Blunt abdominal trauma is a little bit more complicated than Penetrating trauma.
Let’s start by dividing these patients into 3 main categories based on their hemodynamics. The patients are either hemodynamically stable, questionable, or unstable.
The Unstable Patient
If the patient is unstable he/she should be rushed to the OR for definitive management.
The Ehhhhh!?!?!? Patient
Patients who are hemodynamically questionable will have some degree of vital sign abnormalities. They may be tachycardic or have soft pressures. In these patients you want to begin aggressive resuscitation with blood transfusions etc. These patients have often sustained polytrauma and the goal is to figure out where they are bleeding (chest, belly, pelvis, long bone fracture). While you are resuscitating this patient a fast or DPL is performed to see if the source of bleeding is in the peritoneum .
If after resuscitation the patient is stabilizes the patient can be sent to the CT scanner for imaging. If the patient is still questionable after resuscitation the patient should be red lined to the OR.
The Stable Patient
If the patient is stable then an exam is performed to see if there is any tenderness. If the patient has tenderness then a CT scan can be performed to see if there is intraabdominal injury. If the CT is positive then the patient can be admitted or potentially taken to the OR depending on the results of the imaging studies. If the CT is negative should you just send the patient home? The answer is no. Instead, the patient should be observed. This is because initial CT scans are not super sensitive in picking up hollow viscus injuries (i.e. duodenal hematoma, perforation, etc) and pancreatic injuries. Of note: newer generation CT scanners are becoming so good that this recommendation may change.
How long should we obs patients? 1 hour, 6 hours, 12 hours, 24 hours? Unfortunately the guidelines don’t give us an exact time. As a result, it is important to see what your institutional policy is for these patients. .
If the patient has no tenderness on exam the can we just dc them? Again the best thing to do is to put the patient in obs and perform serial abdominal exams in order to not miss a hollow viscus or pancreatic injury.
Eastern Trauma Assocation Guidelines
PRACTICE MANAGEMENT GUIDELINES FOR THE EVALUATION OF BLUNT ABDOMINAL TRAUMA
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