Abdominal Trauma

Abdominal trauma accounts for approximately 15% to 20% of all trauma-related deaths. Intra-abdominal trauma is usually not a single organ system injury; as more organs are injured, the risks of organ dysfunction and death climb. The abdominal cavity contains solid, gas-filled, fluid-filled, and encapsulated organs. These organs are at greater risk for injury than other organs of the body because they have few bony structures to protect them. Although the last five ribs serve as some protection, if they are fractured, the sharp-edged bony fragments can cause further organ damage from lacerations or organ penetration (Table 1).

Table 1 Injuries to the Abdomen

ORGAN OR TISSUE	COMMON INJURIES	SYMPTOMS
Diaphragm	Partially protected by bony structures, the diaphragm is most commonly injured by penetrating trauma (particularly gunshot wounds to the lower chest) Automobile deceleration may lead to rapid rise in intra-abdominal pressure and a burst injury Diaphragmatic tear usually indicates multi-organ involvement	Decreased breath sounds Abdominal peristalsis heard in thorax Acute chest pain and shortness of breath may indicate diaphragmatic tear May be hard to diagnose because of multisystem trauma, or the liver may “plug” the defect and mask it
Esophagus	Penetrating injury is more common than blunt injury May be caused by knives, bullets, foreign body obstruction, usually in the upper esophagus May be caused by iatrogenic perforation May be associated with cervical spine injury	Pain at site of perforation Fever Difficulty swallowing Cervical tenderness Peritoneal irritation
Stomach	Penetrating injury is more common than blunt injury; in one-third of patients, both the anterior and the posterior walls are penetrated May occur as a complication from cardiopulmonary resuscitation or from gastric dilation	Epigastric pain Epigastric tenderness Signs of peritonitis Bloody gastric drainage
Liver	Most commonly injured organ (both blunt and penetrating injuries); blunt injuries (70% of total) usually occur from motor vehicle crashes and steering wheel trauma Highest mortality from blunt injury (more common in suburban areas) and gunshot wound (more common in urban areas) Hemorrhage is most common cause of death from liver injury; overall mortality 10%–15%	Persistent hypotension despite adequate fluid resuscitation Guarding over right upper or lower quadrant; rebound abdominal tenderness Dullness to percussion Abdominal distention and peritoneal irritation Persistent thoracic bleeding
Spleen	Commonly injured organ with blunt abdominal trauma, often in motor vehicle crashes; most common organ injured during sports Injured in penetrating trauma of the left upper quadrant	Hypotension, tachycardia, shortness of breath Peritoneal irritation Abdominal wall tenderness Left upper quadrant pain; pain may radiate to left shoulder Fixed dullness to percussion in left flank; dullness to percussion in right flank that disappears with change of position
Pancreas	Most often penetrating injury (gunshot wounds at close range) Blunt injury from deceleration; injury from steering wheel Often associated (40%) with other organ damage (liver, spleen, vessels)	Pain over pancreas Paralytic ileus Symptoms may occur late (after 24 hr); epigastric pain radiating to back; nausea, vomiting Tenderness to deep palpation
Small intestines	Duodenum, ileum, and jejunum; hollow viscous structure most often injured by penetrating trauma Gunshot wounds account for 70% of cases Incidence of injury is third only to liver and spleen injury When small bowel ruptures from blunt injury, rupture occurs most often at proximal jejunum and terminal ileum	Testicular pain Referred pain to shoulders, chest, back Mild abdominal pain Peritoneal irritation Fever, jaundice, intestinal obstruction
Large intestines	One of the more lethal injuries because of fecal contamination; occurs in 5% of abdominal injuries More than 90% of incidences are penetrating injuries Blunt injuries are often from safety restraints in motor vehicle crashes	Pain, muscle rigidity Guarding, rebound tenderness Blood on rectal examination Fever

