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abdominal
trauma
Last
updated:
Sep
15,
2016

Urgent considerations

See Differential diagnosis for more details

Haemorrhagic shock
The abdominal cavity is a large potential space for haemorrhage that offers little opportunity for a
tamponade effect to arise due to its tendency to distend. Abdominal vascular, splenic, and hepatic
injuries can rapidly result in haemodynamic instability and shock. Similarly, renal injuries can quickly
haemorrhage signicant volumes into the retroperitoneal space. It is therefore critical that initial
evaluation and management are carried out in a timely manner.

Haemorrhagic shock is a condition of reduced perfusion with inadequate oxygen delivery caused by
acute blood loss. It may present with hypotension; tachycardia; oliguria; tachypnoea; diminished or
absent pulses; altered sensorium; and pale, cold, clammy skin. Urgent consult with a surgeon and
anaesthetist is advisable. Patients in haemorrhagic shock require aggressive uid resuscitation, blood
transfusions, and control of the haemorrhage. Patients who are haemodynamically unstable or who have
diffuse abdominal tenderness after penetrating abdominal trauma should be taken urgently for
laparotomy. [8] European guidelines recommend that patients presenting with haemorrhagic shock and
an identied source of bleeding undergo an immediate bleeding control procedure unless initial
resuscitation measures are successful. [9] Patients with gunshot wounds, major stab wounds, or shrapnel
wounds are examples of patients who typically fall into this category. A type and screen should be drawn
and multiple units of packed red blood cells (PRBCs) prepared in anticipation of a transfusion.

Patients with profound haemorrhagic shock, suggested by extreme hypotension and a severely reduced
mental status (i.e., coma), require an immediate un-crossmatched blood transfusion. Pressure delivery
and blood-warming devices can be helpful in situations of profound haemorrhage. With large-volume
transfusions, coagulation may be affected and this needs to be monitored and treated with fresh frozen
plasma and platelets as necessary. These patients require at least 2 functioning large-bore peripheral
intravenous lines for uid administration and a Foley's catheter to allow accurate monitoring of urine
output. If peripheral lines are dicult to place, a short, large-calibre femoral or subclavian central line is
recommended. Long double- or triple-lumen central lines should be avoided as uid cannot be infused
rapidly through these catheters.

A 2009 study has shown that aggressive transfusion of PRBCs, freshly frozen plasma, and platelets
improves the outcome in haemodynamically unstable trauma patients. [10] Delays in the amount of time
prior to laparotomy in an abdominal trauma patient with intra-abdominal bleeding increase morbidity
and mortality. [11] Serum lactate and base-decit calculated from arterial blood gas measurement are
recommended as sensitive tests to estimate and monitor the extent of bleeding and shock. [9]

Guidelines recommend that patients presenting with haemorrhagic shock and an unidentied source of
bleeding (as may occur with blunt trauma) undergo immediate further assessment by a focused
assessment by sonography in trauma (FAST) examination. [12] This test is useful to quickly diagnose
intra-abdominal haemorrhage. [13] [14] The FAST examination uses a bedside ultrasound to provide
images of the RUQ, LUQ, and pelvis to assess for intra-abdominal haemorrhage. A systematic review
found the FAST examination to have a sensitivity of 82% and a specicity of 99% to detect an intra-
abdominal injury. [15] If a FAST examination is unavailable or unreliable, a diagnostic peritoneal lavage
(DPL) may be performed to assess for intraperitoneal bleeding. [16] DPL involves making a small midline
incision below the umbilicus and using a needle and small catheter to aspirate intraperitoneal uid to
assess for blood or bile. If the aspirate is found to contain 10 mL of gross blood or bile, an exploratory
laparotomy is indicated. In the absence of gross blood or bile, DPL requires 1 litre of uid to be infused
into the peritoneum and then drained. The euent should be sent to the laboratory and evaluated.
Laboratory criteria for a positive DPL are:

>1.0 10^12 red blood cells/L (>100,000 red blood cells/mm^3)

>0.50 10^9 white blood cells/L (>500 white blood cells/mm^3)

Presence of bacteria, bile, or food particles.

Patients found to have signicant free intra-abdominal uid according to FAST examination (or DPL) and
haemodynamic instability are recommended to undergo urgent surgery. If patients are
haemodynamically stable, some authors have suggested that patients should undergo multi-slice spiral
CT scanning. [9]

The Eastern Association for the Surgery of Trauma (EAST) makes the following recommendations with
regard to managing penetrating abdominal trauma. [8]

Patients who are haemodynamically unstable or who have diffuse abdominal tenderness after
penetrating abdominal trauma should be taken urgently for laparotomy.

