Author:
Frances E.Rudolf
Allyson A.Kreshak
Description
- Injury results from a sudden increase of pressure to abdomen
- Solid organ injury usually manifests as hemorrhage
- Hollow viscus injuries result in bleeding and peritonitis from contamination with bowel contents
Etiology
- Motor vehicle collisions are the greatest cause of blunt abdominal trauma
- Solid organs are injured more frequently than hollow viscus organs
- The liver and spleen are the most frequently injured organs, followed by the intestines and retroperitoneal structures
- Less frequently injured are the mesentery, pancreas, diaphragm, urinary bladder, urethra, and vascular structures
Pediatric Considerations |
- Children can lose large amounts of intra-abdominal blood quickly due to smaller blood volumes
- Owing to the smaller size of the intrathoracic abdomen, the spleen and liver are more exposed to injury because they lie partially outside the boney rib cage
- Unrecognized pediatric abdominal trauma is a significant contributor to mortality among traumatic injuries in children
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Signs and Symptoms
- Patients present with a spectrum of symptoms from abdominal pain, signs of peritoneal irritation to hypovolemic shock
- Nausea or vomiting
- Labored respiration can be present 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
- Associated injuries (fractures, abdominal wall injuries) may mimic abdominal injuries
- Abrasions or ecchymosis may be indicators of intra-abdominal injury:
- Lap-belt abrasions can be indicative of significant intra-abdominal injuries
- Flank and periumbilical bruising can represent retroperitoneal hemorrhage (late finding)
- Bowel sounds may be absent from peritoneal irritation (late finding)
Essential Workup
- Evaluate and stabilize airway, breathing, and circulation
- Primary objective is to determine need for operative intervention
- Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation, but the examination is limited in detecting intraperitoneal blood
- Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation
- The limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference
- Rectal exam should be done to assess for boney trauma or blood
- Insert Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
- CT is most useful in assessing the need for operative intervention and for evaluating the retroperitoneal space and solid organs
- There are few indications for diagnostic peritoneal lavage in a hemodynamically stable patient when CT is readily available
- CXR can aid in detection of pneumoperitoneum or ruptured diaphragm
- Pelvis radiograph:
- Fracture of the pelvis and gross hematuria may indicate genitourinary injury
- Further evaluation of these structures with retrograde urethrogram or cystogram
- Focused abdominal sonography for trauma (FAST) to detect free intraperitoneal fluid:
- Ultrasound is rapid, requires no contrast agents, and is noninvasive
- Operator dependent
- Does not exclude intra-abdominal injury
Diagnostic Tests & Interpretation
Lab
- Check hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
- Check coagulation markers (platelets, prothrombin, and partial thromboplastin time). Effects of some anticoagulants may not be accurately reflected in lab values
- Type and screen is essential. Cross-match packed red blood cell units for unstable patients
- Urinalysis for blood:
- Microscopic hematuria in the presence of shock should prompt genitourinary evaluation
- Pregnancy test for females of child-bearing age
- Ethanol concentration
- Arterial blood gas:
- Base deficit may suggest hypovolemic shock and help guide the resuscitation
Differential Diagnosis
- Lower thoracic injury may cause abdominal pain
- Fractures (rib, pelvis) may cause abdominal pain
Prehospital
- Titrate fluid resuscitation to clinical response. Target SBP of 90-100 mm Hg
- Normal vital signs do not preclude significant intra-abdominal pathology
Initial Stabilization/Therapy
- Ensure adequate airway:
- Intubate if needed
- O2 100% by nonrebreather face mask
- 2 large-bore IV lines with crystalloid infusion
- Begin infusion of packed red blood cells if no hemodynamic response to 1 L of crystalloid
- If patient is in profound shock, consider immediate transfusion of O-negative blood
- Consider TXA for hemorrhage
- Surgical intervention with laparotomy by a qualified surgeon is indicated for uncontrolled shock, findings of hemoperitoneum, clinical signs of peritonitis, or clinical deterioration during observation
ED Treatment/Procedures
- See Essential Workup
- 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
Medication
- 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
- Intravenous broad-spectrum antibiotics should be administered when laparotomy is indicated
- Correct coagulopathy when clinically indicated
- Administered analgesia when needed. Avoid nonsteroidal anti-inflammatory drugs due to risk of bleeding
Pediatric Considerations |
- Initial volume resuscitation consists of a 20 mL/kg crystalloid fluid bolus (can be repeated)
- If abnormal hemodynamics persist, administer 10 mL/kg PRBC
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