1) The document provides an overview of the evaluation and management of abdominal trauma, including both blunt and penetrating mechanisms. 2) For blunt trauma in unstable patients, the priorities are to assess for peritonitis and perform focused assessment with sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) to detect fluid in the abdomen. 3) In stable blunt trauma, physical exam, FAST, and CT scan are used to identify injuries before considering discharge.

1. ABDOMINAL TRAUMA
Mark Boyko EM

2. Where to Start?
1. Review key aspects of abdo trauma.
2. Important imaging modalities.
3. An Approach to Blunt abdo trauma.
4. An Approach to Penetrating abdo
trauma

3. Anatomy
The anterior abdomen is defined as that
region between the anterior axillary lines
from the anterior costal margins to the groin
creases.

4. Abdominal Layers
Peritoneum
Transversalis Fascia

5. BLUNT TRAUMA
• Most commonly MVA’s
• Also involves fall from
height, assaults, sports
injuries
• Can injure solid organs
(liver, spleen) or hollow
viscus (bowel)

6. How Good is our Physical
Exam?
• Accuracy only 60%
• Serial exams q30min by same physician
does improve detection rate somewhat
• The most important thing to detect is
peritonitis

7. Question
• TRUE OR FALSE: In the setting of
abdominal trauma, absent bowel sounds
after 30 seconds of listening indicates bowel
perforation
FALSE

8. Question
Which organ is most commonly injured in
blunt abdominal trauma?
A) Liver
B) Spleen
C) Bowel
D) Pancreas
E) Bladder

9. Splenic Injury - Grading System
I - Hematoma, subcapsular <10% SA
Capsular Lac <1cm
II - Hematoma, subcapsular 10-50% SA; intraparenchymal <5cm
Capsular Lac 1-3cm
III - Hematoma, subcapsular >50% SA; intraparenchymal >5cm
Capsular Lac >3cm (or parenchymal depth)
IV - Hematoma ruptured into parenchyma
Hilar Injury devascularizing spleen >25%
V - Vascular hilar injury devascularing spleen 100%, or
‘Shattered’

10. Splenic Injury - Grade 4

11. Question
• How soon will you see signs of
retroperitoneal hemorrhage?
A) 30 min
B) 1-2 hrs
C) 4-6 hrs
D) 8-12 hrs
E) >12 hrs

12. Question
TRUE or FALSE: The ‘seat belt sign’ is a
strong indicator of serious abdominal injury
TRUE

13. The American Surgeon 1999
Feb;65(2):181-5.
• Prospective Study of 410 patients,
restrained MVC occupants, 77 had ‘seat
belt sign’. 23% with sign had serious
intrabdominal injury vs 3% without.
Have a high index of suspicion!

15. Physical Exam
BOTTOM LINE: In the trauma patient, a
‘normal’ physical exam of the abdomen
doesn’t equate to much. You NEED to do
further testing.

16. Trauma Labs
Can you name the complete list of trauma labs
ordered at FMC?
•CBC, lytes, Cr, Glucose
•EtOH
•PT/INR
•Type & Screen
•Urinalysis

17. Trauma Labs
• WBC or Hct not particularly helpful in first
few hours
• Amylase/Lipase not helpful for pancreatic
trauma
• LFT’s can indicate trauma, but gives no
indication of the severity.
• BOTTOM LINE: Other than Hgb, your
labs do not guide your clinical management

18. Imaging in Abdominal Trauma
• Plain films generally have NO ROLE in
acute abdominal trauma
• What else do we have?
– FAST ultrasound
– Diagnostic Peritoneal Tap
– CT Scan

19. FAST Ultrasound
The real role of FAST ultrasound is to:
A) Determine who needs a CT scan
B) Determine who needs urgent laparotomy
C) Determine extent of organ damage
D) To look for babies
E) To look cool

20. Question
FAST ultrasound is now called e-FAST…
what does the ‘e’ stand for?
Extended…
Lung bases

21. FAST - Looking for Free Fluid

22. FAST Ultrasound - How Good is
it?
•85% SENS for detecting ANY abdominal trauma
•97% SENS for detecting SURGICALLY
SIGNIFICANT abdo trauma
•100% SENS for all FATAL injuries
Farahmand N, Sirlin CB, Brown MA, et al. Hypotensive patients with blunt abdominal
trauma: performance of screening US. Radiology 2005;235:436–43

23. FAST Ultrasound
Advantages
• Sensitivity at detecting 100cc fluid is 60-95%
• No radiation
Disadvantages
• It is less sensitive and more operator-dependent than
DPL in revealing hemoperitoneum
• Cannot distinguish blood from ascites
• Says nothing about solid organ damage; Chiu et al.
showed 28% solid organ injury despite a normal FAST

24. Diagnostic Peritoneal Taps
Question: What is considered a ‘positive’
peritoneal aspirate?
10 cc of frank blood

25. Diagnostic Peritoneal Taps
DPA - The recovery of 10 cc of frank blood (or more) from the
peritoneum is a strong predictor (90% PPV in blunt trauma) of
intraperitoneal injury, and the procedure is then terminated.
DPL - If aspiration findings are negative, lavage is conducted
in which the peritoneal cavity is washed with saline. RBC
count exceeding 100,000/cc is considered positive and
generally specific for injury. Sensitivity 90%.