Abdominal trauma can be blunt or penetrating. Blunt injuries occur when there is no break in the skin; they often occur as multiple injuries. In blunt injuries, the spleen and liver are the most commonly injured organs. Injury occurs from concussive and compressive forces that cause tears and hematomas to the solid organs, such as the liver, and from deceleration forces. These forces can also cause hollow organs such as the small intestines to deform; if the intraluminal pressure of hollow organs increases as they deform, the organ may rupture. Deceleration forces, such as those that occur from a sudden stop in a car or truck, may also cause stretching and tears along ligaments that support or connect organs, resulting in bleeding and organ damage. Examples of deceleration injuries include hepatic tears along the ligamentum teres (round ligament that is the fibrous remnant of the left umbilical vein of the fetus, originates at the umbilicus, and may attach to the inferior margin of the liver), damage to the renal artery intima, and mesenteric tears of the bowel.

Penetrating injuries are those associated with foreign bodies (knives, bullets) set into motion. The foreign object penetrates the abdominal cavity and dissipates energy into the organ(s) and surrounding areas. The abdominal organs and structures most commonly involved with penetrating trauma include the small bowel, colon, liver, diaphragm, and abdominal vascular structures. The most common cause of mortality in the first 24 hours is hemorrhagic shock. Complications following abdominal trauma include profuse bleeding from aortic dissection or other vascular structures, hemorrhagic shock, peritonitis, abscess formation, septic shock, paralytic ileus, ischemic bowel syndrome, acute renal failure, liver failure, adult respiratory distress syndrome, disseminated intravascular coagulation, and death.

Causes ⬆ ⬇

More than half of the cases of blunt abdominal trauma are caused by motor vehicle crashes (MVCs) and auto-pedestrian collisions. These injuries are often associated with head and chest injuries as well. Other causes of blunt injury include falls, aggravated assaults, and contact sports. Penetrating injuries can occur from gunshot wounds (64% of total), stab wounds (31% of total), shotgun wounds (5% of total), and impalements (< 1% of total).

Genetic Considerations ⬆ ⬇

No clear genetic contributions to susceptibility have been defined.

Sex and Life Span Considerations ⬆ ⬇

Traumatic injuries, which are usually preventable, are the leading cause of death in the first four decades of life. Most blunt abdominal trauma is associated with MVCs, which are two to three times more common in males than in females in the 15- to 24-year-old age group. Penetrating injuries from gunshot wounds and stab wounds, which are on the increase in U.S. preteens, teens, and young adults, are more common in males than females. Men have different patterns of injury than women and a higher injury severity. Analysis of trauma outcomes indicates that, following traumatic injury, males have higher rates of multiple organ failure, pneumonia, and sepsis than females, creating health disparities for men (Marcolini, 2019). Trauma is the third leading cause of death in people 45 to 65 years old and the seventh leading cause of death in people older than 65 years.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

In recent years, Black persons have been killed in traffic crashes at a rate almost 25% higher than White persons (National Highway Traffic Safety Administration [NHTSA, 2021]). Native American persons have the highest rate of MVC injury in the United States, more than twice the rate of Black persons (NHTSA, 2021). Experts have noted that Black and Native American communities tend to be crisscrossed by more dangerous roads than other locations, placing people from those communities at risk for injury. Penetrating injuries from gunshot wounds and stab wounds are more common in non-Hispanic Black persons than in non-Hispanic White persons. Non-Hispanic Black males have adjusted firearm death rates from two to seven times higher than males of other groups. Healthy People 2020 reports that non-Hispanic Black persons have the highest injury death rate in the United States (79.9 injury deaths per 100,000 persons), followed by non-Hispanic White persons (79.2), Native American persons (78.2), Hispanic persons (45.5), and Asian/Pacific Islander persons (25.6). Recent work has shown evidence that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the risk of traffic injury on narrow rural roads, the lack of graded curves and lighted traffic signals on rural highways, and the distance from major trauma centers. Many of the most dangerous occupations, such as mining and agriculture, are found in rural areas and can result in injury, disability, and death. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury (National Center for Health Statistics, 2021).

