Rosen & Barkin's 5-Minute Emergency Medicine Consult (17 page)

• Spectrum from abdominal pain, signs of peritoneal irritation to hypovolemic shock
  
• Nausea or vomiting
  
• Labored respiration from diaphragm irritation or upper abdominal injury
  
• Left shoulder pain with inspiration (Kehr sign) from diaphragmatic irritation owing to bleeding
  
• Delayed presentation possible with small-bowel injury
  

• Evaluate and stabilize airway, breathing, and circulation (ABCs).
  
• Primary objective is to determine need for operative intervention.
  
• Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation.
  
• Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation.
  
• Remember that the limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference.
  
• Abrasions or ecchymoses may be indicators of intra-abdominal injury:
  
  • Roll the patient to assess the back.
    
  • Lap-belt abrasions can be indicative of significant intra-abdominal injuries.
    
• Bowel sounds may be absent from peritoneal irritation (late finding).
  
• Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
  
• Plain film of the pelvis:
  
  • Fracture of the pelvis and gross hematuria may indicate genitourinary injury.
    
  • Further evaluation of these structures with retrograde urethrogram, cystogram, or IV pyelogram
    
• CT most useful in assessing need for operative intervention and for evaluating the retroperitoneal space and solid organs:
  
  • Patient must be stable enough to make trip to scanner.
    
  • Also useful for suspected renal injury
    
• Focused abdominal sonography for trauma (FAST) to detect intraperitoneal fluid:
  
  • US is rapid, requires no contrast agents, and is noninvasive.
    
  • Operator dependent
    
• Diagnostic peritoneal lavage (useful for revealing injuries in the intrathoracic abdomen, pelvic abdomen, and true abdomen) primarily indicated for unstable patients:
  
  • Positive with gross blood, RBC count of >100,000/mm
    ³
    , WBC count of 500/mm
    ³
    , or presence of bile, feces, or food particles
    

• Hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
  
• Type and screen is essential. Cross-match PRBC units for unstable patients.
  
• Urinalysis for blood:
  
  • Microscopic hematuria in the presence of shock is an indication for genitourinary evaluation.
    
• ABG:
  
  • Base deficit may suggest hypovolemic shock and help guide the resuscitation.
    

See “Essential Workup.”

See “Essential Workup”

Lower thoracic injury may cause abdominal pain.

TREATMENT

• Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg
  
• Normal vital signs do not preclude significant intra-abdominal pathology.
  

• Ensure adequate airway:
  
  • Intubate if needed.
    
  • O
    ₂
    100% by nonrebreather face mask
    
• 2 large-bore IV lines with crystalloid infusion
  
• Begin infusion of PRBCs if no response to 2 L of crystalloid.
  
• If patient is in profound shock, consider immediate transfusion of O-negative blood.
  

• Continue stabilization begun in field.
  
• Nasogastric tube to evacuate stomach, decrease distention, and decrease risk of aspiration:
  
  • May relieve respiratory distress if caused by a herniated stomach through the diaphragm
    

• Tetanus toxoid booster: 0.5 mL IM for patients with open wounds
  
• Tetanus immunoglobulin: 250 U IM for patients who have not had complete series
  
• IV antibiotics: Broad-spectrum aerobic with anaerobic coverage such as a 2nd-generation cephalosporin
  

• Crystalloid infusion is 20 mL/kg if patient is in shock.
  
• PRBC dose is 1 mL/kg.
  

FOLLOW-UP

• Postoperative cases
  
• Equivocal findings on diagnostic peritoneal lavage, FAST exam, or CT
  
• Many blunt abdominal trauma patients benefit from admission, monitoring, and serial abdominal exams.
  

No patient in whom you suspect intra-abdominal injury should be discharged home without an appropriate period of observation, despite negative exam or imaging studies.

• Do not delay blood products when patient is in obvious shock despite normal Hct.
  
• Avoid overaggressive resuscitation with crystalloids.
  
• Obtain a pregnancy test in all females of childbearing age.
  
• Do not transport unstable patients to CT for diagnostic imaging.
  

• Amoroso TA. Evaluation of the patient with blunt abdominal trauma: An evidence based approach.
  Emerg Med Clin North Am
  . 1999;17:63–75.
  
• Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries.
  Ann Emerg Med
  . 2004;43(1):120–128.
  
• Kendall JL, Faragher J, Hewitt GJ, et al. Emergency department ultrasound is not a sensitive detector of solid organ injury.
  West J Emerg Med
  . 2009;10(1):1–5.
  
• Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma.
  Br J Surg
  . 2001;88:901–912.
  

CODES

• 459.0 Hemorrhage, unspecified
  
• 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
  
• 868.00 Injury to other intra-abdominal organs without mention of open wound into cavity, unspecified intra-abdominal organ
  

BASICS

Diagnostic procedures: Use of these imaging and procedure modalities will be based on history and physical exam.

DIAGNOSIS

• Abdominal trauma can be seen in a variety of patients ranging from those with isolated abdominal injury to multisystem trauma.
  
• Abdominal trauma is divided into blunt and penetrating injuries. Penetrating abdominal injuries can further be divided into stab wounds and gunshot wounds.
  
• Hemodynamic status should be the primary initial focus of evaluation. Most unstable patients will require early surgical management, while many stable patients with abdominal trauma may be managed nonoperatively.
  

• History should include mechanism of injury, restraint use and type, airbag or helmet use, prehospital vital signs, initial mental status, and change in mental status.
  
• AMPLE history (
  a
  llergies-to-medications and radiographic contrast agents,
  m
  edications taken,
  p
  ast medical and surgical history,
  l
  ast meal,
  e
  vents leading up to the injury)
  

• A comprehensive physical exam should start with ABCDE survey and include full exposure of the patient and careful palpation of all abdominal quadrants.
  
• Abdominal injury in only 45–50% of cases.
  
• The abdominal physical exam is frequently misleading in intoxicated, uncooperative, and multisystem trauma patients.
  

• See “Abdominal Trauma (Blunt)” and “Abdominal Trauma (Penetrating).”
  
• All trauma patients initially managed with:
  
  • ABCDE survey (Airway, Breathing, Circulation, Disability, Exposure)