26. Diagnositic Peritoneal ‘Lavage’
• Is actually a 2 Step Process.
Step 1. DPA (closed).
• Patient supine
• Landmark is 2 fingerwidths below umbilicus
• Local freezing, puncture skin 30-degrees to the head
• Seldinger technique to introduce a DPL catheter
• Aspirate using 30cc syringe

29. DPA
• Advantages
– Highly accurate for hemoperitoneum (SENS
90-100%)
– Most sensitive test for hollow viscus injury
• Disadvantages
– Invasive (complication rate 1-5%)
– Time consuming (20 minutes)
– False positives. Up to 25% non-therapeutic
laparotomies

30. DPA
• If 10cc frank blood or more is aspirated,
you are done, patient needs to go to the OR.
• If the DPA is negative, you proceed to Step
2…

31. Diagnostic Peritoneal Lavage
Step 2. DPL.
• Hook up 1L of Ringer’s to the peritoneal catheter,
and squeeze into the abdomen.
• Once infused, put the empty Ringer’s bag on the
floor, and let it back-fill via gravity
• Send off 10cc for analysis, if 100,000 RBC/cc it is
positive

32. Is there still a role for DPA?
• FAST has largely replaced DPA, likely due
to ease of use.
• However, 2 areas where still is warranted:
– Hemodynamically unstable and an equivocal
FAST
– No FAST available
• “DPL is safe, sensitive, and reduces the use
of CT” (Journal of Trauma 2007)

33. FAST vs DPL
• Journal of Trauma 2007. “Are Diagnostic Peritoneal Lavage or
Focused Abdominal Sonography for Trauma Safe Screening
Investigations for Hemodynamically Stable Patients After Blunt
Abdominal Trauma? A Review of the Literature”
– Screening diagnostic peritoneal lavage and selective CT is a safe diagnostic
strategy for the investigation of blunt abdominal trauma. Further research is
needed to determine the role of focused abdominal sonography for trauma
scanning in diagnostic protocols.
• Emerg Med Clin North Am. 1999 Feb;17(1):63-75, viii.
– The sensitivity of FAST has been reported as anywhere between 42% and
93%
– The sensitivity of DPL for detecting significant intra-abdominal injury has
been reported to range from 82% to 96%
• Cochrane Review 2005 - “there is insufficient evidence to justify the use of
ultrasound as part of the diagnosis of patients with abdominal injury… in

34. CT Scan
• The imaging modality of choice in blunt
abdominal trauma
• SENS 92-96%, SPEC 97% (CAEP, Review
Lavage)
• The organ that brings down CT sensitivity
is the pancreas – only 80% sensitive

35. CT Scan - Bowel Injury?
• CT SENS for bowel injury >90%, enough
to allow immediate d/c from ER (used to
have lower sensitivity which would require
monitoring even after negative CT)
• Protocol: CT with IV contrast only is
equivalent to CT with oral/IV contrast in
trauma

36. BLUNT ABDO TRAUMA:
AN APPROACH
The Unstable Patient
vs
The Stable Patient
… it’s as easy as 1-2-3

37. The UNSTABLE Patient
STEP 1. Is there peritonitis? YES or NO.
YES goes to the OR.

38. The UNSTABLE Patient
STEP 2. Do a FAST.
If positive If negative
To the OR Look for
another area of injury

39. The UNSTABLE Patient
STEP 3. If no other obvious area of injury, do
a DPA.
If positive If negative
To the OR … try and stabilize, get CT

40. The STABLE Patient
STEP 1. Can you evaluate them? (poor
GCS, intoxication)
YES NO
Do Phx CT Scan

41. The STABLE Patient
STEP 2. Is there peritonitis?
YES NO
To the OR …do a FAST

42. The STABLE Patient
STEP 3. Do a FAST.
If positive If negative
Get CT Scan Serial exam q12hrs

43. “Injury Severity Scale”
0 -75
6 areas of the body:
• Head & Neck
• Face
• Chest
• Abdomen
• Extremity
• External
6 options for
injury:
1. Minor
2. Moderate
3. Serious
4. Severe
5. Critical
6. Unsurvivable

44. Example
Region Injury Injury
Score
Square Top
Three
Head&Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion Liver
Complex Rupture Spleen
2
5 25
Extremity Femur # 3
External No Injury 0
Total ISS: 50

46. “Revised Trauma Score”
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
GCS SYS BP RR Score
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

48. Take a breather…
Guinness World Record - Longest Time
Waiting for a Bed at a Hospital?

49. Take a breather…
Guinness World Record - Longest Time
Waiting for a Bed at a Hospital
Tony Collins, United Kingdom 2001 - waited
77hrs, 30 min on a stretcher in a hallway.
Diagnosis was “viral illness”.

