By Gaby Iskander, MD, Marshfield Clinic Trauma Surgeon on staff at Ministry Saint Joseph’s Hospital and Medical Director, Trauma Services at Ministry Saint Joseph’s Hospital
Trauma ranks as one of the nation’s major causes of mortality and morbidity, and is the leading cause of death in people ages 1 to 44. According to the 2009 National Trauma Data Bank (NTDB) data collected from 500 trauma centers, abdominal injury was found in over 81,000 cases.
Examples of blunt abdominal trauma (BAT) are motor vehicle collision, recreational mishaps, falls, and intentional causes, such as assault and penetrating injuries.
Most commonly injured organs are spleen, liver, kidney, pancreas, small bowel, large bowel, stomach, and bladder. The diaphragm also can be injured.
- The clinical exam must be systematic with emphasis on inspection, followed by auscultation and palpation. It should be mentioned here that physical exam can be unreliable in a blunt trauma victim for multiple reasons.
Abdominal sonography: FAST is used to identify fluid in the abdomen, which may be blood, especially in unstable patients. It can be done at the ER bedside or in the OR without moving the patient.
CT scans are considered the standard for the detection of solid organ injuries. The CT scan has limitations, especially with diaphragmatic, pancreatic, and hollow viscous injuries.
MRI has minimal use in patients with BAT, and offers no clear advantage over less invasive modalities in blunt abdominal trauma.
Laboratory: Studies in abdominal injury vary by institution, but usually include: CBC, blood type and screen, cross-match, coagulation and chemistry study.
Resuscitation of the blunt trauma victim starts with crystalloid, LR or normal saline, and in patients with ongoing blood loss, O-negative blood may be used in cases where cross match or type-specific blood is not immediately available.
In solid organ injury, selective nonoperative treatment has become the standard of care in hemodynamically stable patients. Interventional radiology has been a valuable tool in control of hemorrhage when detected by CT scan, especially in pelvic fracture, liver and splenic injury.
- Damage control laparotomy, especially with an open abdomen, is indicated in patients with severe injuries and when the patient is hypothermic, coagulopathic and acidotic.
- Laparotomy to control the source of bleeding, stabilization of patient with fluid and blood products, followed by thorough exploration with repair of injured structure, and is usually followed by closure of the abdomen.