Summary

Abdominal trauma refers to injury to the abdomen from external forces, classified as blunt (MVA, falls, assault) or penetrating (stab wounds, gunshot wounds). It is a leading cause of preventable death in trauma patients. The abdomen is the third most commonly injured region. Blunt trauma typically injures solid organs (spleen, liver, kidney), while penetrating trauma has higher rates of hollow viscus injury. Management ranges from non-operative observation for stable solid organ injuries to emergent laparotomy for hemodynamic instability or peritonitis.

Key Facts

• Incidence: 10% of trauma deaths; abdomen is 3rd most injured region
• Blunt trauma: 80-90% of abdominal trauma cases
• Most commonly injured (blunt): Spleen, followed by liver
• Most commonly injured (penetrating): Small bowel
• Laparotomy rate: GSW approximately 80-90%, stab wounds approximately 25-30%
• Key decision: Hemodynamic stability determines operative vs non-operative management

Clinical Pearls

FAST Positive + Unstable = Theatre: Do not delay for CT. Positive FAST in a hemodynamically unstable patient mandates emergent laparotomy.

Seatbelt Sign: Ecchymosis across abdomen from seatbelt increases risk of hollow viscus and mesenteric injury. Have high suspicion even if initial imaging appears reassuring.

Delayed Splenic Rupture: Can occur hours to weeks after injury. Warn patients about warning signs at discharge.

Why This Matters Clinically

Missed abdominal injury leads to preventable death. Rapid identification using FAST, appropriate resuscitation with damage control principles, and timely operative intervention when indicated saves lives. Non-operative management of solid organ injuries has transformed outcomes in stable patients.

Structured Approach

General:

• Hemodynamic status (HR, BP, lactate)
• Level of consciousness
• Evidence of shock (pale, clammy, confused)

Abdominal Examination:

• Inspect: wounds, seatbelt sign, distension, evisceration
• Palpate: tenderness, guarding, rigidity
• Percussion: shifting dullness (blood), tympany (free air)
• Auscultate: absent bowel sounds, bowel sounds in chest (diaphragm rupture)

Adjuncts:

• Log roll: inspect back for wounds
• Perineal exam: blood at meatus (urethral injury)
• Rectal exam: high-riding prostate, gross blood

Special Tests

Natural History

• Untreated solid organ hemorrhage leads to exsanguination and death
• Untreated hollow viscus injury leads to peritonitis, sepsis, and death
• Delayed recognition increases mortality significantly

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Early recognition and intervention
• Single organ injury
• Low-grade injury
• Young, fit patient
• Rapid access to trauma center

Poor Prognosis:

• Multi-organ injury
• Delayed presentation
• Elderly or comorbid patient
• Associated head injury
• Coagulopathy (lethal triad)

Key Guidelines

1. ATLS 10th Edition (2018) — American College of Surgeons. Standard trauma management principles. ACS ATLS
2. Eastern Association for the Surgery of Trauma (EAST) — Practice management guidelines for solid organ injuries. EAST Guidelines
3. Western Trauma Association (WTA) — Critical decisions in trauma. WTA

Landmark Trials

PROPPR Trial (2015) — Transfusion ratios in trauma

• 680 patients with severe trauma
• Key finding: 1:1:1 ratio (pRBC:FFP:Platelets) achieved hemostasis faster than 1:1:2
• Clinical Impact: Established 1:1:1 as standard in massive transfusion

CRASH-2 Trial (2010) — Tranexamic acid in trauma

• 20,211 patients
• Key finding: TXA reduced mortality if given within 3 hours (RR 0.85)
• Clinical Impact: TXA now standard in bleeding trauma

NOM for Solid Organ Injury Studies — Multiple observational series

• Demonstrated high success rates (greater than 90%) for non-operative management of stable solid organ injuries
• Clinical Impact: NOM is now standard of care for stable patients

Evidence Strength

What is abdominal trauma?

Abdominal trauma means your belly has been injured, either from a direct blow (like in a car crash or fall) or from something sharp (like a knife or gunshot). Inside your belly are important organs like your liver, spleen, kidneys, and intestines. These can be bruised, torn, or bleeding.

Why does it matter?

Some injuries cause internal bleeding that you cannot see. This can be very dangerous if not found quickly. Other injuries can release infection into your belly (if the intestines are torn). Both situations can be life-threatening.

How is it treated?

1. Observation: For smaller injuries to solid organs (liver, spleen, kidney), we often watch you closely in hospital without surgery. We check your blood levels and examine you regularly.
2. Blood transfusion: If you are bleeding significantly, we give you blood transfusions.
3. Surgery: If bleeding is severe or cannot be controlled, or if your intestines are injured, you will need an operation.
4. Special procedures: Sometimes we can stop bleeding with a procedure done through your blood vessels (angioembolization) without a big surgery.

What to expect

• If you had a solid organ injury treated without surgery, you will need to rest and avoid contact sports and strenuous activity for 4-6 weeks
• You may need a follow-up scan to check healing
• Most people recover fully

When to seek help

Return to hospital immediately if you experience:

• Worsening abdominal pain
• Dizziness, fainting, or feeling lightheaded
• Blood in your urine or stool
• Shoulder tip pain (can indicate internal bleeding)
• Fever
• Feeling unwell or "not right"

The "Trauma Call" Scenario

1. Primary Survey (Abdomen)

• Look: "Seatbelt sign" (strip the patient). Distension. Evisceration. Stab wounds (log roll to check back).
• Feel: Rigid? Guarding? (Signs of peritonitis = Laparotomy).
• Listen: Useless in trauma bay (too noisy).

2. The eFAST Scan (Extended Focused Assessment with Sonography for Trauma)

• Question: "Is there free fluid?" (Yes/No). NOT "Is the spleen injured?".
• 4 Views:
  1. RUQ (Morrison's Pouch): Liver/Kidney interface. Most sensitive spot (fluid falls here).
  2. LUQ (Splenorenal): Spleen/Kidney.
  3. Pelvic (Suprapubic): Bladder/Rectum (Pouch of Douglas).
  4. Subxiphoid: Pericardial effusion (Tamponade).
  5. Extended: Lung sliding (Pneumothorax).

3. Interpreting CT Trauma

• Contrast Phases:
  • Arterial: Active bleeding ("Blush"), Artery dissection.
  • Portal Venous: Parenchymal injury (Lacerations suitable for grading).
  • Delayed: Urine leaks (Ureter/Bladder).

Viva Questions:

• Q: Define the Lethal Triad.
  • A: Coagulopathy, Acidosis, Hypothermia.
• Q: What are the indications for immediate Laparotomy in trauma?
  • A: Unstable + Positive FAST/DPL, Peritonitis, Evisceration, GSW (trans-abdominal).
• Q: What is the significance of a Seatbelt Sign?
  • A: High association with hollow viscus (bowel) injury and mesenteric tears.
• Q: Explain "Permissive Hypotension".
  • A: Targeting SBP 80-90mmHg to prevent clot disruption ("Popping the clot") while maintaining cerebral perfusion, until hemostasis is achieved. Contraindicated in TBI.