1) The learner recognized signs of hemorrhagic shock in a patient with blunt abdominal trauma and initiated aggressive resuscitation with intravenous fluids and blood products. 2) Bedside ultrasound revealed free fluid in the Morrison's pouch, indicating possible intra-abdominal bleeding. 3) Given the unstable condition of the patient, the learner appropriately called for an emergency laparotomy without delaying for further imaging studies.

1. Trauma– Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPH

2. Learning Objectives
• Recognize and respond appropriately to a
patient with hemorrhagic shock
• Assess via bedside methods the source
of hemorrhage
• Respond appropriately to evidence of
intra-abdominal hemorrhage with regards
to initial management and disposition

3. Introduction
• Blunt abdominal trauma is common.
• Unknown history, distracting injuries, and
altered mental status make these patients
difficult to diagnose and manage.
• Victims frequently have both abdominal
and extraabdominal injuries.
• Family physicians need to be able to
recognize and treat hemorrhagic shock.

4. Recognition of Hemorrhagic Shock
• Shock: oxygen delivery < tissue demands
• Treatment must restore tissue perfusion not
just blood pressure
• Shock does NOT SBP < 90mmHg
• Recognition includes: mechanism of injury,
patient’s appearance, vitals, level of
mentation, peripheral perfusion and urine
output
• Clinical parameters should be coupled with
objective markers of tissue perfusion--serum
lactate, base deficit, etc.

5. Practical Diagnosis of Shock
• Perform a targeted physical examination
• Diagnostic testing should include chest
radiography, pelvis radiography, and
bedside ultrasound
• Objective serum makers of tissue
perfusion (serum lactate or base deficit)
• Point of care H/H, send CBC, type/cross
• DON’T delay resuscitation for lab results

6. 6 Steps to Treat Hemorrhagic Shock
• Step 1: Effectively manage the airway and
optimize oxygenation.
• Step 2: Identify and control immediate threats to
central perfusion.
• Step 3: Identify and address severe intracranial
injuries.
• Step 4: Identify and control other potentially life-
threatening thoracic and abdominal injuries.
• Step 5: Identify and control potentially limb-
threatening injuries.
• Step 6: Identify and treat noncritical injuries.

7. Treatment of Hemorrhagic Shock
• Obtain immediate type and crossmatch
for 6-8 units of blood
• Massive transfusion defined as > 10 U of
PRBCs in 24 hrs
• Consider use of PRBC to platelet to FFP
ratio of 1:1:1
• May result in decreased need for blood
products
• Give calcium to prevent citrate toxicity

8. Assessing for Sources of Hemorrhage
• Chest radiography:
• Tension pneumothorax? Massive hemothorax?
Aortic injury?
• Pelvis radiography:
• Pelvic ring disruption?
• Focused Assessment with Sonography for
Trauma (FAST):
• Pneumo/hemothorax? Hemopericardium?
Hemoperitoneum?
• If positive, then emergency laparotomy.
• If negative, continue resuscitation, treat other causes.

9. FAST Facts
• Reliably identifies 200-250ml of
intraperitoneal fluid
• Cannot reliably evaluate
retroperitoneum/hollow viscous injury
• Sensitivity/specificity: 75%/98%, NPV:
94%; 86-97% accurate
• Performed using a curvilinear 2.5 or 3.5
MHz probe

10. FAST Views
• Cardiac: parasternal or subxiphoid,
hepatocardiac interface, pericardial space.
• RUQ: hepatorenal interface (Morrison’s
Pouch), diaphragm, inferior pole of kidney.
• LUQ: splenorenal interface, diaphragm,
inferior pole of kidney, inferior tip of spleen.
• Suprapubic: outline of bladder, silhouette of
uterus (females).

11. FAST Algorithm
• Unstable patient: + FAST = OR.
• Stable pt: + FAST = abdominal CT.
• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.
• CT is the “Gold Standard”.

