Blunt Injury to abdomen

Etiology

Signs and symptoms

• Pain
• Tenderness
• Gastrointestinal hemorrhage
• Hypovolemia
• Evidence of peritoneal irritation
• Large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings. 
• Bradycardia may indicate the presence of free intraperitoneal blood.
• Lap belt marks: Correlate with small intestine rupture
• Steering wheel–shaped contusions
• Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign): Indicates retroperitoneal hemorrhage, but is usually delayed for several hours to days
• Abdominal distention
• Auscultation of bowel sounds in the thorax: May indicate a diaphragmatic injury
• Abdominal bruit: May indicate underlying vascular disease or traumatic arteriovenous fistula
• Local or generalized tenderness, guarding, rigidity, or rebound tenderness: Suggests peritoneal injury
• Fullness and doughy consistency on palpation: May indicate intra-abdominal hemorrhage
• Crepitation or instability of the lower thoracic cage: Indicates the potential for splenic or hepatic injuries

DIAGNOSIS:

• Assessment of hemodynamic stability
• In the hemodynamically unstable patient, a rapid evaluation for hemoperitoneum can be accomplished by means of diagnostic peritoneal lavage (DPL) 
• In  hemodynamically stable patient  the focused assessment with sonography for trauma (FAST) should be done 
• Radiographic studies of the abdomen are indicated in stable patients when the physical examination findings are inconclusive.
• Patients with a spinal cord injury
• Those with multiple injuries and unexplained shock
• Obtunded patients with a possible abdominal injury
• Intoxicated patients in whom abdominal injury is suggested
• Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure
• Bedside ultrasonography is a rapid, portable, noninvasive, and accurate examination that can be performed by emergency clinicians and trauma surgeons to detect hemoperitoneum.
• An examination is interpreted as positive if free fluid is found in any of the 4 acoustic windows, negative if no fluid is seen, and indeterminate if any of the windows cannot be adequately assessed. 
• CT scanning often provides the most detailed images of traumatic pathology and may assist in determination of operative intervention Unlike DPL or FAST, CT can determine the source of hemorrhage.

MANAGEMENT:

• Treatment of blunt abdominal trauma begins at the scene of the injury and is continued upon the patient’s arrival at the ED or trauma center.

Indications for laparotomy in a patient with blunt abdominal injury include the following:

• Signs of peritonitis
• Uncontrolled shock or hemorrhage
• Clinical deterioration during observation
• Hemoperitoneum findings on FAST or DPL
• Preferred incision for abdominal exploration in Blunt injury abdomen is Always Midline incision

• For the most part, pediatric patients can be resuscitated and treated nonoperatively; some pediatric surgeons often transfuse up to 40 mL/kg of blood products in an effort to stabilize a pediatric patient
• Hemodynamically stable adults with solid organ injuries, primarily those to the liver and spleen, may be candidates for nonoperative management
• Splenic artery embolotherapy, although not standard of care, may be used for adult blunt splenic injury
• Nonoperative management involves closely monitoring vital signs and frequently repeating the physical examination & IV fluid administration