The primary goal in the evaluation of abdominal trauma is to promptly recognize conditions that require immediate surgical exploration. The most critical error is to delay surgical intervention when it is needed.
Injury to the solid organs causes morbidity and mortality, primarily as a result of acute blood loss. The spleen is the most frequently injured organ in blunt abdominal trauma and is commonly associated with other intraabdominal injuries. The liver also is commonly injured in blunt and penetrating injuries. Tachycardia, hypotension, and acute abdominal tenderness are the primary physical examination findings. Kehr sign, representing referred left shoulder pain, is a classic finding in splenic rupture. Lower left rib fractures should heighten clinical suspicion for splenic injury. Some patients with solid organ injury occasionally may present with minimal symptoms and nonspecific findings on physical examination. This is commonly associated with younger patients and those with distracting injuries, head injury, or intoxication. A single physical examination is insensitive for diagnosing abdominal injuries. Serial physical examinations on an awake, alert, and reliable patient are important for identifying intraabdominal injuries.
These injuries produce symptoms by the combination of blood loss and peritoneal contamination. Perforation of the stomach, small bowel, or colon is accompanied by blood loss from a concomitant mesenteric injury. Gastrointestinal contamination will produce peritoneal signs over time. Patients with head injury, distracting injuries, or intoxication may not exhibit peritoneal signs initially.
Small bowel and colon injuries are most frequently the result of penetrating trauma. However, a deceleration injury can cause a bucket-handle tear of the mesentery or a blow-out injury of the antimesenteric border. Suppurative peritonitis may develop from small bowel and colonic injuries. Inflammation may take 6 to 8 hours to develop.
The diagnosis of retroperitoneal injuries can be difficult. Signs and symptoms may be subtle or absent at initial presentation. Duodenal injuries most often are associated with high-speed vertical or horizontal decelerating trauma. These injuries may range in severity from an intramural hematoma to an extensive crush or laceration. Duodenal ruptures are usually contained within the retroperitoneum. Clinical signs of duodenal injury are often slow to develop. Patients may present with abdominal pain, fever, nausea, and vomiting, although these symptoms may take hours to become clinically apparent.
Pancreatic injury often accompanies rapid deceleration injury or a severe crush injury. The classic case is a blow to the midepigastrium from a steering wheel or the handlebar of a bicycle. Pancreatic injuries can present with subtle signs and symptoms, making the diagnosis elusive. Leakage of activated enzymes from the pancreas can produce retroperitoneal autodigestion, which may become superinfected with bacteria and produce a retroperitoneal abscess.
Presentation of diaphragm injuries is often insidious. Only occasionally is the diagnosis obvious when bowel sounds can be auscultated ...