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Authors: Mark L. Gestring, MD, Division of Trauma, University of Pennsylvania, Philadelphia; Jon W. Johnson, MD, Division of Trauma, University of Pennsylvania, Philadelphia; and Perry W. Stafford, MD, FAACS, FAAP, FCCM, Director, Trauma and Surgical Critical Care, Children’s Hospital of Philadelphia, PA.
Peer Reviewer: Kenneth H. Butler, DO, FACEP, Associate Residency Director, University of Maryland Emergency Medicine Residency Program, University of Maryland School of Medicine, Baltimore.
Injuries to the abdomen remain an important cause of mortality in the trauma patient, despite improved diagnostic and therapeutic modalities. Physical examination can be unreliable in a patient with multiple injuries, and concerns over hemodynamic stability intensify the need for rapid and accurate decision making. Unrecognized abdominal injuries continue to cause preventable deaths and can present a significant diagnostic challenge to the clinician. The existence of abdominal injury must be recognized prior to establishing treatment priorities in the patient with multi-system trauma. Prompt and accurate diagnosis of intra-abdominal injury is necessary to devise an appropriate management strategy and minimize mortality.
Many adjuncts exist to assist the clinician with abdominal evaluation following injury, but the clinician must understand the limitations and indications for each to derive the maximum benefit of the technology without increasing risk to the patient. For example, advances in ultrasound technology and training have seen focused abdominal sonography in trauma examination (FAST) establishing its role in the work-up of the injured patient. The management of abdominal trauma also has changed with the recent shift toward non-operative management of solid organ injury in the blunt trauma patient. This issue will review the recent advances in diagnosis and early management of abdominal trauma, with emphasis on new diagnostic developments and treatment algorithms. — The Editor
While significant strides have been made in reducing the rate at which people are injured, trauma remains a major health problem.1 Trauma is the leading cause of death in the first four decades of life, and is surpassed only by cancer and atherosclerosis as the major cause of death in all age groups. The incidence of permanent disability due to injury is three times higher than the death rate, resulting in huge financial and societal costs.2
Blunt trauma is the most common mechanism of abdominal injury nationwide, with motor vehicle accidents accounting for more than 50% of these cases. Blunt force injuries to intra-abdominal structures generally occur by three mechanisms:
The United States is one of the few Western nations in which penetrating wounds commonly are seen outside of war. Penetrating injuries are more common in urban areas and tend to be more direct in their presentation, with the presence of an abdominal wound causing immediate concern for abdominal injury. Hollow, viscous injury should be suspected in penetrating trauma because the intestine takes up the largest portion of the intra-abdominal volume and is commonly involved. Penetrating injuries, especially gunshot wounds, respect few anatomical boundaries, so many body regions may be injured with a single projectile. In addition, the wounding potential of gunshot wounds is dependent on the velocity, caliber, and mass of the projectile, with higher velocity bullets causing more devastating injuries.4,5 Lastly, secondary missiles, such as damaged bone, also are capable of causing additional injury.
Blunt Trauma. The initial assessment of a trauma patient begins at the scene of an injury with information provided by the patient, family, or paramedic. Following blunt trauma, important information includes extent of vehicular damage, history of ejection from the vehicle, and role of safety devices such as seatbelts and airbags. In penetrating trauma, descriptions of the weapons (rifle vs pistol) are equally helpful. This type of information, when considered in the context of the physical examination, may provide additional clues to potential injury and direct the course of treatment in abdominal trauma. Patient information, including medical and surgical histories and known allergies, is important and should be sought. History of previous intra-abdominal surgery has particular importance because it may alter diagnosis and therapy.
It is prudent to presume that patients who have sustained significant blunt trauma are at risk to have an intra-abdominal injury. Priorities in resuscitation and diagnosis are established based on hemodynamic stability and degree of injury. Evaluation and stabilization of the airway, breathing, and circulation are directed by Advanced Trauma Life Support (ATLS) protocol.6 The goal of this primary survey is the identification and urgent treatment of life-threatening injuries. Resuscitation is carried out concomitantly and continues as the physical examination is completed. The objective of the secondary survey becomes the identification of all injuries by head-to-toe inspection.