Patients who are haemodynaically stable but with an unreliable clinical examination (severe head
injury, spinal cord injury, severe intoxication, or need for sedation or anaesthesia) should have
further diagnostic investigation performed for intraperitoneal injury or undergo exploratory
 laparotomy.

Routine laparotomy is not indicated in haemodynamically stable patients with: abdominal stab
wounds but without signs of peritonitis or diffuse abdominal tenderness (away from the wounding
site) in centres with surgical expertise; abdominal gunshot wounds if the wounds are tangential
and there are no peritoneal signs.

Serial physical examination is reliable in detecting signicant injuries after penetrating trauma to
the abdomen, if performed by experienced clinicians and preferably by the same team.

Patients selected for initial non-operative management should be strongly considered for
abdominopelvic CT to facilitate initial management decisions.

Patients with penetrating injury isolated to the right upper quadrant may be managed without
laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal
tenderness.

The majority of patients with penetrating abdominal trauma managed non-operatively may be
discharged after 24 hours of observation in the presence of a reliable abdominal examination and
minimal or no abdominal tenderness.

Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and

peritoneal penetration.

Missed or delayed diagnosis of intra-abdominal organ injury

Injuries to the spleen, liver, and abdominal vasculature

Signicant intra-abdominal haemorrhage and haemodynamic instability may result from

abdominal vascular, splenic, and hepatic injuries. Thus, if these injuries are missed, the patient may
suffer the consequences of haemorrhagic shock and uncontrolled intra-abdominal bleeding. A
focused assessment with sonography in trauma (FAST) examination and abdominal CT scan with
contrast have important roles in diagnosing these injuries and should be initiated promptly when
these injuries are suspected.

Pancreatic injury

Diagnosis of pancreatic injuries is notoriously dicult due to the retroperitoneal location of the
pancreas, resulting in delay in the development of signs and symptoms. Vague abdominal pain
radiating to the back and abdominal tenderness usually do not appear until some hours after the
traumatic event. An abdominal CT scan is key to making the diagnosis, as serum amylase and
serum lipase may be normal early in the course of the injury and only later become elevated.

Diaphragmatic injury

Missed diaphragmatic injuries are associated with signicant morbidity from herniation and
strangulation of abdominal viscera. There is a high incidence of diaphragmatic injury in thoraco-
abdominal penetrating trauma and blunt abdominal trauma. The patient may complain of chest
pain, abdominal pain, or shortness of breath. There may be haemodynamic instability when the
patient lies supine. Typically, there are diminished breath sounds on the affected side, with bowel
sounds audible over what would normally be the lung elds. Thoraco-abdominal CT is good for
diagnosing diaphragmatic injuries related to blunt trauma, but laparoscopy is better for detecting
diaphragmatic injuries relating to penetrating trauma.

Stomach and small bowel injuries

 Signicant morbidity and mortality accompany a missed or delayed diagnosis of small bowel injury.
With small bowel injury, patients often do not have signs of peritonitis in the early period and the
injury may be missed in the context of blunt abdominal trauma where a small bowel injury is not
suspected, or when a stab wound to the anterior abdomen is misdiagnosed as not having
penetrated the posterior abdominal fascia. Stomach injury often results in a rapid onset of burning
epigastric pain, followed by rigidity and rebound sensitivity. Classically, free air under the
diaphragm is seen on erect chest x-ray with perforation of a hollow viscus, although this is not
always seen and diagnosis may also require abdominal CT and DPL, along with careful evaluation of
the clinical and laboratory ndings.

Mesenteric injury

There is a high rate of delayed diagnosis of mesenteric injury after blunt abdominal trauma, as
patients may be initially asymptomatic and CT scanning has a high false-negative rate. Delayed
diagnosis can result in bowel ischaemia. Maintaining a high level of clinical suspicion, along with
FAST examination and abdominal CT, is important in ensuring that the diagnosis is not missed.

Red ags

Splenic injury
Hepatic injury
Renal injury
Small bowel injury
Pancreatic injury
Diaphragmatic injury
Stomach injury
Colorectal injury
Mesenteric injury
Bladder injury
Abdominal vascular injury

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