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INTRODUCTION

Abdominal trauma accounts for 15% to 20% of all trauma deaths.1 Although the liver is the most frequently injured abdominal organ, the spleen is the most frequently injured intra-abdominal organ from sports accidents.2 Death may occur as a consequence of massive hemorrhage and generally results in early demise soon after the injury. Patients who survive the initial traumatic insult are at risk for infection and sepsis.

PATHOPHYSIOLOGY

BLUNT ABDOMINAL TRAUMA

In blunt trauma, all abdominal structures are at risk, and ultimately the biomechanics of the traumatic force determine which organs are affected. Compressive, shearing or stretching, and acceleration/deceleration forces impact the abdominal cavity and structures leading to abdominal wall, solid organ, or hollow viscous injuries. Abdominal organs may be relatively mobile or fixed. Injury is common in transition areas between these structures, such as the ligament of Treitz, where mesenteric or small bowel injuries may occur.

The most common mechanism for blunt abdominal trauma is a motor vehicle collision.1 Falls, second in frequency as causes of blunt trauma, produce injury due to the fall distance, the impact surface, and the manner of surface impact. Both solid and hollow organ rupture can occur with retroperitoneal injury and hemorrhage resulting when the force is transmitted along the axial skeleton.3 Pedestrians struck by vehicles or motorcyclists and bicyclists who crash generally have no protection to their abdomen and are at high risk for intra-abdominal injuries.

PENETRATING ABDOMINAL TRAUMA

Stab and gunshot wounds produce injury as the foreign object passes through tissue. With gunshot wounds, there may be additional injury from the transmitted energy of the blast. Furthermore, gunshot wounds create secondary missiles such as fragmented bone that may increase the traumatic burden.

The length, trajectory, and fragmentation of the penetrating object will not necessarily be known during the evaluation. Therefore, assume any penetrating injury to the chest, pelvis, flank, or back to have penetrated the abdominal cavity until proven otherwise.

CLINICAL FEATURES

Clinical signs may be obvious (such as evisceration) or occult. Factors making the diagnosis of an abdominal injury challenging include concomitant injuries (particularly significant head injuries), referred pain, intoxication with alcohol or other toxicologic substances, or language barriers. Young, healthy patients may be able to compensate for intra-abdominal hemorrhage before clinical signs become overt. Elderly patients may be on anticoagulation medications or on medications limiting physiologic response, such as antihypertensives (beta-blockers or calcium channel blockers).

PHYSICAL EXAMINATION

Inspect the abdomen for external signs of trauma (e.g., abrasions, lacerations, contusions, seatbelt marks). A normal-appearing abdomen does not exclude serious intra-abdominal injury. Following inspection, palpate the abdomen in all quadrants, making note of general or regional tenderness and signs of acute abdomen (rigidity, rebound, guarding). Regardless of imaging, document serial exams for patients ...

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