Approach to blunt and penetrating abdominal injury: Clinical sciences

Traumatic injuries to the abdomen can occur from blunt forces like shearing from rapid deceleration, or penetrating mechanisms like gunshot or stab wounds. The liver, spleen, and intestine are the most commonly injured organs, as well as major abdominal vasculature for penetrating injuries.

Although the majority of blunt and penetrating abdominal injuries can be managed non-surgically, it is important to quickly identify life-threatening injuries like intraabdominal hemorrhage, retroperitoneal hemorrhage, intraabdominal visceral organ injury, unstable pelvic fracture, and diaphragmatic injury or rupture, to provide timely operative intervention.

Alright, when evaluating a patient with a blunt or penetrating abdominal injury, start with the primary survey by assessing their ABCDE.First, secure the Airway with a low threshold for endotracheal intubation or surgical airway. Stabilize the cervical spine during intubation, and place a C-collar until c-spine injury has been ruled out.

Next, ensure adequate Breathing or ventilation. Then, assess Circulation and obtain 2 large bore IVs or intraosseous access while continuously monitoring vitals. Consider starting resuscitative measures with IV fluids or transfusions if vitals are unstable.

Next assess Disability by evaluating the patient’s Glasgow Coma Scale and perform a pupillary reflex exam. Make sure to immobilize the spine until spine injuries have been ruled out. Finally, expose the patient by removing all clothing and bandages to assess for additional injuries. Don’t forget to cover the patient with warm blankets to prevent hypothermia.

Okay, now that you’ve finished your primary survey, lets begin by looking at unstable patients. If your patient is unstable with a penetrating abdominal injury, get them quickly to the OR because they need urgent surgical management. As for unstable patients with blunt abdominal injury, your next step is to perform the secondary survey including adjunctive tests like an eFAST and x-rays. The focus is to quickly identify life-threatening injuries and signs of impending hemodynamic collapse.

Let’s start with intraabdominal hemorrhage, which can occur when there’s an injury of a highly vascular organ, like the liver or spleen, or major abdominal vasculature.

On exam, you might find signs of hemorrhagic shock, such as hypotension and flat jugular veins, as well as signs of peritonitis like abdominal distension with diffuse tenderness. Keep in mind that you might not be able to assess for peritonitis if the patient is unconscious or unable to communicate pain. Lastly, you might see a seatbelt sign, and if there’s an external wound, you might see active bleeding from the wound.

If eFAST reveals free fluid in the pelvis or abdomen, you are dealing with intraabdominal hemorrhage. This is a surgical emergency that requires immediate intervention to stop the bleeding.

Next up is retroperitoneal hemorrhage. This type of injury occurs when there is an accumulation of blood behind the peritoneum, which is usually caused by damage to the retroperitoneal organs: like the kidneys, aorta, inferior vena cava, parts of the duodenum and colon, as well as the psoas muscle. Because the retroperitoneum is not a confined space, it can hold a significant amount of blood in a short amount of time, quickly leading to hemorrhagic shock.

On exam, you’ll see signs of shock like hypotension, tachycardia, and flat jugular veins. Additionally, you might find abdominal distension of tenderness and bleeding from an external wound if there is one.

On eFAST, there will be no or minimal free fluid in the pelvis or abdomen indicating the bleeding is outside of the peritoneal space. With these findings, think retroperitoneal hemorrhage, which is a surgical emergency.

Moving on, let’s discuss intraabdominal visceral organ injury. This refers to damage to the intestines that can quickly lead to abdominal sepsis, and death. The exam typically reveals abdominal tenderness. In addition, evaluate the wound for peritoneal violation with evisceration of the omentum or intestines. eFAST might show free fluid in the pelvis or abdomen, and on a chest x-ray, you might see free air. These findings support your diagnosis of an intraabdominal visceral organ injury.

Next up is unstable pelvic fracture. This often results from high-force injuries that cause axial instability of the pelvis. Importantly, unstable pelvic fracture is associated with pelvic vascular injuries.

Patients are typically hypotensive and have severe pelvic tenderness and instability on exam. It’s important to assess the pelvic ring, which is done by pushing down on the iliac crests. If your patient feels pain, they probably have a pelvic fracture. However, if you feel laxity of the iliac crests, you are likely dealing with an open-book pelvic fractures. Sometimes, you might also find lower limb length discrepancy or rotational deformity.

eFAST exam showing free or pelvic fluid, and pelvic x-ray showing open-book fracture confirms your diagnosis of unstable pelvic fracture. Next place a pelvic binder immediately because if the pelvis is not stabilized right away, it can lead to life-threatening exsanguination.

Okay, our final life-threatening injury is diaphragmatic injury or rupture. This can occur from thoracoabdominal injuries, which can be penetrating like gunshot wounds, or blunt like a high-speed crash. With diaphragmatic injury, patients are at high risk for developing respiratory failure.

On exam, you’ll usually find hypotension, tachypnea, diminished breath sounds on auscultation, and in severe cases, jugular venous distention. eFAST might show free fluid in the abdomen, but a chest x-ray showing a gastric bubble or even the colon in the thorax confirms your diagnosis of diaphragmatic injury or rupture.