A standardized approach should be used with a patient with abdominal trauma, including primary and secondary surveys, followed by additional diagnostic testing as indicated. Specific factors can make the diagnosis of serious abdominal trauma challenging, particularly in the face of multiple and severe injuries, unknown mechanism of injury, altered mental status, and impending or complete cardiac arrest. Advances in technology in diagnosis and/or treatment with ultrasound, helical computed tomography, and resuscitative endovascular balloon occlusion of the aorta (REBOA) have significantly advanced trauma care, and are still the focus of current and ongoing investigations.
Key points
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Be on the lookout for patients with abdominal trauma who have an immediate indication for laparotomy. These patients should be aggressively resuscitated and prepared for transfer to the operating room in consultation with a trauma surgeon. Axial imaging is contraindicated in this patient population.
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The peritoneum can accommodate nearly all of a patient’s circulating blood volume and, therefore, represents an uncontrollable and potentially catastrophic source of internal hemorrhage. In the unstable multisystem trauma patient, the priority is usually aggressive resuscitation and rapid surgical control of hemorrhage.
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Stable patients with serious injuries can deteriorate without warning. Isolated drops in blood pressure or significant base deficit predict recurrent episodes of hypotension and the need for early therapeutic intervention.
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In stable patients for whom immediate axial imaging is planned, abdominal focused abdominal sonogram for trauma (FAST) adds little additional clinical information and can be omitted. Assessment with FAST should not be used to determine the need for computed tomography (CT) imaging.
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Axial imaging is an excellent test for determining the specific anatomy and severity of injury but when used in the wrong population confers significant risk of harm. CT imaging should be avoided when indications for immediate trauma laparotomy are present.
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Local wound exploration is a safe an effective way to exclude intraabdominal injury in patients with anterior abdominal stab wounds.
What are the immediate management priorities in the unstable patient with abdominal trauma?
The primary survey should proceed in a stepwise and systematic fashion for all trauma patients, regardless of injury pattern, and should address immediate threats to life. The Advanced Trauma Life Support program provides a preliminary framework that allows for a systematic and organized approach; however, when resources permit, multisystem assessment and resuscitation should proceed in parallel rather than in sequence. Specific to the abdomen, the key to efficient management is ruling in or out life-threatening hemorrhage, usually with a combination of mechanism of injury, physical examination, and bedside imaging. The patient who has suffered blunt or penetrating abdominal trauma and is hemodynamically unstable should be aggressively resuscitated and evaluated immediately for surgical exploration. Rapid transport to definitive surgical care is of paramount importance for those with abdominal injuries and ongoing hemodynamic instability. In hypotensive patients with gunshot wounds, delaying operative management by more than 10 minutes is associated with a 3-fold increase in mortality.
Unlike thoracic trauma, hemodynamic instability from intraabdominal injuries arises exclusively from major hemorrhage; therefore, resuscitation should involve the early use of blood and blood products. Excessive crystalloid administration in this context disrupts the coagulation cascade, inhibits clot formation, and should be avoided. A damage control approach that includes permissive hypotension, early tranexamic acid, and a balanced ratio of blood products is preferred until definitive hemostasis can be achieved. Massive or refractory hemodynamic instability should prompt consideration for massive solid organ or vascular injury. Patients with serious blunt abdominal trauma rarely have single-system injuries; other sources of obstructive or hemorrhagic shock should be actively sought and excluded. In general, large-bore peripheral intravenous cannula (14 or 16 gauge, placed in the bilateral antecubital fossae) provides excellent vascular access for the purpose of volume resuscitation. If major abdominal or pelvic trauma is suspected, peripheral and central lines should be placed above the diaphragm, in the subclavian or internal jugular veins. Temporary vascular access can be obtained via intraosseous placement in 1 or both humeral heads.