Global Health Considerations ⬆ ⬇

According to the World Health Organization (WHO), falls from heights of less than 5 meters are the leading cause of injury globally, but estimates are that only 6% of those are related to abdominal trauma. WHO estimates that 1.35 million people die each year from MVCs and cost most countries 3% of their gross domestic product. Globally, more than half of all traffic injuries are among vulnerable road users such as pedestrians, cyclists, and motorcyclists. More than 90% of the world's fatalities in traffic injuries occur in low- and middle-income countries. Even in high-income countries, people from lower socioeconomic backgrounds are more likely to be involved in road traffic crashes than other groups. Sub-Saharan Africa has the highest death rate from traumatic injuries in the world. Rates of firearm injury vary widely around the world, with low rates in Japan and high rates in the United States. Penetrating injury rates depend on industrialization, weapon availability, and the degree of military conflict.

Assessment ⬆ ⬇

ASSESSMENT

History

For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. SAMPLE is a useful mnemonic in trauma assessment: Signs and symptoms, Allergies, Medications, Past medical history, Last meal, and Events or environment leading to presentation. Information regarding the type of trauma (blunt or penetrating) is helpful. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient was restrained, the patient's position in the vehicle, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a helmet. In cases of traumatic injuries from falls, determine the point of impact, the distance of the fall, and the type of landing surface. If the patient has been shot, ask the paramedics or police for ballistics information, including the caliber of the weapon and the range at which the person was shot.

Physical Examination

The patient's appearance may range from anxious but stable to critically injured with full cardiopulmonary arrest. If the patient is hemorrhaging from a critical abdominal injury, they may be profoundly hypotensive with the symptoms of hypovolemic shock (see Hypovolemic/Hemorrhagic Shock, p. 653). The initial evaluation or primary survey of the trauma patient is centered on assessing the Airway, Breathing, Circulation, Disability (neurological status), and Exposure (by completely undressing the patient to check all body surfaces for wounds), known as the ABCDEs of trauma care. The primary survey provides an initial general impression to determine the seriousness of the patient's condition. Life-saving interventions may accompany assessments made during the primary survey in the presence of life- and limb-threatening injuries. The primary survey is followed by a secondary survey, a thorough head-to-toe assessment of all organ systems with a focused history and physical examination. The assessment of the injured patient should be systematic, constant, and include reevaluation. Serial assessments are critical because large amounts of blood can accumulate in the peritoneal or pelvic cavities without early changes in the physical examination. Once the patient is stable, a tertiary survey (complete repetition of the primary and secondary surveys) is completed to determine any injuries that might have been missed during the primary and secondary surveys.

The most common signs and symptoms are pain, abdominal tenderness, and gastrointestinal hemorrhage in the alert patient. When you inspect the patient's abdomen, note any disruption from the normal appearance, such as distention, lacerations, ecchymoses, and penetrating wounds. Inspect for any signs of obvious bleeding, such as ecchymoses around the umbilicus (Cullen sign) or over the left upper quadrant, which may occur with a ruptured spleen (although these signs usually take several hours to develop). Note that Grey Turner sign, bruising of the flank area, may indicate retroperitoneal bleeding. Inspect the perineum for accompanying urinary tract injuries that may lead to bleeding from the urinary meatus, vagina, and rectum. If the patient is obviously pregnant, determine the fetal age, and monitor the patient for premature labor.

Auscultate all four abdominal quadrants for 2 minutes per quadrant to determine the presence of bowel sounds. Although the absence of bowel sounds can indicate underlying bleeding, their absence does not always indicate injury. Bowel sounds heard in the chest cavity may indicate a tear in the diaphragm. Trauma to the large abdominal blood vessels may lead to a friction rub or bruit. Bradycardia may indicate the presence of free intraperitoneal blood. Percussion of the abdomen identifies air, fluid, or tissue intra-abdominally. Air-filled spaces produce tympanic sounds as heard over the stomach. Abnormal hyperresonance can indicate free air; abnormal dullness may indicate bleeding. When you palpate the abdomen and flanks, note any increase in tenderness, which can be indicative of an underlying injury. Note any masses, rigidity, pain, and guarding. Kehr sign—radiating pain to the left shoulder when you palpate the left upper quadrant—is associated with injury to the spleen. Palpate the pelvis for injury.

