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Abdominal Trauma:
Assessment
Trauma

MRCEM Success

CURRICULUM CODE
RP4 Major Trauma

TP5 Abdominal Injury

KEYWORDS
Abdominal Trauma

Diagnostic Peritoneal
Lavage

Emergency Laparatomy

Focused Assessment
with Sonography for
Trauma

Trauma

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 RELATED TOPICS
Trauma

Something wrong?

Abdominal Trauma: Assessment LAST UPDATED: 13TH

FEBRUARY 2021
TRAUMA
 Bookmark

In hypotensive patients, the goal is to rapidly identify an abdominal or pelvic injury and determine whether
it is the cause of hypotension. The patient history, physical exam, and supplemental diagnostic imaging
can establish the presence of abdominal and pelvic injuries that require urgent haemorrhage control.
However, when indications for patient transfer already exist, do not perform time-consuming tests,
including abdominal CT.

Haemodynamically normal patients without signs of peritonitis may undergo a more detailed evaluation to
determine the presence of injuries that can cause delayed morbidity and mortality. This evaluation must
include repeated physical examinations to identify any signs of bleeding or peritonitis that may develop
over time.

X-ray

An AP chest-x-ray is recommended for assessing patients with multisystem blunt trauma

Haemodynamically abnormal patients with penetrating abdominal wounds do not require screening
x-rays in the emergency department
If the patient is haemodynamically normal and has penetrating trauma above the umbilicus or a
suspected thoracoabdominal injury, an upright chest x-ray is useful to exclude an associated
hemothorax or pneumothorax, or to determine the presence of intraperitoneal air
With radiopaque markers or clips applied to all entrance and exit wounds, a supine abdominal x-ray
may be obtained in haemodynamically normal penetrating trauma patients to demonstrate the path
of the missile and determine the presence of retroperitoneal air; obtaining two views (i.e. AP and
lateral) may allow for spatial orientation of foreign bodies
An AP pelvic x-ray may help to establish the source of blood loss in haemodynamically abnormal
patients and in patients with pelvic pain or tenderness; an alert, awake patient without pelvic pain or
tenderness does not require a pelvic radiograph

Focused Assessment with Sonography for Trauma (FAST)

FAST is an accepted, rapid, repeatable, and reliable study for identifying intraperitoneal fluid; it can

also detect cardiac tamponade

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 also detect cardiac tamponade
FAST includes the examination of four regions: the pericardial sac, the hepatorenal fossa, the
splenorenal fossa and the pelvis or pouch of Douglas
For more information on FAST, see separate article

Diagnostic peritoneal lavage (DPL)

DPL is another rapidly performed study to identify haemorrhage

The technique is most useful in patients who are haemodynamically abnormal with blunt abdominal
trauma or in penetrating trauma patients with multiple cavitary or apparent tangential trajectories
Haemodynamically normal patients who require abdominal evaluation in settings where FAST and CT
are not available may benefit from the use of DPL; in settings where CT and/or FAST are available,
DPL is rarely used because it is invasive and requires surgical expertise
Relative contraindications to DPL include previous abdominal operations, morbid obesity, advanced
cirrhosis, and preexisting coagulopathy; note that DPL requires gastric and urinary decompression
for prevention of complications
An open, semi-open, or closed (Seldinger) infraumbilical technique is acceptable in the hands of
trained clinicians; in patients with pelvic fractures, an open supraumbilical approach is preferred to
avoid entering an anterior preperitoneal pelvic hematoma; in patients with advanced pregnancy, use
an open supraumbilical approach to avoid damaging the enlarged uterus
Aspiration of gastrointestinal contents, vegetable fibers, or bile through the lavage catheter
mandates laparotomy; aspiration of 10 cc or more of blood in haemodynamically abnormal patients
requires laparotomy
If gross blood or gastrointestinal contents are not aspirated initially, lavage is performed by instilling
1 L of warmed isotonic crystalloid solution (10 mL/kg in a child) into the peritoneum; after ensuring
adequate mixing of peritoneal contents with the lavage fluid, the e!uent is drained from the
abdomen and sent to the laboratory for quantitative analysis (adequate fluid return is >20% of the
infused volume); a positive test (and thus the need for surgical intervention) is indicated by >
100,000 RBC/mm³, > 500 WCC/mm³ or a positive Gram stain
Complications (although rare) include bleeding secondary to injection of local anaesthetic or incision
of the skin or subcutaneous tissues, peritonitis secondary to intestinal perforation from the catheter,
laceration of the urinary bladder (if bladder not evacuated prior to procedure), injury to other
abdominal and retroperitoneal structures and wound infection at the lavage site

Computed tomography (CT)

CT is a diagnostic procedure that requires transporting the patient to the scanner (i.e. removing the
patient from the resuscitation area), administering IV contrast, and radiation exposure
CT is a time-consuming (although less so with modern CT scanners) procedure that should be used
only in haemodynamically normal patients in whom there is no apparent indication for an emergency
laparotomy; do not perform CT scanning if it delays transfer of a patient to a higher level of care
CT scans provide information relative to specific organ injury and extent, and they can diagnose
retroperitoneal and pelvic organ injuries that are di#cult to assess with a physical examination,

