Chapter 67 - Abdominal trauma

Summary

In patients with blunt abdominal trauma, emergent or urgent laparotomy is performed for hypotension and abdominal hemorrhage (frequently confirmed by diagnostic peritoneal lavage or surgeon-performed ultrasound), overt peritonitis, or obvious signs of abdominal visceral injury without the need for further advanced diagnostic studies. Included are patients with significant blood per rectum after pelvic fracture, evidence of air in the peritoneal cavity or retroperitoneum, intraperitoneal bladder rupture, or renal artery/kidney injury on contrast-enhanced radiographs. All other stable patients whose abdominal examinations are compromised by an abnormal sensorium (related to alcohol, drugs, brain injury), abnormal sensation (due to spinal cord injury), or adjacent injuries are best evaluated by contrasted abdominal helical computed tomography. The use of surgeon-performed ultrasound known as FAST (focused assessment for the sonographic evaluation of the trauma patient) is now routinely performed in all high-volume trauma centers as an adjunct to the secondary survey. The FAST exam has contributed substantially to streamlined algorithms for care of patients assessed after multi-system trauma.

In patients with stab wounds to the abdomen, emergent or urgent laparotomy is performed for abdominal distension and hypotension, overt peritonitis, significant evisceration, or obvious signs of abdominal visceral injury without the need for further advanced diagnostic studies. The last group of patients includes individuals with hematemesis, blood per rectum, or hematuria, patients with a palpable diaphragmatic defect prior to chest tube insertion, and patients with genitourinary injuries detected on contrast-enhanced studies. All other stable and reasonably cooperative patients undergo local exploration of the stab wound to verify peritoneal penetration. Asymptomatic patients with peritoneal penetration can either be watched for 24 hours, undergo a diagnostic peritoneal lavage, or undergo diagnostic laparoscopy to make certain that there is no underlying visceral injury. The diagnosis of intra-abdominal injury is rarely delayed more than 10–12 hours in patients with false-negative results on initial physical examination. Patients who undergo wound exploration that confirms absence of peritoneal penetration can be discharged from the emergency room.