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Stabilization of Trauma in the ER
Abdominal Trauma
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- General Approach to Abdominal Trauma
The initial evaluation of the injured abdomen looks for hemorrhage or spillage of bowel content. Other injuries, such as pancreatic or biliary injury, are not acutely life-threatening and are therefore less urgent. Despite the multitude of intraabdominal organs, and the wide variation of presentation of injured patients, the question is: “Is there blood or peritoneal contamination?”
Evaluate the abdomen during the secondary survey. The primary goal is to decide if surgery is necessary. If you find no need for immediate surgery, further evaluation of the abdomen can wait until other urgent problems are treated.
No abdominal problem, including evisceration, takes precedence over the evaluation and stabilization measures of the primary survey!
Abdominal evaluation presents special problems. The unconscious patient’s exam provides virtually no clues. Even in alert patients, the level of pain and the reaction to palpation are of little help in differentiating severe from trivial injury during the critical early period following injury. Peritoneal signs may not develop for one to four hours. And the abdomen contains a multitude of organs whose function is largely invisible, and whose pain response to injury helps very little in identifying the injured organ.
The physician approaches the injured abdomen in a simplistic fashion: If the abdomen is tender or if the patient has a decreased level of consciousness, assume significant injury. If the patient is hypotensive, or will undergo urgent surgery for a non-abdominal problem, perform peritoneal lavage. If the patient is sufficiently stable and other problems are not emergent, order a CT scan of the abdomen.
Tender Abdomen or Decreased LOC
Hypotensive on arrival or
Emergency non-abdominal surgery — Peritoneal Lavage
(+/- Abd x-rays)
Stable, no urgent conditions — Abd x-rays, CT scan
Exact, organ-specific diagnosis is often not possible, nor wise. The patient who has free air on abdominal x-ray needs rapid laparotomy, rather than an attempt to localize the organ rupture. Similarly, the patient with hypotension, left upper quadrant pain, and a positive peritoneal lavage needs surgery now. Assume a ruptured spleen. If it turns out to be a bruised left abdomen and a laceration of the mesenteric blood vessels, so what? Your goal is to identify the need for surgery.
The exam notes the location and relative severity of tenderness, and seeks any clues such as broken ribs, or a steering wheel mark across the abdomen. If any evidence of injury is present, make a decision about further evaluation after the secondary survey, when the patient’s other problems are known.
All gunshot wounds will require surgical exploration. Some knife wounds are managed conservatively. X-rays and peritoneal lavage may be used to screen for bowel laceration or major bleeding.
Stabilization of Abdominal Injury
Complete the primary (ABC) survey. Infuse fluid rapidly for the patient with evidence of shock. Examine the abdomen during the secondary survey.
Place an NG tube and foley catheter. Cover any open wounds to protect the viscera.
The abdominal compartment of anti-shock trousers must NOT be inflated if the patient is pregnant, if there is an open abdominal wound, or if rupture of the diaphragm is suspected. Rupture of the diaphragm is more common than realized. It should be anticipated with any patient with a penetrating wound of the upper abdomen or lower chest. Back to Top
Liver Injury
The liver may be lacerated by either blunt or penetrating trauma. Liver laceration is common. Biliary tract injury is unusual, and harder to diagnose.
Clinical Findings: In blunt trauma, there will often be fractures of the 7-9th ribs overlying the liver. Right upper quadrant tenderness will be present. Rebound sensitivity and guarding will not be present until blood has been in the abdomen long enough to cause peritoneal irritation — about two hours.
Diagnosis: Suspect liver laceration when penetrating trauma involves the right lower chest or right upper abdomen, or when right upper quadrant tenderness accompanies blunt trauma. If the patient is stable, a CT scan of the abdomen may demonstrate a laceration that can be managed non-operatively. If the patient is in shock, or has other urgent injuries, perform peritoneal lavage to confirm intraperitoneal hemorrhage. Finding bile on peritoneal lavage means biliary tract injury.
Treatment: Large lacerations and gunshot injuries require laparotomy and repair. Many small lacerations can be followed conservatively. Back to Top
Spleen Injury
The spleen is the most commonly injured organ in blunt abdominal trauma. Hypotension from hemorrhage is the most common presenting finding.