Intraabdominal hemorrhage resulting in hypotension requires definitive surgical treatment regardless of associated injuries. As a third space for hemorrhage, the peritoneum presents the dual dangers of a noncompressible source of bleeding that can accommodate nearly all of a patient’s circulating blood volume, making it the priority for management even in the face of other serious injuries. Traumatic brain injury (TBI), contained blunt thoracic aortic injury, extremity injuries without severe hemorrhage, and ischemia to any extremity may be addressed once hemorrhage control occurs. Patients with both major abdominal hemorrhage and a significant pelvic fracture that remains unstable after resuscitation and application of a pelvic binder are best managed in the operating room (OR) in the absence of a hybrid room. Compared with angiography, the OR is typically available immediately, and allows for management of both intraabdominal injuries and temporizing of pelvic bleeding with preperitoneal packing. Angiography can still proceed after laparotomy and preperitoneal packing if ongoing pelvic bleeding is suspected. The advent of the hybrid OR allows some institutions to bring the patient to a single location for all hemostatic procedures, including exploratory laparotomy, angiography, and orthopedic and neurosurgical interventions. This the most ideal place for the patient requiring multiple emergent procedures. TBI is often not fully characterized until a computerized tomography (CT) scan is performed, which usually occurs after hemorrhage control. If a patient has physical examination findings suggestive of severe TBI or imminent herniation, a neurosurgical team should be consulted early and ideally attend the trauma laparotomy so that emergency decompression maneuvers can be performed concurrent with laparotomy. In all situations of gross instability, the key is to achieve immediate hemostasis, often by way of a damage control laparotomy; associated injuries can be diagnosed and treated in conjunction with or immediately once early hemorrhage is stayed.
Diagnostic peritoneal aspirate (DPA) is valuable for a patient who is too unstable for CT, in whom an intraabdominal source of hemorrhage cannot be ruled out by mechanism of injury or bedside imaging. Specifically, DPA can assist in decision-making when suspicion of intraperitoneal hemorrhage remains high following an indeterminate or negative focused abdominal sonogram for trauma (FAST) examination. Similar to diagnostic peritoneal lavage (DPL), DPA involves entering the peritoneal cavity under direct visualization and placement of a DPL or central line catheter. Aspiration of 10 mL or more of frank blood in the presence of ongoing hemodynamic instability is an indication for immediate laparotomy. The lavage component can be used to detect red cells not visible on inspection or the presence of food fibers, although the utility of these findings for informing immediate surgical decision-making in grossly unstable patients is debatable.
CT imaging is contraindicated in unstable patients with an indication for laparotomy. Definitive surgical treatment should never be delayed in favor of additional imaging tests. Although well-intentioned, pursuing CT imaging in this population prolongs bleeding time without adding data to inform surgical decision-making. Similarly, transport to a trauma center should not be delayed in unstable patients in favor of CT imaging. Common indications for immediate laparotomy are listed in Box 1 .
Absolute: prepare for the operating room
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Ongoing or gross hemodynamic instability, with or without a positive FAST examination or DPA
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Generalized peritonitis
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Implement in situ
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Evisceration
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Relative indications: discuss with a trauma surgeon
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Free air on plain films or CT imaging a
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Signs of gastrointestinal hemorrhage with a suspected traumatic source (frank blood in the nasogastric aspirate or on digital rectal examination)
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Penetrating abdominal trauma: gunshot wounds (most) and stab wounds (some)
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Multisystem trauma with ongoing hemodynamic instability, where the source of injury is not known
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a Free air in the abdomen is not pathognomonic for intraabdominal injury because air may track from thoracic or external sources.
What are the immediate management priorities in the unstable patient with abdominal trauma?
The primary survey should proceed in a stepwise and systematic fashion for all trauma patients, regardless of injury pattern, and should address immediate threats to life. The Advanced Trauma Life Support program provides a preliminary framework that allows for a systematic and organized approach; however, when resources permit, multisystem assessment and resuscitation should proceed in parallel rather than in sequence. Specific to the abdomen, the key to efficient management is ruling in or out life-threatening hemorrhage, usually with a combination of mechanism of injury, physical examination, and bedside imaging. The patient who has suffered blunt or penetrating abdominal trauma and is hemodynamically unstable should be aggressively resuscitated and evaluated immediately for surgical exploration. Rapid transport to definitive surgical care is of paramount importance for those with abdominal injuries and ongoing hemodynamic instability. In hypotensive patients with gunshot wounds, delaying operative management by more than 10 minutes is associated with a 3-fold increase in mortality.