The most important initial concern in the treatment of a patient with suspected abdominal trauma is an assessment of hemodynamic stability. In the unstable patient, the question of abdominal involvement must be addressed quickly. This is rapidly accomplished by identifying free intra-abdominal fluid (assumed to be blood in the hypotensive patient) using diagnostic peritoneal lavage (DPL) or FAST. If there is no apparent chest trauma and a hypotensive trauma patient has free fluid in the peritoneal cavity, the source of the hypotension is most likely abdominal hemorrhage, and further resuscitation (as well as surgical treatment) most likely will be required. If no free fluid is identified, an extra-abdominal source should be sought to explain the hypotension.
Warmed crystalloid is used for initial volume resuscitation. Most instances of hypotension in the immediate peritrauma period should be treated aggressively with volume, typically warmed saline or lactated Ringer’s solution (LR). Hemodynamic instability despite the administration of 2 liters of fluid in the adult patient is an indication for blood transfusion and suggests that operative intervention may be necessary. Type O, Rh(-) blood should be administered if type specific blood is not yet available. In the patient with abdominal trauma, persistent hemodynamic instability despite volume therapy requires emergent laparotomy.
The abdominal cavity is divided into three distinct regions: peritoneal cavity, pelvic cavity, and retroperitoneal space. Large amounts of blood can accumulate in the peritoneal and pelvic cavity without significant, early change in physical examination. In addition, the retroperitoneal space is separated from the rest of the abdomen, making injury to retroperitoneal structures difficult to detect by examination. In the awake, neurologically intact patient with unequivocal signs and symptoms of abdominal injury such as evisceration, peritonitis, or obvious penetrating injury, the standard approach calls for surgical exploration without further diagnostic tests. Similarly, emergent laparotomy is indicated in the unstable blunt trauma patient with evidence of intra-abdominal bleeding detected by DPL or FAST examination. While physical exam can be misleading, it remains the most important technique for identifying the patient in need of urgent laparotomy.
Choice of initial laboratory studies may vary by institution, but should include at least a complete blood count (CBC), coagulation studies, blood typing and cross matching where indicated, urinalysis, and serum pregnancy in females of appropriate age. All patients with either blunt or penetrating abdominal trauma should have their tetanus immunization history reviewed. If this is not clear or not current, prophylaxis should be given. If laparotomy is planned, a preoperative dose of broad spectrum antibiotics, typically a second-generation cephalosporin is given prior to the incision. If no enteric contamination is encountered, no further antibiotics are required. In the event of enteric spillage, however, a short postoperative course (usually 24 hours) should be continued.7
In the evaluation of patients following penetrating injury, it is important to know the surface anatomy of the abdomen with respect to external landmarks to avoid missing injuries whose trajectory might threaten intra-abdominal structures. Intra-abdominal contents can move into the lower chest as a result of diaphragmatic excursion with respiration. The identification of bullet wounds is of paramount importance. Frequently missed wound locations such as the axilla, perineum, and buttock region must be carefully inspected. When dealing with stab wounds, the location, as well as the depth and direction of the wound, must be noted.
Physical examination of the abdomen following blunt injury begins with inspection, making careful note of findings such as ecchymosis from seat belts, tire marks, and other external signs of bruising. While physical examination has a tendency to be unreliable following trauma, this information can be very helpful with clinical decision making.
The greatest compromise of the physical examination occurs in the setting of neurologic dysfunction. Such dysfunction may be caused by head injury or may be a consequence of substance abuse. This reality limits, or in some cases negates, the reliability of the physical examination. The presence of spinal cord injuries creates further confusion by producing hypotension caused by sympathetic collapse in the presence of a meaningless abdominal exam. All of these limitations to a precise physical examination have led to the development of more objective measurements of intra-abdominal injuries.
