Chapter 39 Abdominal Trauma

Abdominal injuries account for 13% to 15% of traumatic deaths, making this the third leading cause of trauma mortality.¹ Knowing the mechanism of injury, conducting a diligent physical examination, maintaining a high degree of suspicion, and performing serial evaluations are essential for reducing the morbidity and mortality related to abdominal trauma. The two mechanisms of injury most commonly associated with abdominal trauma are blunt and penetrating; each of these forces produces distinctive patterns of organ damage.

Many blunt abdominal injuries are not evident on initial physical examination. Frequent reassessment is needed to detect injuries that manifest over time.

Blunt Trauma

Blunt abdominal trauma (BAT) results when force is applied to the abdominal wall without creating an open wound.

• In the United States, motor vehicle crashes are the leading cause of BAT, responsible for 50% or more of significant injuries.²

• Other mechanisms of BAT are contact sports, falls, and physical abuse.³

• The abdominal viscera and other structures are injured by direct blows, compression, or deceleration.

• Compression injuries occur from direct blows against a fixed object (lap belt, steering wheel, or the spine).

• Deceleration forces between relatively fixed and free objects cause a shearing or tearing type of injury; part of the tissue continues to move forward while another part remains stationary.⁴

• The solid organs—most frequently the spleen, liver, and kidneys—are likely to rupture in response to blunt force.

• Although seat belts save lives, they are nonetheless associated with their own constellation of injuries, including visceral rupture, organ compression, orthopedic fractures, and abdominal vessel tears.

• The placement of the seat belt above the bony pelvic area can cause momentary trapping of the underlying tissue against the spine and lead to shearing and compression injuries.

• A red mark or bruise with the imprint of a seat belt may indicate underlying damage and requires frequent monitoring.

• Symptoms of seat belt injury may develop slowly.

Penetrating Trauma

Penetrating trauma results when an object—such as a bullet, a knife blade, or projectile fragments—pierces the abdominal wall, entering the abdominal cavity.

• In the United States, the leading cause of penetrating abdominal trauma is interpersonal violence, particularly in urban settings.¹

• Stab wounds most commonly produce intestinal injury, but many do not penetrate the peritoneal cavity. Thus they are associated with a lower mortality rate and may not require surgery.

• On the other hand, 96% to 98% of abdominal gunshot wounds involve significant damage to intra-abdominal organs and vessels, necessitating emergent operative intervention.³

Physical Assessment of the Abdomen

While penetrating injuries may be restricted to the abdomen, BAT is rarely an isolated event. Head and chest trauma, and other life-threatening injuries, routinely complicate assessment and care.

Perform a thorough physical examination with diagnostic procedures when assessing patients, particularly individuals who are unconscious, are intoxicated, have altered level of consciousness at baseline, or have experienced a head injury. A person with concomitant spinal cord injuries will have altered sensations that will affect the abdominal examination. The absence of clinical findings does not rule out the presence of abdominal injury, especially in patients who are pregnant or have concurrent neurologic deficits.

Inspect the abdomen for the following:

• Obvious penetrating wounds

• Ecchymosis and abrasions

• Flank bruising

• Distension

• Rectal bleeding

• Testicular swelling

• Ballance, Cullen, or Grey-Turner signs (Table 39-1)

TABLE 39-1 CLINICAL SIGNS ASSOCIATED WITH ABDOMINAL TRAUMA

SIGN	DESCRIPTION	INDICATION
Ballance sign^a	Fixed dullness to percussion in left flank and dullness in right flank that disappears with change of position	Presence of fluid blood on right side but coagulation on left side
Cullen sign	Bluish purple bruise or ecchymosis around the umbilicus	Retroperitoneal bleeding
Grey-Turner sign	Bluish purple bruise or ecchymosis over flank or back area	Retroperitoneal bleeding
Kehr’s sign	Pain that radiates to the left shoulder	Intra-abdominal blood, fluid, or air irritating the phrenic nerve at the diaphragm
Rebound tenderness	Pain on release of deep palpation	Peritoneal irritation