Unlike thoracic trauma, hemodynamic instability from intraabdominal injuries arises exclusively from major hemorrhage; therefore, resuscitation should involve the early use of blood and blood products. Excessive crystalloid administration in this context disrupts the coagulation cascade, inhibits clot formation, and should be avoided. A damage control approach that includes permissive hypotension, early tranexamic acid, and a balanced ratio of blood products is preferred until definitive hemostasis can be achieved. Massive or refractory hemodynamic instability should prompt consideration for massive solid organ or vascular injury. Patients with serious blunt abdominal trauma rarely have single-system injuries; other sources of obstructive or hemorrhagic shock should be actively sought and excluded. In general, large-bore peripheral intravenous cannula (14 or 16 gauge, placed in the bilateral antecubital fossae) provides excellent vascular access for the purpose of volume resuscitation. If major abdominal or pelvic trauma is suspected, peripheral and central lines should be placed above the diaphragm, in the subclavian or internal jugular veins. Temporary vascular access can be obtained via intraosseous placement in 1 or both humeral heads.
Intraabdominal hemorrhage resulting in hypotension requires definitive surgical treatment regardless of associated injuries. As a third space for hemorrhage, the peritoneum presents the dual dangers of a noncompressible source of bleeding that can accommodate nearly all of a patient’s circulating blood volume, making it the priority for management even in the face of other serious injuries. Traumatic brain injury (TBI), contained blunt thoracic aortic injury, extremity injuries without severe hemorrhage, and ischemia to any extremity may be addressed once hemorrhage control occurs. Patients with both major abdominal hemorrhage and a significant pelvic fracture that remains unstable after resuscitation and application of a pelvic binder are best managed in the operating room (OR) in the absence of a hybrid room. Compared with angiography, the OR is typically available immediately, and allows for management of both intraabdominal injuries and temporizing of pelvic bleeding with preperitoneal packing. Angiography can still proceed after laparotomy and preperitoneal packing if ongoing pelvic bleeding is suspected. The advent of the hybrid OR allows some institutions to bring the patient to a single location for all hemostatic procedures, including exploratory laparotomy, angiography, and orthopedic and neurosurgical interventions. This the most ideal place for the patient requiring multiple emergent procedures. TBI is often not fully characterized until a computerized tomography (CT) scan is performed, which usually occurs after hemorrhage control. If a patient has physical examination findings suggestive of severe TBI or imminent herniation, a neurosurgical team should be consulted early and ideally attend the trauma laparotomy so that emergency decompression maneuvers can be performed concurrent with laparotomy. In all situations of gross instability, the key is to achieve immediate hemostasis, often by way of a damage control laparotomy; associated injuries can be diagnosed and treated in conjunction with or immediately once early hemorrhage is stayed.
Diagnostic peritoneal aspirate (DPA) is valuable for a patient who is too unstable for CT, in whom an intraabdominal source of hemorrhage cannot be ruled out by mechanism of injury or bedside imaging. Specifically, DPA can assist in decision-making when suspicion of intraperitoneal hemorrhage remains high following an indeterminate or negative focused abdominal sonogram for trauma (FAST) examination. Similar to diagnostic peritoneal lavage (DPL), DPA involves entering the peritoneal cavity under direct visualization and placement of a DPL or central line catheter. Aspiration of 10 mL or more of frank blood in the presence of ongoing hemodynamic instability is an indication for immediate laparotomy. The lavage component can be used to detect red cells not visible on inspection or the presence of food fibers, although the utility of these findings for informing immediate surgical decision-making in grossly unstable patients is debatable.
CT imaging is contraindicated in unstable patients with an indication for laparotomy. Definitive surgical treatment should never be delayed in favor of additional imaging tests. Although well-intentioned, pursuing CT imaging in this population prolongs bleeding time without adding data to inform surgical decision-making. Similarly, transport to a trauma center should not be delayed in unstable patients in favor of CT imaging. Common indications for immediate laparotomy are listed in Box 1 .
Absolute: prepare for the operating room
- •
Ongoing or gross hemodynamic instability, with or without a positive FAST examination or DPA
- •
Generalized peritonitis
- •
Implement in situ
- •
Evisceration
- •
Relative indications: discuss with a trauma surgeon
- •
Free air on plain films or CT imaging a
- •
Signs of gastrointestinal hemorrhage with a suspected traumatic source (frank blood in the nasogastric aspirate or on digital rectal examination)
- •
Penetrating abdominal trauma: gunshot wounds (most) and stab wounds (some)
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Multisystem trauma with ongoing hemodynamic instability, where the source of injury is not known
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a Free air in the abdomen is not pathognomonic for intraabdominal injury because air may track from thoracic or external sources.
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