Rosen & Barkin's 5-Minute Emergency Medicine Consult (657 page)

Delay in diagnosis of 1–2 days is common and increases morbidity.

TREATMENT

• Standard advanced trauma life support protocols, including airway, breathing, and circulation management
  
• Aggressive fluid resuscitation, central line suggested with pressure infusion of warmed IV fluid (lactated Ringer solution or normal saline)
  
• Cover eviscerated small bowel with moist gauze; do not remove impaled foreign body in ED.
  

• Immediate transfer to OR is required for patients with an indication for laparotomy:
  
  • Evisceration
    
  • Abdominal pain with hypotension
    
  • Positive DPL or abdominal CT
    
  • Thoracic abdominal herniation visualized on chest radiograph
    
  • Impaled foreign body
    
  • Penetrating gunshot wound to the abdomen
    
  • Tetanus and antibiotic prophylaxis should be given for penetrating abdominal wounds and blunt injury requiring surgical exploration.
    
• Local wound exploration is safe for abdominal stab wounds.
  
• Serial abdominal exams and observation for otherwise stable patients
  
• Judicious analgesia as BP permits after diagnosis is established
  

• Cefotetan (Cefotan): 1–2 g (peds: 20 mg/kg) IV q12h
  or
  
• Cefoxitin (Mefoxin): 1–2 g (peds: 40 mg/kg) IV q6h
  or
  
• Ceftizoxime (Cefizox): 1–2 g (peds: 50 mg/kg) IV q8–12h
  +
  
• Metronidazole: 500 mg (peds: 7.5 mg/kg) IV q6h
  

FOLLOW-UP

• Indication for laparotomy
  
• Abnormal mental status/intoxication with abdominal injury
  
• Presence of abdominal pain, tenderness (even with a negative workup) mandates admission for observation and serial exams.
  
• Stab and gunshot wounds that violate the abdominal fascia, positive DPL, or worsening findings on clinical exam
  

• Minimal mechanism blunt trauma in a sober patient with normal exam result who has no abdominal pain and will receive adequate follow-up
  
• Explicit discharge instructions to return for worsening signs/symptoms are important to identify those with unsuspected injury.
  
• Penetrating wounds that do not violate abdominal fascia
  

Discharged patients who develop abdominal complaints should return promptly to the ED.

• Small-bowel injury should be considered in any blunt/penetrating abdominal trauma victim.
  
• Initial presentation of patients with small-bowel injuries may be unimpressive.
  
• Presence of a “seat belt sign” doubles the risk for small-bowel injury.
  
• CT scanning may miss a significant percentage of small-bowel injuries.
  
• Observation and serial exams are an important aspect of detecting occult injuries.
  

• CDC Fact Sheet “Blast Injuries: Abdominal Blast Injuries” 2009. Available at
  www.emergency.cdc.gov/Blastinjuries
  .
  
• Cordle R, Cantor R. Pediatric trauma. In: Rosen P, ed.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. St. Louis, MO: CV Mosby; 2009.
  
• Diercks DB, Mehrotra A, Nazarian DJ. Clinical policy: Critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma.
  Ann Emerg Med
  . 2011;57:387–404.
  
• Gross E, Martel M. Multiple trauma. In: Rosen P, ed.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. St. Louis, MO: CV Mosby; 2009.
  
• Herr S, Fallat ME. Abusive abdominal and thoracic trauma.
  Clin Ped Emerg Med
  . 2006;7:149–152.
  

CODES

• 863.20 Injury to small intestine, unspecified site, without open wound into cavity
  
• 863.29 Other injury to small intestine, without mention of open wound into cavity
  
• 863.30 Injury to small intestine, unspecified site, with open wound into cavity
  

BASICS

• Suspect smoke inhalation in anyone involved in a fire within a closed space or with a history of loss of consciousness.
  
• May cause direct injury to the upper (supraglottic) airway structures
  
• May cause chemical/irritant effect to lower airway structures
  
• May cause systemic toxicity from inhaled substances
  

• Direct heat injury from heated gases/smoke:
  
  • Limited to supraglottic structures because of the heat-dissipating properties of the upper airway
    
• Irritant effect from smoke components
  
• Systemic toxicity from inhaled cellular toxins:
  
  • Carbon monoxide
    
  • Hydrogen cyanide
    

DIAGNOSIS

• Exposure to a fire or heavy smoke
  
• Typically in a confined space
  
• Maintain high index of suspicion with history of loss of consciousness
  

• May have a normal physical exam with symptoms developing during the 24-hr interval following exposure
  
• Upper airway (supraglottic):
  
  • Nasopharyngeal irritation
    
  • Hoarseness
    
  • Stridor
    
  • Cough
    
• Lower airway:
  
  • Chest discomfort
    
  • Hemoptysis
    
  • Bronchospasm
    
  • Bronchorrhea
    
• May have symptoms and signs of carbon monoxide and/or cyanide toxicity
  

• Pulse oximetry:
  
  • May be falsely elevated in cases of carbon monoxide exposure
    
• ABG measurement:
  
  • Hypoxia
    
  • Metabolic acidosis in cases of carbon monoxide or hydrogen cyanide
    
• Chest radiography:
  
  • Initial radiograph typically normal
    
  • May show signs of pulmonary injury over the next 24 hr
    

• Electrolytes, BUN, creatinine, glucose
  
• CBC
  
• Coagulation profile
  
• Creatine phosphokinase when indicated in burn patients
  
• Carboxyhemoglobin to evaluate for potential carbon monoxide exposure
  
• Cyanide level:
  
  • In suspected cases of cyanide exposure, do not wait for the level before initiating therapy.
    
  • May send lactate level as a marker of cyanide toxicity
    
• Pregnancy test
  

• Peak expiratory flow rate:
  
  • Low peak flow associated with more severe injury
    
• PaO
  ₂
  /FiO
  ₂
  ratio:
  
  • A ratio of <300 after initial resuscitation is associated with the development of respiratory failure.