Blunt Abdominal Trauma

Eric L. Legome and Joseph P. Freedman

Blunt abdominal trauma (BAT) accounts for a minority of all traumatic deaths but represents an important source of morbidity. The variety of clinical presentations, limitations of the physical examination, and the absence of consistent clinical markers make patients with BAT a particularly challenging population. Death owing to abdominal injury may be prevented by early recognition of intra-abdominal hemorrhage. After initial resuscitation, one of the primary objectives of the emergency physician (EP) is to decide which patients require early intervention and timely consultations. Although injuries to solid organs are most frequently involved after BAT, the clinician must also search for the more subtle injuries to the bowel, mesentery, and pancreas. The history and physical examination continue to be essential components of the evaluation, however, a significant portion of patients will require imaging. Focused assessment with sonography for trauma (FAST) and abdominal computed tomography (CT) scanning are paramount in both ruling in and excluding intra-abdominal pathology and planning definitive treatment.

CLINICAL PRESENTATION

The signs and symptoms of BAT are highly variable, and obtaining a complete and accurate history and physical examination may be unreliable due to concomitant head injury, medications, substance abuse, multisystem trauma, distracting injuries, spinal cord injuries, or shock. Though historical factors and physical findings should guide decision making, the presence or absence of many findings is neither sensitive nor specific (1,2).

Although hypotension in the field or on arrival increases the likelihood of severe bleeding, vital signs may be normal upon presentation to the emergency department (ED). Injuries that produce minimal bleeding, for example, diaphragm perforation, and those isolated to the retroperitoneum typically result in a paucity of physical findings.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of injury in BAT includes both intra-abdominal and extra-abdominal etiologies. The most common intra-abdominal concerns are the solid organ injuries of the spleen or liver. Next most commonly injured are the hollow viscous organs, that is, the small and large bowel. These comprise less than 10% of intra-abdominal injuries. The gallbladder, pancreas, or vascular structures may also be injured, although these injuries are infrequent and are usually found in combination with hollow or solid viscous injuries. Occasionally there is an isolated injury to the bowel mesentery.

In addition to these intra-abdominal injuries, there may be extra-abdominal findings that mimic intra-abdominal injury. These include muscle strains, contusions, or rectus sheath hematomas. Muscle injuries tend to cause pain mainly over the involved muscular area and do not lead to hemodynamic instability; the pain may intensify when palpation is performed on the contracted muscle. However, these findings may coexist with an intra-abdominal injury and the presence of these findings cannot exclude an intra-abdominal injury.

ED EVALUATION

The assessment of the blunt trauma patient must be performed within the context of the patient’s hemodynamic status and potential for life- or limb-threatening injuries. The ABCs of resuscitation are rapidly performed on arrival. The secondary survey, including the abdominal examination, proceeds after the primary survey is complete. In general, the more critically injured the patient, the faster the EP must determine the need for laparotomy, blood transfusion, or angiography, and obtain early surgical consultation.

History

Upon arrival, a brief history is obtained. One common approach is the AMPLE format (allergies, medications, past medical history, last meal, and events surrounding the injury). In addition, the patient should be questioned about specific areas of pain. Obtaining the history also allows the EP to judge the patient’s mental status.

Other valuable sources of information are the prehospital care providers and witnesses or passengers who may arrive with the patient. After a description of the mechanism and events of the injury, most paramedic reports indicate mental status changes, vital signs, evaluation of the ABCs, significant complaints, and interventions. Certain historical factors, such as prehospital vital signs and mechanism of injury, have classically been associated with a greater chance of serious injury. Mechanism alone tends to be poorly predictive of the need for operative intervention or advanced therapeutic maneuvers (3–5). On the other hand, a history of prehospital hypotension, a requirement for significant volume resuscitation, declining mental status, the presence of a femoral fracture, or the need for either prehospital or ED intubation increases the likelihood of intra-abdominal injury (6–8).

Physical Examination

Despite the necessity of a directed physical examination, the EP must be aware of its limitations. The physical examination is not sensitive enough to diagnose all patients with operative intra-abdominal injuries, nor is it specific enough to rule in an injury, even in patients with guarding and rigidity. The literature has cited a wide variability in the physical examination. For example, one study found the examination to be 65% accurate in the setting of BAT, whereas another trauma center reported abdominal examination alone as adequate in only 35% of patients (4,9). A recent systematic review suggested that the physical examination alone is probably insufficient for excluding intra-abdominal injury; however the presence of rebound tenderness, distention, and a seat-belt sign can increase the likelihood of BAT (1).

