Approach to blunt and penetrating abdominal injury: Clinical sciences

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Introduction0:00–0:48

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.

Primary Survey/Acute Management0:48–1:58

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.

Unstable Patient1:58–2:31

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.

Intraabdominal Hemorrhage2:31–3:23

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.

Retroperitoneal Hemorrhage3:23–4:23

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.

Intraabdominal visceral organ injury4:23–4:59

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.

Unstable Pelvic Fracture4:59–6:05

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.

Diaphragmatic Injury & Rupture6:05–6:48

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.
Alright, let’s go back to the primary survey and talk about stable patients. Your next step here is to perform the secondary survey and obtain adjunctive tests like trauma labs, including type and screen, pregnancy test, CBC, CMP, lactate, urinalysis, and urine tox screen.

Stable Patient6:48–7:19

Additionally, obtain diagnostic tests such as eFAST, abdominal x-ray, and a CT of the abdomen and pelvis in select cases.
Let’s start with penetrating abdominal injuries, which have a higher likelihood of intraabdominal organ damage. In this case, you should perform a local wound exploration to determine the depth and extent of the injury.

Penetrating injury7:19–8:20

If, within the wound, you see that it violates the abdominal wall fascia, the injury likely extends to the peritoneum, so it’s a deep penetrating injury, which is a surgical emergency.
These patients need to be taken to the OR right away for an exploratory laparotomy which will be both diagnostic and therapeutic.
If treatment is delayed, the patient can quickly decompensate even if they were stable initially. On the other hand, if local wound exploration reveals that it doesn’t violate the abdominal wall fascia, that’s a superficial abdominal injury.
If the diagnosis unclear during local wound exploration, you can consider getting a CT to verify the extent of the injury.
Let’s move on and discuss blunt injuries in stable patients. The first injury we’ll look at is stable pelvic fractures.

Blunt injury/Stable pelvic fractures8:20–9:29

Stable in this context refers to the structure of the pelvis, not the hemodynamic status of the patient. Unlike unstable fractures, stable fractures maintain the integrity of the pelvic ring.
History usually reveals high-force mechanisms of injury like a high-speed motor vehicle crash or an elderly patient who suffered a fall.
Exam typically shows pelvic tenderness on palpation. Make sure to perform urogenital and rectal exams to assess for blood at the urethral meatus, scrotal hematoma, or signs of associated rectal or vaginal injuries, which can indicate pelvic organ injury from the fractured pelvic bones.
An x-ray of the pelvis typically shows the pelvic fracture, confirming your diagnosis. Here’s a clinical pearl!
The bladder and urethra are the most commonly injured pelvic organs from pelvic fractures, so consider getting a cystogram or a urethrogram.
Next up is solid organ injury, which usually occurs from high-impact traumas like a high-speed motor vehicle crash, or assault.

Solid organ injury9:29–10:32

Exam typically reveals abdominal tenderness with associated bruising like a seat belt sign. Labs might show decreased hemoglobin and hematocrit indicating acute blood loss anemia, elevated liver function tests, or elevated creatinine.
Urinalysis might show hematuria indicating kidney injury. Typically, CT of the abdomen will show a hematoma around the kidney, liver, spleen, or pancreas which should lead you to consider injury of that solid organ.
Next, obtain a CT Angiography, or CTA to evaluate for any vascular injuries within the solid organ. CTA showing a contrast extravasation called a blush or a hematoma in or around the injured solid organ confirms your diagnosis of solid organ injury.
Let’s now discuss vascular mesenteric injury. Blunt trauma like high-impact injury or a high-speed motor vehicle crash accounts for most cases.

Mesenteric Vascular Injury10:32–11:20

On exam, patients typically have abdominal tenderness, distention, rebound, and guarding. The initial CT of the abdomen likely shows free fluid in the abdomen, possibly with some mesenteric fat stranding.
With these findings, consider a mesenteric injury. Next, order a CT angiography or CTA to evaluate for vascular injury.
If it shows contrast extravasation from the mesenteric vessels or sudden cut-off of contrast within the vessels, you can confirm your diagnosis of vascular mesenteric injury.

Blunt Aortic Injury11:20–12:27

Lastly, let’s talk about blunt abdominal aortic injury. Patients often present after sustaining a high-impact blunt force injury from a motor vehicle crash or fall from a significant height.
Most patients with aortic injury do not make it to the hospital, so the ones that do should be managed quickly. Exam usually reveals abdominal tenderness, and sometimes unequal pulses or a pulsatile mass.
In some cases, the patient might have acute neurological deficits as a result of the aortic injury impeding blood flow to the spinal cord.
eFAST and x-ray are typically unremarkable, but the initial CT of the abdomen might reveal an aortic wall injury and may show contained contrast within the aortic wall, or even a pseudoaneurysm.
With these findings, consider blunt aortic injury. Next, order a CTA of the chest, abdomen, and pelvis to visualize the entire aorta.
If you see an aortic intimal tear or intramural hematoma, think blunt aortic injury. Alright, as a quick recap… Unstable patients with penetrating abdominal injury should go to the OR immediately.

Review12:27–13:09

The ones with blunt injury should be assessed for life-threatening conditions, including intraabdominal hemorrhage, retroperitoneal hemorrhage, intraabdominal visceral organ injury, unstable pelvic fracture, and diaphragm injury.
As for the stable patients, if they sustained a penetrating injury, assess the depth of the wound. However, if they sustained a blunt injury, consider stable pelvic fractures, solid organ injury, mesenteric vascular injury, or blunt aortic injury.