Despite primary and secondary surveys, a missed injury rate of 9% or more can be expected.8 Although these injuries are generally not life threatening, they may be debilitating and can compromise the long-term outcome. A tertiary survey, or complete follow-up physical exam, should be performed after the patient has been admitted and stabilized to address this problem.9
In the hemodynamically unstable patient, a rapid assessment needs to be made regarding the presence or absence of intra-abdominal free fluid. This question usually needs to be answered urgently to establish whether surgical intervention will be required. In contrast, evaluation of the stable patient is less urgent and allows the use of various modalities that are not available to the patient in shock. Indications for additional evaluation in this subset of patients include:
The majority of trauma patients have multisystem trauma on presentation, and distracting injuries commonly are present. As mentioned previously, the physical examination can be inaccurate and unreliable in the early post-injury period. The following adjuncts are available to assist with abdominal assessment.
Plain Radiographs. Initial radiographs of the torso frequently are used during the initial evaluation of the trauma patient. The chest x-ray is an essential part of the initial assessment and may aid in the diagnosis of abdominal injuries such as ruptured hemidiaphram or pneumoperitoneum caused by bowel rupture. The use of pelvic radiographs also is common in most centers. While this radiograph is vital in the unstable patient who might have an undiagnosed pelvic fracture, its role as a routine study is in question. Patients who are awake and appear to have a stable, non-tender pelvis probably do not benefit from this examination, especially if a computed tomography (CT) scan is planned to evaluate the abdomen.
Plain abdominal films have limited utility in the evaluation of blunt abdominal trauma and rarely contribute to operative decision-making. Their use generally is not warranted in the trauma population. In the patient with penetrating injury to the abdomen, however, a quick abdominal flat plate might be helpful in assessing trajectory and ruling out retained missiles. The study should be completed without delay of operative intervention.
Diagnostic Peritoneal Lavage. DPL was the first well-established, reliably objective method for detecting the presence of blood in the abdominal cavity.10
During DPL, a catheter is introduced into the peritoneal cavity. If more than 10 mL of gross blood or any intestinal contents are aspirated, the test is considered grossly positive. If not, 1000 mL of warm crystalloid is instilled into the peritoneal cavity through the catheter, and the fluid is allowed to mix with the intra-peritoneal contents and then drain by gravity. A microscopically positive test reveals more than 100,000 red blood cells (RBC)/mm3, more than 500 white blood cells (WBC)/mm3, higher amylase or bile level than serum, or the presence of bacteria or vegetable matter. In addition, evidence of DPL fluid in either a foley catheter or a chest tube constitutes a positive lavage. Only about 30 ccs of blood in the peritoneal cavity are needed to produce a microscopically positive lavage.
DPL has been shown to have a diagnostic accuracy of 98-100%, a sensitivity of 98-100%, and a specificity of 90-96%. A false-positive rate of 2% also has been reported. DPL remains the most sensitive method for detecting intra-peritoneal blood. A limitation of this technique is that it only evaluates the peritoneal cavity and cannot detect a retro-peritoneal injury.
A closed, guide wire technique is preferred in most centers because of a shorter procedure time,11 lower complication rate, and results comparable to an open technique.12 Prepackaged, sterile DPL kits are available commercially. Gastric and urinary bladder decompression must be assured prior to this invasive procedure.
DPL is indicated in the unstable patient to determine whether intra-abdominal bleeding is present. It also may be performed in the operating room or intensive care unit to evaluate the abdomen of a patient in whom physical examination is unreliable in the setting of clinical deterioration. The only absolute contraindication to DPL is the obvious need for laparotomy. Relative contraindications include a history of multiple abdominal operations, morbid obesity, and late stages of pregnancy. The current major concerns with DPL are its oversensitivity and nonspecificity,13 which do not limit its use in unstable patients, but decrease its role in the evaluation of patients with solid organ injury who are known to have intra-abdominal blood but might be candidates for non-operative management.14 DPL also has a role in evaluating patients who are found to have free fluid on CT scan in the absence of visible solid organ injury, a finding that has been linked to small bowel injury.15 With the availability of faster and better imaging technique (primarily CT) the role of DPL has mostly shifted to the evaluation of the unstable trauma patient.