To perform the physical examination, the patient should be completely undressed and life threats addressed first. Concomitant evaluation and therapeutic interventions of the airway, breathing, and circulation are the first priority. The abdominal examination should begin with inspection for abrasions or ecchymosis. Ecchymosis over the lower abdomen in a lap-belt distribution is suspicious for hollow viscous injury and vertebral fractures. Although Cullen sign (ecchymosis around the umbilicus) and Turner sign (ecchymosis of the flanks) are associated with retroperitoneal bleeding, they are highly insensitive and often take hours to manifest. Auscultation for bowel sounds has not been formally studied but probably has no utility in the initial examination.

Palpation of the abdomen begins with examination of the lower chest. Lower rib fractures, especially with high-energy trauma, are associated with a significant rate of associated intra-abdominal injury (10,11). The abdomen should be carefully palpated, paying particular attention to the right and left upper quadrants (RUQs and LUQs). The finding of Kehr sign (pain in the shoulder unrelated to shoulder tenderness or range of motion) is associated with the presence of blood irritating the diaphragm and is often secondary to splenic or liver injury.

Pelvic stability is assessed by palpating and applying distraction and compressive forces over the iliac crest and over the symphysis pubis. Care should be taken not to use excessive force to avoid disrupting an unstable fracture and increasing bleeding. Patients with pelvic fractures have a significant incidence of intra-abdominal injury, ranging from 30% to >50% in those with severe or unstable fractures (12).

Rectal examination is rarely useful in blunt trauma patients. It may provide some added information in seriously injured patients with pelvic fractures or concern for gastrointestinal disruption; however, it is highly unlikely to be helpful, and its inaccuracy may confuse the clinical picture. It may demonstrate a high-riding or boggy prostate in patients with urethral disruption. Gross blood on rectal examination may indicate gastrointestinal rupture and mandates surgical consultation. Stool evaluation for occult blood has not been shown to be predictive of traumatic injury (13). In addition, trauma patients find the rectal examination the most uncomfortable part of the physical examination, so if performed, it should be limited to those patients with a reasonable expectation of pathology (14). The external genitalia should be inspected for blood at the meatus, scrotal hematoma, or urethral outlet bleeding, which may signify a bladder or urethral injury. The patient should then be log-rolled with palpation of the lumbar and thoracic area. Lumbar fractures, particularly those in conjunction with the seat-belt sign, are markers of hollow viscous injury.

Plain Radiographs

The plain abdominal radiograph has no utility in the evaluation of BAT. It is not reliable in diagnosing intra-abdominal pathology and therapeutic interventions should not be planned on the basis of the results. A chest radiograph should be performed to assist in evaluating the aorta, lungs, and rib cage. It may show evidence of a ruptured diaphragm in anywhere from 20% to 80% of patients with this injury (15,16). Pelvic films should be obtained based on the reliability of the examination and on physical findings. The current evidence shows that in the stable and alert blunt trauma patient without distracting injuries, a normal clinical examination can rule out a clinically important pelvic fracture (17–19). On the other hand, a patient with hemodynamic instability or in whom there is a reasonable suspicion of a fracture by examination or mechanism should have one performed early in the course. In stable patients with no evidence of instability who will be rapidly undergoing a CT scan of the abdomen and pelvis, it is reasonable to forego the plain film for the more sensitive CT.

Laboratory Tests

Laboratory analysis of most trauma patients is generally more extensive than necessary and rarely offers insight into diagnosing an occult injury. Though laboratory testing based on clinical parameters is cost effective without compromising care, most trauma centers use some type of protocol to standardize and speed the laboratory evaluation of patients. The patient who is fully awake and alert, has sustained minimal trauma, and has no distracting injury may not require any testing. Rational laboratory analysis in most patients with BAT can be limited to a complete blood count, basic electrolytes, blood type and screen, and urinalysis. Women of childbearing age should have a pregnancy test performed.

