Blunt Abdominal Trauma (Case 37)

Chapter 54 Blunt Abdominal Trauma (Case 37)



Kevin M. Bradley, MD, Carlos R. Medina, MD


Case: A 62-year-old male presents with suspected blunt abdominal trauma resulting from a motor vehicle accident.



Differential Diagnosis











Solid organ injury (spleen, liver, kidney, pancreas) Hollow viscous injury (stomach, small bowel, colon)
Vascular injury (mesenteric vessel disruption esp. elderly) Diaphragm rupture



Speaking Intelligently


When I evaluate a patient injured in a motor vehicle accident, I first assess for life-threatening injuries during the resuscitation. I establish priorities in the resuscitation, and I address the A-B-C-D-E. After I evaluate for Airway, Breathing, Circulation, Disability, and Exposure, I begin the secondary survey (complete physical examination), and in this case, I focus my attention on the abdomen, looking for tenderness, guarding, distention, and rebound. I make note of injury patterns (lap belt markings, abrasions, ecchymosis), and I try to ascertain the mechanism of injury from paramedics, police, or bystanders. I remember important elements of the hx by using the mnemonic AMPLE (Allergies; Medications; Past medical hx; Last meal; Events leading to presentation). If the patient is hypotensive and other life-threatening injuries have been r/o, I consider the following possibilities: hemorrhage into the abdomen, pelvic fracture with bleeding in the retroperitoneum, long bone (e.g., femur) fracture with bleeding, hemothorax, or blood loss from an open wound.



PATIENT CARE



Clinical Thinking



• Review the approach to the management of the trauma patient as needed (Chapter 47).

• Airway: Assess for airway patency and if the patient can protect his or her airway.

• Breathing: Quickly evaluate for tracheal deviation, breath sounds over each lung field, crepitus, and jugular venous distention.

• Circulation: Insert two large-bore (14- or 16-gauge) IV lines and start fluid resuscitation. Send a type and crossmatch specimen.

• Disability: Check the pupils and assess the neurological status (Glasgow Coma Scale). The spine should be evaluated for tenderness and/or step-offs.

• Exposure: Inspect for additional wounds and possible associated injuries once all clothing is removed. Control for hypothermia.


History



• The mechanism of injury (restrained, airbag deployment, vehicle impact and damage, prolonged extrication, ejection from vehicle) should be determined.

• Ask about loss of consciousness at the time of the accident.

• Evaluate for presence of alcohol or drug use.

• Assess for shortness of breath, chest or abdominal pain, or tenderness elsewhere.

• Gather an AMPLE hx and, if female, whether the patient may be pregnant.


Physical Examination



• Initial examination: If the patient is hemodynamically unstable, a comprehensive secondary survey is postponed (go back to the ABCs and evaluate for life-threatening injuries). Assess for reasons that may make the physical examination unreliable, such as distracting injuries (e.g., long bone fracture), altered mental state, or drug or alcohol intoxication.

• Inspection: Look for external signs of injuries (i.e., a pattern of injury, ecchymosis, or abrasions).

• Auscultation: Absence of bowel sounds may suggest abdominal injury, but ileus after trauma also is common.

• Palpation: Assess for tenderness, guarding, distention, or rebound. Also check for pelvic stability or tenderness and perform a rectal examination (assess the prostate and rectal tone, and evaluate stool for gross or occult blood). Presence of a high-riding prostate suggests the possibility of a urethral injury. Pelvic tenderness or instability suggests pelvic fracture.

• Percussion: Tenderness upon percussion may constitute a peritoneal sign. Tenderness usually mandates further evaluation and/or diagnostic studies.


Tests for Consideration
























• Blood type and screen: Assume that all patients will require operative intervention.
 $65

• Obtain uncrossmatched blood, if clinically indicated.
 $440/unit

• CBC, basic metabolic profiles, and coagulopathy parameters are generally standard, although the yield from these tests is often low.
 $120

• Urine hCG should be checked in women of child-bearing age, as the management of a pregnant woman might differ greatly from that of a nonpregnant woman.
 $56

• Serum amylase might indicate injury to a hollow viscus but, like the other serum chemistries, may lag behind clinical signs of injury.
 $35

• Diagnostic peritoneal lavage (DPL) may be indicated if abdominal evaluation by focused assessment sonography in trauma (FAST) is equivocal and the patient remains hypotensive.
 $450



IMAGING CONSIDERATIONS





























Editor’s note: The severely injured blunt trauma patient may require an extensive radiographic evaluation. For an overview of the tests suggested below, the reader is referred to Chapter 48, Trauma Radiology Tools.  
Anterior-posterior (erect, if possible) chest radiography (end of expiration) $120
Lateral cervical spine radiography $50
AP pelvic radiography $80
FAST: Assess for presence of free fluid in the following spaces: pericardial, hepatorenal, splenorenal, pelvic. A positive FAST examination in a hemodynamically unstable patient is an indication for laparotomy. A positive result in a patient with stable VS needs further evaluation with CT. $190
Depending on clinical situation:  
CT of head, spine, thorax, abdomen, and pelvis: CT is performed in the patient with stable VS and abdominal tenderness, unreliable examination because of abnormal sensorium, or positive FAST examination result in the stable patient. $800 each
Angiography: Performed by skilled interventional radiologists in stable patients for whom CT reveals a contrast blush within a solid organ or the pelvis. $1,100

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Blunt Abdominal Trauma (Case 37)

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