IMMEDIATE MANAGEMENT OF LIFE-THREATENING INJURIES
Posttraumatic intra-abdominal injuries are common life-threatening injuries. The abdomen encompasses a relatively large area, extending from the apex of the diaphragm to the level of the iliac crests. It contains a number of organs and vascular structures that may be injured secondary to a traumatic injury and is also closely associated with both thoracic and pelvic structures. Any penetrating injury below the level of the nipple line—roughly the level of the apex of the diaphragm—warrants evaluation for intra-abdominal injury. Abdominal trauma is, traditionally, described as either blunt or penetrating trauma and the organs and structures injured may vary depending on both the type and location of the trauma. Most blunt abdominal trauma is secondary to motor vehicle collisions, whereas the majority of penetrating injuries are predominantly secondary to gunshot or stab wounds. Patients with abdominal trauma require rapid assessment, stabilization, and early surgical consultation when indicated to maximize the chances of a successful outcome.
Initial management of all trauma patients should be the same, assessing the airway, breathing, circulation, disability, exposures (ABCDEs) of trauma. While “airway” is first in the trauma algorithm, circulation needs to be simultaneously assessed. Realistically, the primary survey components of circulation, airway, and breathing are all assessed at the same time—with disability and exposure shortly thereafter.
In regards to airway and breathing, it is important to note that—posteriorly—part of the lower lobes of both lungs sit below the level of the apex of the diaphragm. Diminished or absent breath sounds should raise clinical suspicion for a possible pneumothorax or hemothorax. In regards to circulation, if gross external hemorrhage is present, it may be controlled with direct pressure. Obtain intravenous (IV) access, preferably with at least two large-bore (≥18-gauge) peripheral catheters. If peripheral IV access is inadequate or unobtainable, place a central venous catheter or interosseous (IO) line. The practitioner’s threshold for placing an IO line should be low. Begin appropriate fluid resuscitation with either crystalloid fluids or blood—depending on the clinical situation.
For disability and exposure, the patient must be fully exposed. Completely undress the patient while taking precautions to prevent or recognize and correct associated hypothermia. Particularly for penetrating trauma, exploration of the back, all skin folds, and axillae is crucial. Identify all wounds and document their location. To help identify the trajectory of penetrating projectiles, place a radiopaque marker (eg, paper clip or wound marker) at the wound site prior to obtaining X-rays. Do not remove impaled foreign bodies because they may be providing hemostasis from a vascular injury.
Special Considerations for Assessment of Abdominal Trauma
Any penetrating injury below the level of the nipple line warrants evaluation for intra-abdominal injury. For patients involved in motor vehicle accidents, carefully examine the chest and abdomen looking for ecchymosis or erythema in the area of the clavicles or across the ...