The hematocrit value is influenced by many factors, including the rate of blood loss, dilutional effects of intravenous fluids, fluid shifts from the interstitium to the intravascular space, and preinjury level. Though an initial low hemoglobin <8 g/dL may be useful to prognosticate major injury and outcome (20), the main value is as a baseline blood count. Leukocytosis may be present but is a nonspecific finding. Baseline chemistries provide information regarding blood glucose, creatinine, and evidence of acidosis. Gross hematuria is significant and should prompt evaluation of the genitourinary (GU) tract. The presence of microscopic hematuria is of less clear significance, as it has been found to be poorly sensitive or specific for significant GU injury and, in the absence of a pelvic fracture or unexplained hypotension, does not mandate workup (21).

Other studies to consider, mostly for the severely injured patient or elderly patient, include liver function studies, coagulation profiles, arterial blood gas, and alcohol and drug screening. Liver enzymes that are significantly elevated to two to three time normal may represent hepatic injury, although it is unclear how much they add to objective radiologic testing based on mechanism and physical examination (22). Coagulation studies are useful in anticoagulated patients, those with a history or stigmata of liver disease, pregnant patients, or those with the possibility of disseminated intravascular coagulation owing to shock.

Analysis of the arterial or venous blood gas may provide diagnostic and prognostic information in the major trauma patient. Those patients with base deficits less than –6 (i.e., –7 or greater) have an increased risk of intra-abdominal hemorrhage. High initial lactates have been associated with significantly increased mortality in several trauma database reviews (23). Serial base deficits or serial lactates indicate trends in patient status. Monitoring the deficit for improvement or normalization helps discern whether ongoing resuscitation is effective. The failure to normalize a base deficit by several hours predicted a significantly greater morbidity and mortality in one study (24,25).

Serum amylase and lipase are inaccurate for pancreatic injury. One study showed that 53% of BAT patients had at least one elevation during an initial or subsequent measurement, yet <2% had a pancreatic injury. Other studies have confirmed the lack of utility of a screening amylase or lipase in the blunt trauma patient (26).

Ethanol levels and drug screens may provide additional information about the reliability of the physical examination.

Diagnostic Peritoneal Lavage

Diagnostic peritoneal lavage (DPL) is a rapid and accurate test for determining the existence of intraperitoneal blood. Although it is invasive, DPL has a low (<1%) complication rate of bleeding, perforation, or infection. Once part of the standard evaluation of BAT patients, it has been largely replaced by CT scan in the stable patient and by ultrasound for the unstable patient. DPL still has utility in the unstable patient with an unclear or indeterminate ultrasound result or in the stable patient with a significant concern for a hollow viscous or mesenteric injury, either by examination or after an equivocal CT scan. DPL also plays a major role when CT scan and ultrasound are not available, and therefore remains an important diagnostic tool for the EP.

The two main techniques are open and closed. The closed technique is faster and is not associated with a significant increase in complication rate. The open technique relies on direct visualization and incision of the peritoneum, whereas the closed technique is performed using the Seldinger technique after skin incision. Though generally performed in the infraumbilical area, a supraumbilical approach should be performed in patients with pelvic fractures or previous surgical scars and in the pregnant patient. In some cases, a semi-open technique may be performed. With this technique, the skin, and sometimes the fascia, is incised, and the catheter (placed over a trocar) is inserted blindly into the peritoneal cavity. Most centers perform either the open or the closed technique. The sensitivity and specificity of DPL for intra-abdominal blood are both in the 95% to 99% range, with accuracy ranging between 92% and 98%. The specificity of DPL for predicting the need for a therapeutic laparotomy is somewhat lower, and it should be interpreted in light of the overall clinical picture. A positive DPL in a hemodynamically stable patient should not automatically lead to laparotomy. It had previously been estimated that up to 30% of grossly positive lavages lead to nontherapeutic laparotomies. With the advances in nonoperative management of solid organ injuries, this number is probably higher. The lavage is insensitive for retroperitoneal injuries, is not specific for site and extent of injury, and may diagnose injuries that do not require operative intervention. The only absolute contraindication for DPL is the need for emergency laparotomy.

Criteria for a positive test after blunt trauma include an initial aspirate of >10 mL of blood (grossly positive lavage) or >100,000 RBC/mm³ in the lavage fluid. Patients with a grossly positive lavage (initial aspiration of 10 mL of blood) who are unstable should undergo immediate laparotomy. If <10 mL is aspirated, this amount of blood should be added back into the peritoneal cavity and counted toward the final lavage fluid red blood cell (RBC) determination. Generally, patients with RBC counts between 25,000 and 100,000 RBC/mm³ should undergo CT scan and patients with counts >100,000 RBC/mm³ should be seriously considered for CT scanning if they remain hemodynamically stable. However, this is more of a historical remnant as most of these patients today would have had a CT as the primary test rather than a DPL. Other lavage criteria based on the leukocyte count and amylase are less sensitive and more controversial and should be interpreted in light of the clinical examination. Gross bile or fecal material should be considered a positive lavage.