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 FAST, and DPL
Relative contraindications for using CT include a delay until the scanner is available, an
uncooperative patient who cannot be safely sedated, and allergy to the contrast agent
CT can miss some gastrointestinal, diaphragmatic, and pancreatic injuries
In the absence of hepatic or splenic injuries, the presence of free fluid in the abdominal cavity
suggests an injury to the gastrointestinal tract and/or its mesentery, and many trauma surgeons
believe this finding to be an indication for early operative intervention

Diagnostic laparoscopy or thoracoscopy

Diagnostic laparoscopy is an accepted method for evaluating a haemodynamically normal,

penetrating trauma patient with potential tangential injury and without indication for laparotomy.
Laparoscopy is useful to diagnose diaphragmatic injury and peritoneal penetration
The need for general anaesthesia limits its usefulness

Contrast studies

Contrast studies can aid in the diagnosis of specifically suspected injuries, but they should not delay the
care of haemodynamically abnormal patients. These studies include:

Urethrography

Urethrography should be performed before inserting a urinary catheter when a urethral injury
is suspected

Cystography

A cystogram or CT cystography is the most e$ective method of diagnosing an intraperitoneal

or extraperitoneal bladder rupture

Intravenous pyelogram

Suspected urinary system injuries are best evaluated by contrast-enhanced CT scan but if CT
is not available, intravenous pyelogram (IVP) provides an alternative

Gastrointestinal contrast studies

Isolated injuries to retroperitoneal gastrointestinal structures (e.g. duodenum, ascending or

descending colon, rectum, biliary tract, and pancreas) may not immediately cause peritonitis
and may not be detected on DPL or FAST
When injury to one of these structures is suspected, CT with contrast, specific upper and lower
gastrointestinal intravenous contrast studies, and pancreaticobiliary imaging studies can be
useful
However, the surgeon who ultimately cares for the patient will guide these studies

Indications for laparotomy

Surgical judgment is required to determine the timing and need for laparotomy. The following indications
are commonly used to facilitate the decision-making process in this regard:

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 are commonly used to facilitate the decision-making process in this regard:

Blunt abdominal trauma with hypotension, with a positive FAST or clinical evidence of intraperitoneal
bleeding, or without another source of bleeding
Hypotension with an abdominal wound that penetrates the anterior fascia
Gunshot wounds that traverse the peritoneal cavity
Evisceration
Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
Peritonitis
Free air, retroperitoneal air, or rupture of the hemidiaphragm
Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder
injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma
Blunt or penetrating abdominal trauma with aspiration of gastrointestinal contents, vegetable fibers,
or bile from DPL, or aspiration of 10 cc or more of blood in haemodynamically abnormal patients

Comparison of DPL, FAST and CT in abdominal trauma

Procedure FAST DPL CT

Indications Abnormal Abnormal Normal

haemodynamics haemodynamics haemodynamics
in blunt in blunt in blunt or
abdominal abdominal penetrating
trauma trauma abdominal trauma
Penetrating Penetrating Penetrating
abdominal abdominal back/flank trauma
trauma without trauma without without other
other other indications for
indications for indications for immediate
immediate immediate laparotomy
laparotomy laparotomy

Contraindications Absolute: An Absolute: An Absolute:

existing existing haemodynamically
indication for indication for unstable patient
laparotomy laparotomy Relative: a delay
Relative: n/a Relative:
until the scanner
Previous
is available, an
abdominal
uncooperative
surgery, morbid
patient who
obesity,
cannot be safely
advanced
sedated, allergy to
cirrhosis, pre-
the contrast agent
existing
coagulopathy

Time 2 - 4 mins 10 - 15 mins Variable

Sensitivity Medium High High

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 Sensitivity Medium High High

Specificity High Low High

Advantages Early operative Early operative Anatomic

determination determination diagnosis
Non-invasive Performed Non-invasive
Performed rapidly Repeatable
rapidly Can detect Visualises
Repeatable bowel injury retroperitoneal
No need for No need for structures
transport from transport from Visualises bony
resuscitation resuscitation and soft-tissue
area area structures
Visualises
extraluminal air

Disadvantages Operator- Invasive Higher cost and

dependent Risk of longer time
Bowel gas and procedure- Radiation and IV
subcutaneous related injury contrast exposure
air distort Requires gastric Can miss
images and urinary diaphragm injuries
Can miss decompression Can miss some
diaphragm, for prevention bowel and
bowel, and of pancreatic injuries
pancreatic complications Requires transport
injuries Not repeatable from resuscitation
Does not Interferes with area
completely interpretation of
assess subsequent CT
retroperitoneal or FAST
structures Low specificity
Does not Can miss
visualise diaphragm
extraluminal air injuries
Body habitus
can limit image
clarity

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