12. What About Diagnostic Peritoneal
Aspiration (DPA)?
• Can be performed if - FAST in blunt
abdominal trauma.
• If DPA +, then emergency laparotomy.
• If DPA -, then seek and treat other
sources.
• Perform serial abdominal exams.
• Perform serial FAST exams.
• If patient stabilizes, then CT.
• Get surgery involved!

13. Indications for Emergency
Laparotomy
• Peritonism
• Free air under the diaphragm
• Significant gastrointestinal hemorrhage
• Hypotension with + FAST scan or + DPA
• Do NOT keep trauma patients if you lack
resources to care for them!

14. Summary
• Recognize and treat hemorrhagic shock
aggressively with blood products
• Assess for hemorrhage with bedside
methods: CXR, pelvis, and FAST
• Unstable patient: + FAST = OR.
• Stable pt: + FAST = abdominal CT.
• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.

15. References
1. Puskarich MA. Initial evaluation and management of blunt
abdominal trauma in adults. In: UpToDate, Hockberger RS,
Moreira ME (Ed), UpToDate, Waltham, MA, 2012.
2. Nickson C. “Trauma! Blunt abdominal trauma decision
making.” Weblog entry. Life in the Fastlane Blog.
http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/
3. Eastern Association for the Surgery of Trauma Guidelines
Workgroup. Evaluation of blunt abdominal trauma. 2010
Edition. Chicago, IL.
http://www.east.org/resources/treatment-
guidelines/category/trauma
4. American College of Surgeons. ATLS Textbook, 9th Edition. 1
September 2012.

16. Simulation Training Assessment Tool
(STAT)– Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPH, FAAFP

17. CRITICAL ACTIONS ME NI M SUSTAIN IMPROVE
Completes Primary Survey:
recognizes shock
MK2
Safety net – IV, oxygen,
monitors (2 x 16G IV)
MK2
Completes Secondary Survey:
recognizes abdominal source
MK2
Completes bedside FAST
(+ Morrison’s Pouch)
PC5
Recognizes positive FAST: calls
surgery
PC5
Bedside labs: POC CBC, lactate,
BAL, VBG, blood type/screen/X-
match
MK2
Bedside rads: port chest, lat C-
spine, AP pelvis
MK2
Gives emergency release blood
transfusion
MK2
If unstable: no CT, to OR
If stabilizes: CT, then OR
MK2
TOTAL
SBP
4
SCENARIO ALGORITHM
SET UP:
“Rural” ER Simulated Room
Bedside US and/or FAST simulator
Real patient with simulated skin/abdomen
PRE ARRIVAL:
FP in rural ER, lab, rad, OR
35 y/o male s/p unrestrained driver MVA
arrives via EMS, in c-collar. VS BP 90/50, HR
110, RR 18, SpO2 97% on RA, GCS 15
ARRIVAL:
Full spinal precautions, has 1 IV in place. Pt
awake, alert, conversing, but in mild distress,
no meds, no allergies, no sig PMHx or PSHx
PRIMARY SURVEY:
A – talking initially, then somnolent
B – labored, RR 24, nl breath sounds
C – BP 85/40, HR 130, cool extremities
D – GCS 14, somnolent, oriented to person
when responds to voice
E – no other trauma, mild abd distension,
hypoactive BS
SECONDARY SURVEY:
Other exam normal, c-spine non tender,
pelvis stable, rectal guaiac negative
Abdominal exam tense, tender, absent BS
LABS & IMAGES:
Chest, c-spine, pelvis negative
Labs – WBC 9, H/H 8/24, platelets 150,
lactate 4, VBG: 7.35/46/40/50%/-8
Positive FAST in RUQ, no CT indicated
Blood type and screen/X-match
DISPOSITION:
Must transfuse blood , call Surgeon and direct
to OR, otherwise pt dies of hemorrhage
Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma
Date: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s):
Learning Objectives:
1. Recognize and respond appropriately to a patient with hemorrhagic shock.
2. Assess via bedside methods the source of hemorrhage.
3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial
management and disposition.
ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)

19. Perihepatic

20. Perihepatic

21. Perisplenic

22. Perisplenic

23. Pelvic

24. Pelvic

25. Pericardium

26. Pericardium