Computed Tomography. The advancements in CT technology and reduced scan time have revolutionized the care of patients with abdominal trauma. CT scanning accurately detects intra-abdominal injury in trauma patients and has become the gold standard against which other modalities are compared. In addition, a CT scan of the abdomen offers the ability to simultaneously evaluate associated injuries, most notably vertebral and pelvic fractures, as well as injuries in other body regions, including the brain16 and thoracic cavity.17 The CT scan is sensitive to approximately 100-200 mL of free fluid in the pelvis or peritoneal cavity. Prospective studies have shown CT to be as sensitive as DPL in the evaluation of abdominal injury. CT scans, however, have the ability to determine the source of hemorrhage, while DPL only can determine if blood is present in the abdominal cavity. Additionally, many retroperitoneal injuries go undetected with DPL, whereas CT provides imaging of the pancreas, duodenum, and genitourinary system. In blunt trauma, CT has supplanted intravenous pyelography for the evaluation of hematuria. Renal artery injuries are being detected more frequently and earlier than in the past with the use of this modality. Many renal artery injuries were previously unrecognized because they are associated with minimal or absent microscopic hematuria. CT evaluation has provided a means of accurate detection.
Current limitations to abdominal CT include its marginal sensitivity for the diagnosis of diaphragmatic,18 pancreatic, and bowel injuries,19,20 as well as the requirement for intravenous contrast administration. In addition, CT is not an appropriate modality for the evaluation of unstable patients. These patients require a rapid assessment of whether intra-abdominal bleeding is the cause of their hypotension, and this question is better left to DPL or FAST.
The increased likelihood that blunt injury to an intra-abdominal solid organ will be managed non-operatively only increases the need for specific diagnosis which, in many cases, can be provided only by CT scan. Lastly, abdominal CT has been shown to be helpful in detection of occult pneumothoraces that are not seen on initial chest x-ray. In a recent evaluation, 55% of patients who had a pneumothorax on admission were identified through the use of abdominal CT scan.21 These occult pneumothoraces represent potentially life-threatening injuries, especially if the patient is to undergo mechanical ventilation or general anesthesia.
Ultrasonography. FAST is gaining acceptance in the United States as a rapid and reliable tool in the evaluation of the injured abdomen. Multiple recent studies have shown this modality to be quick, portable, accurate, noninvasive, non-expensive, and reproducable in the hands of clinicians.22-26 This technology has been shown to be a reliable and sensitive means of detecting hemoperitoneum27-31 and hemopericardium32 in the traumatized patient, without the need for intravenous contrast. Blood may be detected in fewer than four minutes and with minimal training in most cases.33 It is particularly valuable in patients with prior laparotomies, for whom DPL is relatively contraindicated, and pregnant patients, where an initial view of the fetus can be obtained. It is actually ideal in the assessment of the pregnant trauma patient, providing information on fetal viability, and placental integrity, as well as maternal injuries. In addition, recent studies have demonstrated a role for FAST in detecting hemothorax.34,35
The FAST exam is an abbreviated sonographic evaluation of the abdomen, done at the bedside, focusing on dependent regions to determine the presence of free fluid within the peritoneal cavity. Typically, the areas imaged include Morison’s pouch, the splenorenal recess, and the pouch of Douglas since these are the sites where blood is most likely to collect in the supine trauma patient. In addition, FAST provides an excellent view of the pericardial space to aid in the diagnosis of hemopericardium.36
Unlike DPL, which tends to leave residual fluid in the abdominal cavity and requires an incision, albeit small, the FAST exam does not interfere with serial abdominal examinations or subsequent imaging studies. The device is designed for ease of operation and comes with an appropriate probe to image the abdominal cavity. Its portability allows easy access to the operating room or the intensive care unit for follow-up studies. In experienced hands, the diagnostic accuracy in the trauma setting approaches that of DPL, with reported sensitivity of 89-96% and specificity of 97-100%. In fact, FAST has virtually replaced DPL as the procedure of choice in the evaluation of the hemodynamically unstable trauma patient in many centers.
