Continuing Education Activity

Abdominal trauma caused by blunt force is a common presentation in the emergency room seen in adults and children. The chief cause of blunt abdominal trauma in the United States is motor vehicle accidents. This activity describes the clinical presentation, evaluation, and management of blunt abdominal trauma and the importance of the interprofessional team in educating patients on the prevention of abdominal injuries.

Objectives:

• Describe the types of injuries sustained in blunt abdominal trauma.

• Outline the clinical presentation of blunt abdominal trauma.

• Explain the management and rehabilitation strategies for patients with blunt abdominal trauma.

• Describe how an interprofessional team can collaborate to improve the rapid diagnosis, resuscitation, evaluation, and management of this condition and education of patients about safe driving to prevent blunt abdominal trauma.

Introduction

Abdominal trauma caused by blunt force is a common presentation in the emergency department seen in adults and children.[1][2]

Etiology

The chief cause of blunt abdominal trauma in the United States is motor vehicle accidents. Other rare causes include falls from heights, bicycle injuries, injuries sustained during sporting activities, and industrial accidents. In children, the most common causes are due to motor vehicle injuries and bicycle accidents.[3][4]

Epidemiology

Blunt trauma to the abdomen can occur in people of all ages and is associated with high morbidity. Each year, thousands of patients with blunt abdominal injuries are seen in emergency departments, and this substantially increases the cost of healthcare.[5][6]

Pathophysiology

Blunt abdominal trauma can cause damage to the internal organs, resulting in internal bleeding, cause contusions, or injuries to the bowel, spleen, liver,  and intestines. Patients can also present with extra-abdominal injuries, such as extremity injuries. [7][8]

History and Physical

Because the presentation is often not straightforward, the diagnosis can be difficult and often time-consuming. Besides pain, the patient may present with bleeding per rectum, unstable vital signs, and the presence of peritonitis. The physical exam may reveal marks from a lap belt, ecchymosis, abdominal distention, absent bowel sounds, and tenderness to palpation. If peritonitis is present, abdominal rigidity, guarding, and rebound tenderness may be present. The mechanism of injury, motor vehicle speed, associated deaths at the scene, and uses of alcohol or other substances of abuse must be taken into account so as not to miss an injury. Cullen's sign is a periumbilical ecchymosis that develops when retroperitoneal bleeding dissects along the falciform ligament anteriorly.

Evaluation

The evaluation of any trauma patient begins with evaluating the airway, accessing the breathing, and managing the circulation. The diagnosis of intra-abdominal injury following blunt trauma depends primarily on the hemodynamic status of the patient. If the patient is hemodynamically stable, a CT scan is the ideal test for solid organ injury in the abdomen and pelvis. For unstable patients, one may perform an ultrasound (Extended Focused Assessment with Sonography for Trauma (EFAST)) or diagnostic peritoneal lavage, both of which are associated with a high rate of false negatives and false positives.[3][9][10]

All indications for trauma ultrasound include blunt or penetrating trauma to the torso where there is a suspicion of intraperitoneal hemorrhage, pericardial tamponade, and hemothorax.

The Extended Focused Assessment with Sonography for Trauma (EFAST) exam includes the following views:

1. RUQ (right upper quadrant)

• One should evaluate for free fluid in Morison's pouch or the hepatorenal space, the lower pole of the kidney, and the space below the diaphragm on the right. In the supine patient, the hepatorenal space is the most dependent area and the least obstructed for fluid flow. Fluid in the abdomen can move freely to the right pericolic gutter into this space.

2. Perisplenic space LUQ (left upper quadrant)

• One should visualize the diaphragm and the entire spleen
• Check above the diaphragm for signs of free fluid in the left hemithorax. On the left, fluid flows preferentially into the subphrenic area and not into the splenorenal area,  which is important because the subphrenic area may be difficult to visualize due to bowel gas and splenic flexure gas.

3. Pelvis (bladder)

• Visualize the interface w/ the rectum, prostate, or uterus.
• Additionally, a second image can be viewed in a longitudinal plane.
• Fluid in the pelvic region flows to the microvesicular area in the male patient and the pouch of Douglas in the female patient because these areas are the most dependent areas of the pelvis.