Computed Tomography

CT scan of the abdomen and pelvis is the best method for radiographic evaluation of the stable patient. Owing to limitations in the physical examination of the trauma patient, most patients except the minimally injured will require some sort of diagnostic test or observation. The CT offers the ability to perform, in a relatively rapid fashion, a quantitative and qualitative diagnostic test.

Abdominal CT after blunt trauma is indicated in patients with an unreliable physical examination. This includes patients with altered sensorium, spinal cord trauma, or distracting injuries or when general anesthesia is planned for another injury and there is a concern for intra-abdominal injury. CT also evaluates for suspected retroperitoneal, small bowel, renal, or pancreatic injury. It also provides excellent visualization of pelvic and spinal fractures. CT images may also reveal a pneumothorax or hemothorax and rib fractures missed on initial plain radiograph. With each generational improvement in CT scanners, image reconstructions are greatly enhanced with thinner slices, higher spatial resolution, and increased speed. Artifacts caused by motion, respiration, and pulsations are significantly decreased.

Multidetector CT (MDCT) images more anatomic area as the IV contrast material travels through the body, resulting in better detail of structures. Thus, because of the greater anatomic coverage during optimal IV contrast material opacification, vascular structures and parenchymal organs are imaged more effectively, and the ability to construct 3D reformations is greatly enhanced (27,28). A common approach some trauma centers are using is to perform a CT from head to pelvis, that is, “the pan scan,” in the multitrauma patient. Though seemingly cost prohibitive, it may actually be less expensive given that the extra time to perform the scan takes minutes, there is no increased use of film when images are stored on a picture archival retrieval system, and scans of the bones can be included, obviating the need for plain films. This approach, however, must be balanced by the radiation load incurred and the long-term potential, although low, for radiation-induced carcinomas (29). Currently, this approach remains controversial as clinicians attempt to balance the cost, radiation, and resource utilization with the efficiency of the “pan scan” (30).

Some controversy remains regarding abdominal CT and the need for oral contrast medium to opacify the bowel. Although the major disadvantages (the delay to scan and possibility of aspiration) are very small, it remains unclear exactly how much it contributes to care. It can assist in diagnosing bowel and pancreatic injury, although the incidence of injury to these structures is low. Extravasated contrast is a pathognomonic finding; however, it has a low sensitivity. Contrast improves the ability to see bowel wall thickening, although most patients with this finding alone do not need intervention. Although several reviews and studies have led to mixed conclusions and its use remains an institutional preference, increasingly the evidence suggests that it is probably not needed (31,32). The most recent American College of Radiology Appropriateness criteria also agrees with this approach, no longer recommending oral contrast in CT studies of BAT (33). Given its limited assistance, if oral contrast is administered, CT should not be delayed while waiting for passage of the contrast material, unless there is a strong suspicion for bowel or pancreatic injury and the patient is stable.

Another major limitation of abdominal CT scan is the decreased sensitivity for bowel, mesenteric, and pancreatic injury. Hollow viscous injury has historically been one of the most elusive diagnoses to make by CT in trauma. It is found in approximately 1% to 5% of patients with significant BAT and may be higher with certain mechanisms such as a seat-belt injury. Air, extravasated contrast, active mesenteric bleeding, or bowel injury with mesenteric hematoma are indications for surgical intervention. Unfortunately, these are relatively insensitive and rare findings. The significance of isolated free intraperitoneal fluid is more controversial. Several studies have found a high likelihood of bowel or mesenteric injury and others document a low likelihood (34,35,37). In general, it should probably be taken seriously, and the EP should strongly consider admitting or observing the patient with this finding in addition to obtaining surgical consultation. Findings such as mesenteric infiltration or hematoma or bowel thickening are often seen in patients with less serious lesions; these patients may often be safely observed. In the past, reported sensitivities for diagnosing bowel injury with CT were as low as 41%. The newer scanners have improved resolution and provide better diagnostic accuracy (32,36).

