Abdominal trauma accounts for 15% to 20% of
all trauma deaths.1 These deaths primarily occur
soon after injury as a result of hemorrhage, although some occur
later due to complications from sepsis.
Injuries to the abdomen can be from blunt or penetrating mechanisms, or,
The most common mechanism of blunt abdominal trauma in the U.S.
is a motor vehicle crash.1 This diffuse injury
pattern puts all abdominal organs at risk for injury. The biomechanics
of blunt trauma to the abdomen involve compressive, shearing, or
stretching forces. The outcome may be injury to solid organs (e.g.,
liver or spleen) or hollow viscera (e.g., the GI tract).
Injury can also result from the movement of organs within the
body. Some organs are rigidly fixed, whereas others are more mobile.
Injury is particularly common in areas of transition between fixed
and mobile organs. Examples at areas of transition include mesenteric
or small bowel injuries, primarily at the ligament of Treitz or
at the junction of the distal small bowel and right colon.
Falls from a height produce a unique pattern of injury. Injury
severity is a function of distance, the surface on which the victim
lands, and whether the fall is broken. Intra-abdominal injuries
are rare in falls from a height. When abdominal injuries do occur,
hollow visceral rupture is the most common injury.2 Retroperitoneal
injuries occur frequently due to force transmitted up the axial
skeleton and are associated with severe retroperitoneal hemorrhage.
Intra-abdominal solid organs can be injured when patients land on
Pedestrians struck by motor vehicles are completely unprotected,
and all force is applied directly to the patient’s body.
Motorcyclists and bicyclists are generally protected only by a helmet.
Stab wounds directly injure tissue as the blade passes through
the body. External examination of the wound may underestimate internal
damage and cannot define the trajectory. Assume that any stab
wound in the lower chest, pelvis, flank, or back causes abdominal
injury until proven otherwise.
Gunshot wounds injure in several ways. Bullets may injure organs
directly, by secondary missiles such as bone or bullet fragments,
or from energy transmitted from the bullet (blast effect). Bullets
designed to break apart once they enter a victim cause much more
tissue destruction than ones that remain intact. Entrance and exit
wounds can approximate the trajectory. Localization of the foreign
body helps predict organs at risk. Bullets, however, may not travel
in a straight line. Thus, all structures in any proximity to the
presumed trajectory must be considered injured (see Chapter e263.1, Wound Ballistics).
Abdominal injury often presents insidiously. Young patients may
lose 50% to 60% of their blood volume and remain
asymptomatic.3 In addition, trauma to the abdomen
may be accompanied by neurologic alterations from concomitant brain
injury or alcohol/drug intoxication. Abdominal tenderness,
distention, or tympany may not be present until patients have suffered
significant intra-abdominal blood loss. Some patients develop
tenderness early with hemoperitoneum; others may remain asymptomatic
for many hours or days. Reliance on the physical examination
alone will lead to an unacceptable rate of both nontherapeutic laparotomy
and missed injuries. More than 35% of blunt trauma patients
thought to have a “benign abdomen” on initial
physical examination are later found to have significant intra-abdominal
injury requiring laparotomy.4 Therefore, a thorough,
methodical, and comprehensive approach to the diagnosis and management
of torso trauma is essential.
Solid organ injuries usually produce symptoms and signs due to
blood loss. Patients often develop hypotension, tachycardia, and
confusion with >30% blood loss.5 Assuming
that a hemodynamically stable patient does not have an abdominal
injury can be disastrous. Blunt solid organ injuries can bleed slowly
and not produce initial hemodynamic alterations or peritoneal signs
with later sudden, profound onset of hypovolemic shock.
Hollow visceral injuries produce symptoms and signs by the combination
of blood loss and peritoneal contamination. Perforation of the stomach,
small bowel, or colon is often accompanied by some blood loss, such
as that caused by a concomitant mesenteric injury. GI contamination
will produce physical examination findings over a period of time. Again,
patients with traumatic brain injuries or intoxication may not demonstrate
signs of injury initially. In addition, patients with substantial
injuries elsewhere may be distracted from abdominal pain for a number
Gastric injuries produce symptoms by chemical irritation when
acidic contents are spilled into the abdominal cavity. Symptoms
from acid spill often occur early but may take more time if patients
are on H2 blockers. Small bowel and colonic injuries elicit
symptoms because bacterial content produces suppurative peritonitis.
The inflammatory changes may take 6 to 8 hours to manifest.
Symptoms and signs of retroperitoneal injury may be subtle or
completely absent initially. Occasionally, retroperitoneal injuries,
such as a small retroperitoneal hematoma, produce abdominal pain
even if they are relatively insignificant.
Duodenal injuries may also be asymptomatic at the time of presentation. Duodenal
wall hematomas can cause gastric outlet obstruction with abdominal
pain, nausea, and vomiting. Duodenal rupture is often contained
within the retroperitoneum, particularly when caused by blunt trauma. Duodenal
rupture often occurs from rapid increases in intraluminal pressure
when both the pylorus and proximal small bowel develop spasm, most
often after high-speed vertical or horizontal deceleration. Duodenal
rupture may present with abdominal pain, fever, and tenderness,
although these symptoms may take hours or days to become clinically
Pancreatic injuries often occur from rapid deceleration as well.
Pancreatic transection usually occurs in the mid-body as the pancreas
is displaced against the vertebral column. Unrestrained drivers
who hit the steering column ...