4. Cardiac view: Subcostal or any other cardiac view. See below

5. Normal Lung: Lung sliding back and forth is normally secondary to the normal anatomy of the parietal and visceral pleural movement. Also, the pleura moves with respect to the ribs and comet tail artifacts.

Pneumothorax: With a pneumothorax, there is no lung sliding back and forth. One will note the pleura and ribs move together. There will be NO comet tail artifacts.

CARDIAC

Subxiphoid four-chamber 

Both the anterior and posterior pericardium should be visualized for anterior or posterior fluid in the pericardium.

• Parasternal views should be attempted if the subxiphoid view is not adequate.
• Both the anterior and posterior pericardium should be visualized.

Parasternal long axis (PSLA)

• Both the anterior and posterior pericardium should be visualized.
• In the ideal plane, the mitral and aortic valves will be visible, as well as a long view of the left ventricle.

Parasternal short axis (PSSA)

• The left ventricle will appear as a ring, with the right ventricle more anterior.

Apical Four-chamber

• Though rarely useful in the emergency department, this view allows easy comparison of left and right ventricles.
• All four chambers should be visible in this plan.

Treatment / Management

Treatment of patients with blunt abdominal injury requires the routine ABCs (Airway, Breathing, and Circulation). Once the airway is protected, it is mandatory to protect the cervical spine. After the primary survey is complete, patients who are hypotensive require aggressive fluid resuscitation. If hemodynamic instability persists, blood should be typed and crossed, but in the meantime, immediate transfusion with O negative blood can be done (O+ for males and women past childbearing years). All patients with blunt abdominal trauma who have signs of peritonitis, frank bleeding, or worsening of clinical signs require an immediate laparotomy. Non-surgical treatment in patients with blunt abdominal injury depends on the clinical features, hemodynamic stability, and results of the CT scan. Advances in angiography can now help control hemorrhage with the use of embolization therapy, which is more cost-effective than laparotomy. In general, the prognosis of patients with blunt abdominal trauma is good. [11][12][13]

Differential Diagnosis

• Domestic violence

• Hemorrhagic stroke

• Hypovolemic shock

• Lower genitourinary trauma

• Penetrating abdominal trauma in emergency medicine

• Pregnancy trauma

• Upper genitourinary trauma

Complications

• Inadequate resuscitation
• Missed abdominal injuries
• Delays in diagnosis and treatment
• Intraabdominal sepsis
• Delayed splenic rupture

Consultations

Trauma surgeon

Radiologist

Deterrence and Patient Education

• Wearing seat belts
• Not texting while driving
• Not drinking and driving
• Not using the mobile phone while driving

Pearls and Other Issues

Mortality rates have substantially decreased in the last two decades as trauma centers have streamlined the approach to diagnosis and management. Mortality rates do vary from 2% to 10% and are most common in people with multiple organ injuries who present with shock and frank hemorrhage.

According to the Centers for Disease Control, traumatic injury is the leading cause of death in people younger than the age of 44. Many traumatic injuries can be prevented, beginning with awareness and education. Blunt abdominal trauma is in the top three categories of preventable injuries. These include older adults falls and preventable motor vehicle accidents in teens.

Enhancing Healthcare Team Outcomes

Blunt abdominal trauma results in thousands of admissions each year, resulting in great costs to the healthcare system. While the actual injury is managed by a team of healthcare professionals, there is also a focus on preventing such injuries. The nurses not only are responsible for monitoring these patients but they also have an important role in patient education. To prevent blunt abdominal trauma, the public has to be educated on wearing a safety belt. These safety devices have to be worn even if the motor vehicle comes fitted with airbags. More importantly, the public must be educated about defensive driving and maintaining a safe distance from other automobiles on the road. Plus, the public should be told about the consequences of drinking and driving. Finally, the nurse and the pharmacist should educate the public on avoiding distractions in the car, like eating, texting, or using a mobile phone.[14][15] [Level 5]

Outcomes

In the past two decades, the outcomes of blunt abdominal trauma have improved. However, there are very few papers published on long-term data, and hence, the eventual outcome of these patients remains unknown. For patients with minor blunt trauma, the outcomes are good, but for those who suffer multiple organ injuries, the in-hospital mortality can vary from 3% to 10%. The ready availability of CT scans has also allowed physicians to closely monitor these patients without performing unnecessary surgeries.[16][17][18] [Level 2]