Laparoscopy. The role of laparoscopy in the evaluation and treatment of abdominal trauma remains limited. Its ability to examine anterior intra-peritoneal structures in a minimally invasive fashion is appealing, but this limited visualization of only part of the abdominal cavity has been associated with an unacceptably high missed injury rate.37 Current indications for laparoscopy are limited to assessment of peritoneal violation following penetrating injuries (i.e., stab wounds) if penetration of the abdominal wall is not clearly discernable.38 If no penetration is seen, no further exploration is required. If peritoneal violation is identified, formal laparotomy would be advocated by most centers. Few trauma surgeons would rely on laparoscopy for a complete intra-abdominal examination following penetrating injury, and there is currently no role for the procedure following blunt trauma.39 In addition, complications such as induced tension pneumothorax, small bowel injury, and intra-abdominal vessel injury have been described.40
The evaluation of the penetrating abdominal trauma patient differs based on the mechanism of injury (stab vs gunshot wounds). The major diagnostic question involves the determination of peritoneal penetration. It is routinely assumed that the peritoneum has been violated and that intra-abdominal injury has occurred when dealing with gunshot wounds. Any wound from the nipple line to the gluteal crease has the potential to cause significant injury in either the peritoneal or retroperitoneal cavity and should never be underestimated. In fact, a gunshot wound anywhere on the trunk should be considered to pose a threat to intra-abdominal organs because the trajectory of a bullet cannot always be predicted with accuracy. Most civilian wounds are caused by low-velocity bullets, which can change course when deviated by bone or even soft tissue. Two-thirds of low-velocity missiles striking the torso do not exit the body.41 While conventional abdominal radiographs are rarely helpful in blunt trauma, they may play a role in the initial evaluation of gunshot wounds. These films can be helpful in determining trajectory and accounting for bullets if definitive therapy is not delayed by the x-ray process, and the skin wounds are marked prior to film exposure.
Torso wounds associated with clear signs of peritoneal irritation on physical examination or hemodynamic instability require urgent surgical exploration. Most gunshot wounds will fall into this category and a liberal standard for surgical intervention should be applied if peritoneal involvement is suspected. One should consider laparotomy the diagnostic modality of choice in this patient population.
Stab wounds, however, often present in stable patients with equivocal abdominal findings. In the patient with a stab wound to the abdomen, it is important to consider the location of the wound, the length of the weapon, and the depth of the wound in determining the diagnostic approach. Once again, the main question involves peritoneal violation, which cannot be assumed in all stab wounds. High rates of negative surgical explorations in patients with abdominal stab wounds due to policies of mandatory exploration led to development of selective management strategies.42 Four approaches have been described for dealing with these sometimes difficult diagnostic dilemmas: observation, local wound exploration, DPL, and diagnostic laparoscopy.
Observation. Observation and serial abdominal examinations are probably the simplest selective approaches, but require careful attention to observer continuity. Subtle changes in abdominal examination and development of fever, tachycardia, or leukocytosis are indications for exploration.43 The time needed for proper observation remains debatable, but most proponents suggest a minimum of 24 hours.
Local Wound Exploration. Local wound exploration is meant to provide direct information about peritoneal violation and can be performed in the trauma resuscitation area. The procedure involves formal skin preparation, use of local anesthetic, and enlargement of the initial wound. The tract is then followed to determine if the posterior fascia and peritoneum have been violated. A negative exploration is one in which the wound does not penetrate the posterior fascia (transversalis fascia), and a patient may be discharged if no further injuries exist. Penetration of the posterior fascia or inability to find the end of the tract constitutes a positive exploration and mandates further evaluation.
