Blunt Abdominal Trauma – Traps for Young Players

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  1. The exact mechanism of injury and mitigating factors is an important part of risk stratification. Merely noting ‘fall from height’ or ‘T-boned front seat passenger’ is not adequate. Reference to forces involved, direction and to what part of anatomy needs to be ascertained
  2.  Signs of peritonism are specific but insensitive for serious injury. The presence of isolated tenderness even without peritonism warrants at least prolonged observation.
  3. There are no risk stratifying scoring systems for blunt abdominal trauma in adults. PECARN rules for children are highly sensitive but poorly specific. They are applicable only in early but not delayed presentations. If there is significant concern, prolonged admission with serial abdominal exam is an alternative to imaging.
  4. Hollow viscus injuries tends to have a more insidious course because intra-abdominal sepsis (not haemorrhage) is the main complication
  5. Identifying evolving signs of peritonism is a clinical diagnosis requiring a degree of practice, skill and judgement. It involves a combination of findings such as pain with movement, cough tenderness, percussion tenderness, rebound tenderness and involuntary guarding. To accurately elicit these findings requires experience. However, absence of peritonism or unwell ‘appearance’ at initial presentation does not exclude serious injury.
  6. Persistently abnormal vital signs are a red flag. They are either an indication for imaging, close serial examination or intervention.
  7.  Ultrasound is insensitive for identifying low grade solid organ injuries and any hollow viscus injury. Their main utility is in identifying significant intra-peritoneal haemorrhage or an advanced collection in unstable patients that require immediately intervention. A single ultrasound study is inadequate to rule out injury in low to intermediate risk trauma. There may be a role for serial ultrsound examinations in combination with clinical evaluation in a low-resource environment or mass casuasulty situation to identify evolving injuries.
  8. Abdominal CT is the gold standard and sensitivity is enhanced with contrast. If there is clinical concern of active bleeding (haemodynamic instability), arterial phase contrast should be administered to observe for contrast blush. Portal venous phase contrast is better for detailing organ injuries. Abdominal CT in adults is equivalent to about 500 CXRs. If minimising radiation exposure is a concern, consult a senior clinician. 7) Most serious injuries declared themselves within 24 hour. This is suggested by any of the following: increasing pain, abnormal vitals signs or changes in laboratory parameters e.g. falling haemoglobin, rising inflammatory markers, evolving metabolic acidosis.
  9. Many solid organ injuries can still be managed conservatively in adults and children but under close observation. Evidence of shock or sepsis are indications for intervention. The duration for which observation must occur in low-grade injuries injuries has not been fully established.
  10. Angiography is an alternative to surgery in selected cases of solid visceral injury even in borderline stable patients. Discuss with surgeon, radiologist and anaesthetist if this option is suitable. Resources must be in place to immediately move to laparotomy if angiography fails.
  11. Any patient who is discharged as low-risk or proven stable low-grade injury should be warned of the signs of delayed haemorrhage or sepsis e.g. increasing pain, fever, pre-syncope, persistent vomiting. haematemesis, haematochezia, haematuria and to return immediately

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