Clinical Findings: The injury should be suspected when the 9-10th ribs on the left are fractured, or when left upper quadrant tenderness and tachycardia are present. Commonly the patient complains of pain in the left shoulder — but this is usually not present for an hour or two. Peritoneal signs such as rebound sensitivity and guarding will be delayed until the blood has had time to cause local irritation of the peritoneum.
Diagnosis: Any patient with tachycardia or hypotension and left upper quadrant tenderness is assumed to have a ruptured spleen until proven otherwise. Establish the diagnosis by peritoneal lavage in patients with evidence of significant hemorrhage, or by CT scanning in those who are stable.
Treatment: Small lacerations may be observed in the hospital without repair. Larger lacerations may be treated with oversewing, or by splenectomy. Back to Top
Kidney Injury
Kidney injury is common with falls and automobile accidents. Suspect it with fractures of the 11th-12th ribs or flank tenderness. If hematuria (to any degree) is present, the nature of the injury must be determined. Kidney lacerations can bleed extensively into the retroperitoneal space.
Clinical Findings: The ruptured kidney usually presents with pain on inspiration in the abdomen and flank, and CVA tenderness. Gross hematuria will almost invariably be present, but the injury can still occur with only microscopic hematuria. Flank discoloration is a late finding that will never be present in the emergency department. The contused kidney can present with identical findings.
Diagnosis: Differentiating between the lacerated kidney and the contused kidney requires IVP examination or CT scan. If a contrast study such as an aortogram is required for another reason, the kidneys can be assessed during the course of that study. The lacerated kidney will show leakage of dye, whereas the contused kidney will either be normal or show a “blush” of dye in the kidney stroma. A non-visualizing kidney implies severe rupture or avulsion of the renal pedicle.
Treatment: The contused kidney is simply observed. Some kidney lacerations can be managed non-operatively. Surgical consultation is mandatory for any kidney that shows extravasation of dye. Back to Top
Bowel Rupture
Most commonly, injuries that break the wall of the bowel are due to penetrating injury. In penetrating trauma, the small bowel is most frequently injured, followed by the stomach and large intestine.
Rupture also can occur when a localized crush occurs, such as when the steering wheel pinches the duodenum against the spine. In blunt trauma, most commonly the duodenum is injured, due to its location and its ligamentous attachments.
Clinical Findings: Symptoms are caused by the intestinal contents, rather than blood loss. Stomach rupture causes rapid onset of burning epigastric pain, followed quickly by rigidity and rebound sensitivity. Small bowel and colon injury may present only with vague generalized pain, with peritonitis following after hours. Duodenal injury may cause back pain.
Diagnosis: The diagnosis of bowel rupture is made by finding free air on abdominal x-ray. Use a decubitus or cross-table view for the patient who cannot stand for an upright view. Duodenal or sigmoid colon injury may result in retroperitoneal air only. Peritoneal lavage will show WBCs and intestinal content, except for retroperitoneal duodenal or sigmoid rupture. Contrast examination may be required in equivocal cases, if surgery is not indicated for another reason.
Treatment: Surgical repair is required. Back to Top
Pancreas Injury
Pancreatic injury is notoriously difficult to diagnose. Most cases are discovered only at surgical exploration. The injury should be suspected after a localized blow to the mid-abdomen, such as motorcycle handlebars or steering wheel. Pancreas injury has a high mortality. Duodenal or biliary duct injury are often present as well.
Clinical Findings: Suspect the injury with any localized blow to the abdomen. The patient often experiences vague upper and mid-abdominal pain that radiates into the back. Hours after the injury, generalized peritoneal irritation may reveal the presence of traumatic pancreatitis.
Diagnosis: Serum amylase determinations are usually not helpful in the acute setting. A CT scan establishes the diagnosis. Equivocal cases can be investigated with ERCP (endoscopic retrograde canulation of the pancreas) once other injuries have been stabilized.
Treatment: Management may be surgical or conservative, depending on the degree of injury, and on the presence of associated injuries. Surgical consultation is mandatory. Back to Top
All material referenced through this menu is excerpted from copyrighted works by Bruce Argyle, MD. You are welcome to use selected portions, as long as appropriate credit is given. The credit for the text referenced through this menu is:
Argyle, B., Trauma One! Computer Program Manual.
Mad Scientist Software, Alpine, UT
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