50. PENETRATING Abdo Trauma

51. Question
Most commonly injured organ in penetrating
trauma?
A) Liver
B) Spleen
C) Bowel
D) Kidney
E) Bladder

52. Stab Wounds
• 3x more common than firearms, but
firearms will kill more
• Used to be ‘mandatory exploration’, this is
changing
• 70% of the time your peritoneum is
violated, but only 25% require the OR
• Any stab wound to the lower chest, back,
flank or pelvis has entered the abdominal
cavity until proven otherwise

53. Stab Wounds - Non operative
Management
• No peritonitis,
• No evisceration,
• No hemodynamic instability
…can be safely selected for non-operative
care

54. Gunshot Wounds
• Bullets do not move in straight lines,
anything can be injured
• Trauma surgeon will want to know type of
gun, estimate of distance, number of shots,
etc.
• Look carefully in the folds (axilla, groin)
• Count your bullet holes! Even is good, odd
is bad.

55. Imaging in Penetrating Trauma
• Plain films have a better role here than in
blunt abdo trauma
• Can give you an idea of bullet trajectory, or
remains of steel implementation

56. Question
TRUE or FALSE: FAST ultrasound has a
role in penetrating trauma.
TRUE

57. FAST in Penetrating Trauma
– FAST is now being used for penetrating
trauma.
– A positive FAST has a positive predictive value
of >90 percent, but a negative FAST does not
rule out peritoneal violation.
– Sensitivity 60-90% in early studies

58. DPA/DPL
• Known to have very high sensitivity for
intrabdominal injury from gunshot wounds
• 10,000 RBC/cc threshold gives SENS 96%
• Only tells you if there is blood in the
abdomen, doesn’t tell you which organ is
affected
If normal CT --> Observe / discharge

59. CT Scan
• Stab or Gunshot - SENS 97%, SPEC 98%
with triple contrast, but a recent study
shows only IV contrast approaches same
numbers

60. An APPROACH - Penetrating
Trauma
2 BIG QUESTIONS:
1. Has the peritoneal lining been disrupted?
2. If so, is there organ injury?

61. An APPROACH
STEP 1. The following are DIRECT TO OR in penetrating
trauma:
1. Hemodynamic Instability. Ensure you have ruled out an intrathoric
cause for this ie hemothorax, pneumothorax, tamponade.
2. Peritoneal Signs. Strong NPV if totally normal. Grey area for ‘equivocal’
patients.
3. Evisceration. This one is obvious.
4. Diaphragmatic injury – left sided.
5. Frank GI Bleeding. Blood back from NG tube or frank hematemesis.
6. Implements in Situ. Do NOT remove this in the ER unless it is hindering
your resuscitation effort.
7. Free air. Fairly non-specific finding, take it in context (have they had a
recent laparotomy, is their an involved lung injury?)

62. Diaphragmatic Rupture

63. An APPROACH
STEP 2. Has the peritoneal lining been
disrupted?
1. Free air on radiograph.
2. Local wound exploration.
3. FAST. Helpful if positive.
4. Laparoscopy
BOTTOM LINE: If you cannot confidently
rule it out, assume it has been disrupted.

64. Local Wound Exploration
• Do we actually do this??
• “Local wound exploration remains a valuable triage
tool for the evaluation of anterior abdominal stab
wounds” -The American Journal of Surgery 2009
• “Non-operative Management of Abdominal Gunshot
Wounds” -Annals of Emergency Medicine 2004… “local
wound exploration should not be used in gunshot wounds”.

65. An APPROACH
STEP 3. Is there an injury that requires
operative repair?
CT Scan
Normal CT --> Observe / discharge

66. Non-operative Management of
Penetrating Trauma
• Gaining favour
• A number of recent studies showing the use
of CT Scan and serial physical exams can
keep people out of the OR
• Annals of Surgery 2001 Prospective Study –
1856 patients, 42% treated non-operatively
-> decision made on Phx and CT, majority
of these d/c home without an operation.

67. So… In Summary
BLUNT TRAUMA
UNSTABLE PATIENT!

68. UNSTABLE
1. Is there peritonitis? YES or NO
2. Is there a positive FAST? YES or NO
3. Is there a positive DPA? YES or NO
CT Scan is your friend.

69. In Summary
BLUNT TRAUMA
STABLE PATIENT…

70. STABLE
Relax….
1. Can you evaluate them? YES or NO
2. Is there peritonitis? YES or NO
3. Is there a positive FAST? YES
or NO

71. In Summary…
PENETRATING TRAUMA
UNSTABLE PATIENT!

72. UNSTABLE
1. Do they have a ‘Direct to OR’ indication?
YES or NO
2. Is there a positive FAST? YES or NO
3. Is there a positive DPA? YES or NO
Xray and CT Scan are your friends.

73. In Summary…
PENETRATING TRAUMA
STABLE PATIENT…

74. STABLE
Relax…
1. Has the peritoneal lining been disrupted?
YES or NO
2. If so, is there organ injury?
YES or NO

75. Ask Me For References
• Questions??