peritoneal), and injury to intra-abdominal structures (eg, urinary bladder, small bowel, uterus). These complications may increase the possibility of false-positive studies. Additionally, infection of the incision, peritonitis from the catheter placement, laceration of the urinary bladder, or injury to other intra-abdominal organs can occur. Bleeding from the incision, dissection, or catheter insertion can cause false-positive results that may lead to unnecessary laparotomy. Achieve appropriate hemostasis prior to entering the peritoneum and placing the catheter. False-positive DPL results can occur if an infraumbilical approach is used in a patient with a pelvic fracture. A pelvic x-ray film should be obtained prior to performing DPL if a pelvic fracture is suggested. Before DPL is attempted, the urinary bladder and stomach should be decompressed. DPL has been shown in some studies to have a diagnostic accuracy of 98-100%, a sensitivity of 98-100%, and a specificity of 90-96%. It has some advantages, including high sensitivity, rapidity, and immediate interpretation. The main limitations of DPL include its potential for iatrogenic abdominal injury and its high sensitivity, which can lead to nontherapeutic laparotomies. With the availability of fast, noninvasive, and better imaging modalities (eg, FAST, CT scanning), the role of DPL is now limited to the evaluation of unstable trauma patients in whom FAST results are negative or inconclusive. In some contexts, DPL may be complemented with a CT scan if the patient has positive lavage results but stabilizes.