Psychosocial

Changes in lifestyle may be required depending on the type of injury. Large incisions and scars may be present. If injury to the colon has occurred, a colostomy, whether temporary or permanent, alters the patient's body image and lifestyle. The sudden alteration in comfort, potential body image changes, and possible impaired functioning of vital organ systems can often be overwhelming and lead to maladaptive coping. Physical injury can lead to long-standing psychological trauma, posttraumatic stress disorder, and depression. Injuries that occur in the home, particularly in children, pregnant women, or older patients, may be the result of neglect, abuse, or violence. Providers are responsible for inquiring about possible neglect, abuse, or violence, which may have mandatory reporting requirements. If alcohol or other drugs of abuse were involved in the injury, determine if assessment and follow-up are needed.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Contrast-enhanced computed tomography (CT) scan	Normal and intact abdominal structures	Injured or ruptured organs; accumulation of blood or air in the peritoneum, in the retroperitoneum, or above the diaphragm	Provides detailed pictures of the intra-abdominal and retroperitoneal structures, the presence of bleeding, hematoma formation, abdominal fluid accumulation, and the grade of injury
Focused abdominal sonogram for trauma (FAST); four acoustic windows (pericardiac, perihepatic, perisplenic, pelvic)	No fluid seen in four acoustic windows	Positive scan shows accumulation of blood or free fluid in the peritoneum	Provides rapid evaluation of hemoperitoneum; experts consider FAST's accuracy equal to that of diagnostic peritoneal lavage (DPL) (see below) (high specificity) to identify fluid accumulation, but negative FAST results cannot be relied on to rule out intraperitoneal injury (low sensitivity)
DPL; indicated in spinal cord injury, multiple injuries with unexplained shock, intoxicated or unresponsive patients with possible abdominal injury; in many institutions, DPL has been replaced by FAST and/or CT	Negative lavage without presence of excessive bleeding or bilious or fecal material	Direct aspiration of 15–20 mL of blood, bile, or fecal material from a peritoneal catheter; following lavage with 1 L of normal saline, the presence of 100,000/mm³red cells or 100–500/mm³ white cells is a positive lavage; this is 90% sensitive for detecting intra-abdominal hemorrhage	Determines presence of intra-abdominal hemorrhage or rupture of hollow organs; contraindicated when there are existing indications for laparotomy

Other Tests: Complete blood count; coagulation profile; blood type, screen, and crossmatch; serum drug and alcohol screens; serum chemistries; serum glucose; serum amylase; serum lipase; abdominal, chest, and cervical spine radiographs; urinalysis and excretory urograms; arteriography; magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct injuries.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective breathing pattern related to pain and abdominal distension as evidenced by tachypnea, altered chest excursion, decreased vital capacity, hypoxemia, and/or hypoventilation

Outcomes

OutcomesRespiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control; Treatment behavior: Illness or injury; Pain control; Comfort status: Physical

Interventions

InterventionsAirway management; Anxiety reduction; Oxygen therapy; Airway insertion and stabilization; Pain management: Acute; Mechanical ventilation: Pneumonia prevention; Positioning; Respiratory monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The initial care of the patient with abdominal trauma follows the ABCDEs of trauma care. Measures to ensure adequate oxygenation and tissue perfusion include the establishment of an effective airway and a supplemental oxygen source, support of breathing, control of the source of blood loss, and replacement of intravascular volume. Titrate IV fluids to maintain a systolic blood pressure of 100 mm Hg; overaggressive fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

Surgical

The focus is on four broad components of care: control of bleeding, identification of injuries, control of contamination, and reconstruction of the injured area. Generally, a laparotomy is performed for signs of peritonitis, rapid clinical deterioration, uncontrolled shock or hemorrhage, or positive findings on the FAST or DPL. Damage control surgery, or damage control laparotomy, is an abbreviated laparotomy that occurs after control of bleeding or hemorrhage. Techniques include intra-abdominal packing or leaving the abdominal fascia open after the surgery. Definitive surgical repair with reconstruction of the abdomen occurs 24 to 48 hours after injury. Some patients may have their intra-abdominal pressure monitored after surgery to prevent abdominal compartment syndrome.

Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years. Esophageal and gastric injury are often managed with gastric decompression with a nasogastric tube, antibiotic therapy, and surgical repair of the esophageal tear. Liver injury may be managed nonoperatively or operatively, depending on the degree of injury and the amount of bleeding. Patients with liver injury are apt to experience problems with albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation, resistance to infection, and nutritional balance. Management of injuries to the spleen depends on the patient's age, stability, associated injuries, and type of splenic injury. Because removal of the spleen places the patient at risk for immune compromise, splenectomy is the treatment of choice only when the spleen is totally separated from the blood supply, when the patient is markedly hemodynamically unstable, or when the spleen is totally macerated. Treatment of pancreatic injury depends on the degree of pancreatic damage, but drainage of the area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage from pancreatic enzymes. Small and large bowel perforation or lacerations are managed by surgical exploration and repair. Preoperative and postoperative antibiotics are administered to prevent sepsis, and the patient may need to be rewarmed if hypothermia occurs.

Nutritional

Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to eliminate gastrointestinal feedings for extended periods of time depending on the injury and the surgical intervention required. Total parenteral nutrition may be used to provide nutritional requirements.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Histamine-2 blockers	Varies with drug	Ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid)	Block gastric secretion and maintain pH of gastric contents above 4, thereby decreasing inflammation
Antibiotics	Varies with drug	Cefotetan (Cefotan) or combined therapy, often an aminoglycoside (gentamicin, tobramycin) and clindamycin (Cleocin) or metronidazole (Flagyl)	Prophylaxis to prevent infection after penetrating trauma; treatment of bacterial infection

Other Therapies: Narcotic analgesia to manage pain and limit atelectasis and pneumonia; morphine sulfate and fentanyl are the drugs of choice; axiolytics such as lorazepam reduce anxiety; generally a tetanus toxoid booster is administered.

Independent

The most important priority is the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. Be prepared to assist with endotracheal intubation and mechanical ventilation by maintaining an intubation tray within immediate reach at all times. Maintain a working endotracheal suction at the bedside as well. If the patient is hemodynamically stable, position the patient for full lung expansion, usually in the semi-Fowler position with the arms elevated on pillows. If the cervical spine is at risk after an injury, maintain the body alignment and prevent flexion and extension by using a cervical collar or other strategy as dictated by trauma service protocol.

The nurse is the key to providing adequate pain control. Encourage the patient to describe and rate the pain on a scale of 1 through 10 to help you evaluate whether the pain is being controlled successfully. Consider using nonpharmacologic strategies, such as diversionary activities or massage, to manage pain as an adjunct to analgesia.

Emotional support of the patient and family is also a key nursing intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the ABCs, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives and keep them updated as to the patient's response to therapy. Notify the physician if the family needs to speak to the physician about the patient's progress. If blood component therapy is essential to manage bleeding, answer the patient's and family's questions about the risks of hepatitis and HIV transmission.

Evidence-Based Practice and Health Policy

Hanna, K., Asmar, S., Ditillo, M., Chehab, M., Khurrum, M., Bible, L., Douglas, M., & Joseph, B. (2021). Readmission with major abdominal complications after penetrating abdominal trauma. Journal of Surgical Research, 257, 69–78.

Major abdominal complications are a frequent occurrence following surgical treatment for penetrating abdominal trauma. The authors proposed to study all patients who had an exploratory laparotomy and were readmitted within 6 months of the injury to determine complication rates.
They studied 4,473 patients with a mean age of 32 years. The rate of major abdominal complications within 6 months was 22%. Further analysis predicted that complications were most often associated with firearm injuries, damage control laparotomy, large bowel perforation, biliary-pancreatic injury, hepatic injury, and blood transfusion.
Firearm injuries have a higher potential than other injuries to lead to major abdominal complications, particularly after damage control laparotomy.

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DRG Information ⬇

Introduction ⬆ ⬇