Pancreatic injury remains a difficult diagnosis. Elevations of amylase or lipase are inaccurate for detecting this injury. Though the incidence of pancreatic injury in BAT patients is <1% and the need for operative intervention is even lower, CT is only 50% to 78% sensitive and tends to underestimate the extent and magnitude of the injuries. These patients, however, often undergo exploration for other concomitant injuries (39).

Diaphragmatic injuries, though relatively uncommon, remain diagnostic dilemmas. Studies of helical CT in diaphragmatic injury have found it better in the acute phase and with visceral herniation. Pathognomonic signs for this injury include the “collar sign”—a waist like constriction of the abdominal viscera, intrathoracic herniation of abdominal contents, and discontinuity of the diaphragm. In one small study of helical CT, these signs were highly specific, with a moderately high sensitivity; CT detected approximately 80% of left-sided and 50% of right-sided herniations. The newer scanners have improved sensitivity and specificity, with values reaching 84% and 77%, respectively, using coronal and sagittal reconstructions. Familiarity and greater use of MDCT should improve the ability to make this diagnosis in the acute phase (38).

CT is the diagnostic test of choice in the stable patient with a high suspicion for intra-abdominal injury or with an unreliable examination. It is also being used with increasing frequency in the patient who is moderately stable (i.e., the patient who is able to maintain vital signs, although they may be fluctuating, or the patient with ongoing hemorrhage who can be adequately resuscitated) in whom nonoperative management is still a possibility. A multi-institutional prospective study of 2,774 patients with suspected BAT found that a negative CT scan has a negative predictive value of 99.63%. This has tremendous implications for cost savings. A patient without other significant injuries, pain or social concerns with a normal abdominal CT can be safely discharged. The chance of a missed significant abdominal injury is extremely low (39). Despite the high sensitivity of CT scanning BAT patients, recent studies and ACEP guidelines have focused on identifying a population of patients with BAT who are at low risk of adverse outcomes, in whom CT scanning may increase radiation dose without adding valuable clinical information (1). These patients are those who have no abdominal tenderness, hypotension, altered mental status, costal margin tenderness, abnormal chest radiograph, hematocrit under 30%, and hematuria. The clinical prediction rule has yet to be externally validated but may help limit CT usage on BAT patients with a low likelihood of intra-abdominal injury.

While the pendulum has swung in the last decade toward increasing use of CT scan with BAT to provide efficient clinical care with a high sensitivity for all intra-abdominal injuries, research is now looking to help define the patient populations in which historical and physical factors can safely exclude important BAT without imaging.

Ultrasound

The advent and increasing usage of ultrasound represented a paradigm shift in the evaluation and management of the blunt trauma patient. The FAST examination is a directed assessment of the abdomen and pericardium with the goal of detecting hemoperitoneum or pericardium. Although operator dependent, it is a rapid bedside test that can be done at the bedside with the secondary survey. The FAST examination is performed on the supine patient with the examiner positioned on the patient’s right side. Four locations are scanned: (a) the RUQ, (b) LUQ, (c) the suprapubic region, and (d) the pericardium. The examiner looks for unclotted blood, which appears black or anechoic on the ultrasound screen. The RUQ view is generally the initial view. This view detects blood in Morison’s pouch, a dependent space between the kidney and liver. Although this location has the greatest yield, the addition of all abdominal views has been found to significantly increase the sensitivity by up to 40%. The LUQ is examined next, specifically looking for blood in the splenorenal space. Either view of the upper quadrants may also reveal a hemothorax or pneumothorax. Trendelenburg positioning may improve the sensitivity of either of these views. The suprapubic view evaluates the cul-de-sac between the rectum and bladder (the pouch of Douglas), and the heart and pericardium are examined by a subxiphoid view. The suprapubic view should be performed before the Foley catheter is placed, as the full bladder acts as an acoustic window and enhances visualization of peritoneal fluid (40,41).

