Rosen & Barkin's 5-Minute Emergency Medicine Consult (19 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Abdominal Trauma, Blunt
  
• Abdominal Trauma, Penetrating
  

CODES

• 88.02 Other abdomen tomography
  
• 88.19 Other x-ray of abdomen
  
• 88.76 Diagnostic ultrasound of abdomen and retroperitoneum
  

BASICS

• Solid organ injury usually results in hemorrhage.
  
• Hollow viscus injury can lead to spillage of bowel contents and peritonitis.
  
• Associated conditions:
  
  • Injury to both thoracic and abdominal structures occurs in 25% of cases.
    

80% of gunshot wounds and 20–30% of stab wounds result in significant intra-abdominal injury. Commonly injured structures include:

• Liver (37%)
  
• Small bowel (26%)
  
• Stomach (19%)
  
• Colon (17%)
  
• Major vessel (13%)
  
• Retroperitoneum (10%)
  
• Mesentery/omentum (10%)
  
• Other:
  
  • Spleen (7%)
    
  • Diaphragm (5%)
    
  • Kidney (5%)
    
  • Pancreas (4%)
    
  • Duodenum (2%)
    
  • Biliary (1%)
    

DIAGNOSIS

• Penetrating wound from knife, gun, or other foreign object
  
• Spectrum of presentation ranging from localized pain to peritoneal signs:
  
  • High-velocity projectile can cause extensive direct tissue damage.
    
  • Secondary missiles and temporary cavitation of effected structures
    
  • Exit wound may be larger than entrance wound, but small entrance and exit wounds can conceal massive internal damage.
    
• Remember the borders of the abdomen: Superior from the nipples (anteriorly) or inferior tip of scapula (posteriorly) to inferior gluteal folds.
  

• Diagnosis of intra-abdominal injury from gunshot wounds to the abdomen are made by laparotomy in the operating room.
  
• Locally explore stab wounds to anterior abdomen:
  
  • If the wound penetrates the anterior fascial layer, the patient should undergo diagnostic peritoneal lavage or bedside US.
    
• Diagnostic laparoscopy is useful in diagnosing diaphragmatic injury and spleen and liver lacerations:
  
  • May help avoid unnecessary surgery.
    
• CT is useful in the evaluation of patients with a suspected retroperitoneal injury:
  
  • Not reliable for detection of hollow viscus or diaphragmatic injuries
    
• If 10,000 RBC/mm
  ³
  or more are found in the diagnostic peritoneal lavage fluid, the patient should undergo laparotomy.
  
• If <10,000 RBC/mm
  ³
  are present, the patient should be observed for 8–24 hr for the development of peritoneal signs.
  

• Hemoglobin or hematocrit:
  
  • Repeated measurements to assess for ongoing hemorrhage
    
• Urinalysis for blood to assess for possible genitourinary tract damage
  
• ABG:
  
  • Base deficit may be helpful in assessing hypovolemia and guide volume resuscitation.
    
• Type and cross-match for all patients with significant intra-abdominal injuries.
  

• Plain films:
  
  • Obtain after placement of markers for localization of foreign bodies, missiles, associated fractures, and free air.
    
• IV pyelogram:
  
  • For possible renal injury
    
• Bedside abdominal US (FAST: Focused abdominal sonography for trauma):
  
  • May reveal intraperitoneal blood or fluid
    
• CT with IV contrast in experienced facilities and with stable patients:
  
  • For possible retroperitoneal and solid organ injuries
    

• In cases of upper abdominal wounds, consider the possibility of intrathoracic injury.
  
• In cases of wounds to the lower thoracic area, consider the possibility of intra-abdominal injury.
  

TREATMENT

• Controversies:
  
  • Military antishock trousers (MAST) should not be used.
    
  • Titrate fluid resuscitation to clinical response.
    
• Caution:
  
  • Apply sterile dressings to open wounds and moistened sterile dressings to eviscerated bowel.
    
  • Secure impaled foreign objects in place; do not remove them.
    

• 2 large-bore IV lines with crystalloid infusion
  
• If no response to 2 L of crystalloid, infuse 2–4 units packed red blood cells:
  
  • May use O negative blood initially if patient is unstable
    
  • Type-specific and cross-matched blood when it becomes available
    
• 100% oxygen by nonrebreather face mask
  

• Children in hypovolemic shock should receive 20 mL/kg boluses of crystalloid.
  
• Children in severe hypovolemic shock should receive 1 mL/kg of packed red blood cells.
  
• Age <8 yr is a relative contraindication for diagnostic peritoneal lavage.
  

• Nasogastric tube placement:
  
  • Will decrease aspiration risk
    
  • Place nasogastric tube before performing diagnostic peritoneal lavage to decompress stomach and reduce risk of iatrogenic injury.
    
  • May relieve respiratory distress in cases of diaphragmatic injury with herniated abdominal contents in the thorax
    
• Foley catheter placement:
  
  • Insert after ruling out urethral injuries
    
  • Facilitates rapid assessment of genitourinary injury
    
  • Assists in monitoring of urinary output
    
• Tetanus if appropriate; tetanus immunoglobulin if primary tetanus series not administered
  

• Tetanus: 0.5 mL IM
  
• Tetanus immunoglobulin: 250 units IM for patients who have not had a complete series
  
• IV antibiotics: Antibiotics with coverage against gram-negative and anaerobic organisms:
  
  • Ampicillin/sulbactam:
    
    • Adults: 3 g q6h IV (peds: 50 mg/kg IV)
      
  • Cefotetan:
    
    • Adults: 2 g q12h IV (peds: 40 mg/kg IV)
      
  • Cefoxitin:
    
    • Adults: 2 g q6h IV (peds: 80 mg/kg q6h IV)
      
  • Piperacillin/tazobactam:
    
    • Adults: 3.375 g IV (peds: 75 mg/kg IV)
      
  • Ticarcillin/clavulanate:
    
    • Adults: 3.1 g IV (peds: 75 mg/kg IV)
      
• Additional anaerobic coverage:
  
  • Clindamycin:
    
    • Adults: 600–900 mg IV (peds: 10 mg/kg IV)
      
  • Metronidazole:
    
    • Adults: 1 g IV (peds: 15 mg/kg IV)
      
• Combination therapy:
  
  • Adults: Ampicillin 500 mg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 1 g IV
    
  • Peds: Ampicillin 50 mg/kg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 15 mg/kg IV
    

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