Diagnostic Peritoneal Lavage. DPL has been advocated by some as a method to determine if intra-abdominal injury has occurred in the patient with an abdominal stab wound.44 Criteria for positive DPL are adjusted and range from RBC counts higher than 1000/mm3 to RBC counts higher than 100,000/mm3. In general, a higher sensitivity and a higher negative laparotomy rate result as the threshold value is lowered. In this setting, the values accepted as a positive study are much lower than those for the patient with blunt trauma. DPL is somewhat limited, however, because of its inability to assess rupture of the diaphragm or injury to the retroperitoneal structures, which can account for large blood loss.
Laparoscopy. The use of laparoscopy also has been advocated in this population to evaluate the peritoneum for violation. This technique provides a reliable look at the peritoneal surface, but is less effective at assessing the intra-abdominal contents to rule out injury. If peritoneal penetration is found, formal laparotomy is advised.
The thought process in the evaluation of the injured abdomen following blunt trauma is different than that for penetrating trauma. The magnitude of blunt force applied to the patient puts many body regions at risk. Frequently, multi-system injuries coexist, forcing priorities to be established. The management strategy chosen for abdominal injury must be compatible with the treatment plan for coexisting injuries.
The use of CT in this setting is helpful because it allows evaluation of several body cavities during one scan. CT diagnosis of abdominal trauma has dramatically altered the way these patients are managed. With newer high-resolution, rapid imaging, the physician can reliably determine the extent of solid viscous injuries and formulate a management strategy. The liberal use of CT in the trauma resuscitation area also identifies patients who do not require hospital admission. In fact, a recent study demonstrated that patients with an abdominal CT scan, which was obtained on a helical or spiral CT scanner and showed no organ injury or peritoneal fluid could be safely discharged from the emergency department without a period of either inpatient or outpatient observation.45 Non-operative management protocols based on CT diagnosis and hemodynamic status pioneered in pediatric patients are now commonly employed in the treatment of adult solid organ injury, primarily the liver and spleen.
Non-Operative Management of Blunt Abdominal Trauma. As experience with the non-operative management of solid organ injuries has increased, CT has assumed increasing importance, since it has the ability to determine the severity of organ injury. The American Association for the Surgery of Trauma (AAST) has developed organ injury scales to grade all solid organ injuries based on CT findings.46-48 Guidelines by the Eastern Association for the Surgery of Trauma (EAST) concluded that "management of blunt hepatic and/or splenic injuries in a hemodynamically stable patient is reasonable." Recent data, however, suggest that blunt hepatic and splenic injuries behave differently.
Patients with blunt injuries to the liver who require operation present with hemodynamic instability. Patients with blunt hepatic injury who are stable and undergo abdominal CT generally can be managed nonoperatively, irrespective of the grade of the hepatic injury or the quantity of hemoperitoneum.49-52 In contrast, grade of blunt splenic injury and quantity of hemoperitoneum, unlike hepatic injury, are predictive of success when employing nonoperative management. Failure of nonoperative management increased progressively with grade of splenic injury (4.8% for AAST grade I compared with 75% in grade V).53-56
Indications for laparotomy in patients who failed nonoperative management were, most commonly, decreasing hematocrit, change on CT scan, hypotension, and abdominal pain. The trend toward non-operative management is likely to continue as trauma surgeons become more comfortable with this approach and as imaging modalities improve. The patient is generally admitted to an ICU setting where careful attention is paid to hemodynamics and serial hemoglobin checks. Coagululopathies are aggressively reversed and blood products are given if necessary. Deterioration in clinical status such as hemodynamic instability or change in abdominal examination warrants additional investigation with CT or surgical exploration.57-59
Diagnosis and management of abdominal injury is a vital part of the trauma resuscitation process. A working knowledge of ATLS principles and a high degree of clinical suspicion are required to avoid diagnostic errors. An appreciation of available technology and an understanding of its limitations will help in decision-making when dealing with these complex patients. The realization that serious abdominal injury is generally treated operatively should prompt the early involvement of surgical consultants.
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