The FAST examination has become a standard part of the EP and trauma surgeon’s evaluation of the blunt trauma patient. In many centers it is considered the first-line diagnostic study to identify or exclude significant hemoperitoneum. Clear benefits of ultrasound are that it is rapid, noninvasive, inexpensive, repeatable, and relatively portable. The test can be performed in conjunction with resuscitation, usually takes <5 minutes, and has a relatively steep learning curve. Its sensitivity and specificity range from 81% to 98% and 94% to 98%, respectively. The sensitivity and specificity vary somewhat depending on the amount of free fluid present and the expertise of the examiner (42,43). Though ultrasound is moderately sensitive for as little as 100 to 200 mL of fluid, sensitivities increase to >90% with volumes of fluid close to 700 mL. In other words, ultrasound is highly sensitive in patients with enough blood loss to cause hemodynamic instability, although one cannot fully exclude an intra-abdominal lesion based on a negative ultrasound in an unstable patient. The sensitivity of the FAST examination also increases when serial examinations are performed, separated by 30 minutes. Accuracy has been reported to range between 96% and 98% (34). The level of accuracy is independent of whether an EP, surgeon, radiologist, or ultrasound technician performs the study; they all have comparable results. Though there is controversy over the exact number of studies and instructional time needed for proficiency, current studies appear to support that several hours of instruction, and roughly 20 hands-on studies lead to excellent accuracy in defining hemoperitoneum (44–46).

In US, FAST has largely supplanted DPL, especially in unstable patients, and has been used as a diagnostic adjunct in the stable patient in conjunction with physical examination or, more commonly, CT scan. Compared to DPL, ultrasound allows for a quicker, safer, and noninvasive test without interference with other resuscitative procedures. Unlike DPL, it does not require extra time or modification for the pregnant patient or patients with pelvic fractures, previous surgery, or coagulopathy.

Most centers use some variation of the algorithm from Denver published in 1997 (47). The initial test in all BAT patients is the ultrasound. If the patient is unstable and the FAST is positive, immediate laparotomy is performed. In the unstable patient, if the FAST is negative or equivocal and intra-abdominal injury is a concern, a DPL is performed. A CT scan follows a positive ultrasound in a stable patient. A negative ultrasound is followed by a CT scan or by serial ultrasounds, physical examinations, and a 6-hour hematocrit. A concerning change in physical examination, ultrasound findings, or significant drop in hematocrit is followed by either a CT scan or laparotomy. Although outcome studies are limited, literature has shown that implementation of point-of-care sonography protocol can limit CT scans, and minimize the time to definitive intervention in BAT patients (47,48). This must be balanced, at least in the Denver study, with the increased time of observation of the patients who were observed after ultrasound.

Though ultrasound clearly is valuable in the unstable patient, it has some disadvantages compared to CT scan in the stable patient. Although highly sensitive for large amounts of hemoperitoneum, it is less so with small amounts, and it is not reliable at providing a qualitative assessment of a solid organ injury. The sensitivity of ultrasound for identifying solid organ injury is approximately 30% when performed by sonographers trained for limited bedside ultrasound. It also does not provide information about bowel or pancreatic injury or evaluate the retroperitoneum (34). Patients at significant risk for intraperitoneal injury such as those with abdominal abrasions, lower rib fractures, multiple traumatic injuries, pelvic or long-bone fractures, or inability to be clinically followed up may be poor candidates for ultrasound as the only modality for evaluation. At a minimum, these patients should not be evaluated using a single examination at a single point in their course.

Overall, ultrasound provides a very useful initial test in BAT. Though it can potentially predict the need for surgical repair based on the amount of fluid observed, its main utility has been in the unstable patient as a replacement for DPL. As it does not reliably grade or even diagnose solid organ injury, it is most valuable as an adjunct to CT in the stable patient. In most centers, given the increasing availability of CT and the high negative predictive value, a negative or equivocal ultrasound is often followed by abdominal CT scanning. However, from the beginning of the resuscitation, ultrasound alerts the team to the presence of intraperitoneal injury within seconds to minutes and can be used to rapidly triage patients to the operating room or radiology suite. In addition, owing to its portability and accessibility, ultrasound can be repeated to detect hemoperitoneum if the hemodynamic status of the patient changes.

Angiography

Interventional angiography is increasingly important and more frequently employed in the treatment of hemodynamically stable BAT patients. As the technology of CT improves, active hemorrhage is increasingly identified faster and more accurately. If an actively bleeding spleen, liver, or kidney is visualized and the patient is clinically stable, a dedicated angiography team may be able to intervene to rapidly embolize the lesion and avoid laparotomy. Angioembolization, along with close observation and serial examinations, has been shown to increase the effectiveness of nonoperative management of BAT patients. The precise population of BAT patients who will benefit from nonoperative management, and specifically, angiography, has yet to be fully elucidated (28,49,50).