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Abdominal injuries are potentially life-threatening and should be approached with caution. Following trauma, the abdomen may be a sanctuary for a broad spectrum of injuries that, if not discovered and corrected expeditiously, may lead to deleterious consequences. Traditionally these injuries are classified as either blunt trauma or penetrating injuries. The majority of blunt abdominal trauma is secondary to motor vehicle collisions, whereas the majority of penetrating injuries is 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.
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Initial management of all trauma patients is the same, and abdominal trauma is no exception. Following ATLS protocols, begin the assessment with a rapid primary survey, including evaluation of the airway, breathing, circulation, disability, and exposure.
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Assess the airway while maintaining cervical spine immobilization until potential injury is ruled out. Jaw thrust without head extension can be used to open the airway of a trauma patient. Administer high-flow oxygen, and intubate the patient if indicated.
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First assess breathing by auscultating for breath sounds. Diminished or absent breath sounds should raise clinical suspicion for a possible pneumothorax. Next, inspect for asymmetry of chest wall movement, open wounds, or flail segments. Then palpate the chest wall carefully. Palpable crepitus may indicate a pneumothorax or rib fractures. Rapidly perform needle decompression or tube thoracostomy when indicated (See Chapter 24). Pulse oximetry and capnography may be useful.
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Assess circulation. If gross external hemorrhage is present, control with direct pressure. Assess pulses, capillary refill, and blood pressure. Obtain intravenous access, preferably with at least two large-bore (≥16-gauge) peripheral catheters. If peripheral intravenous access is inadequate or unattainable, place a central venous catheter or interosseous line. Begin fluid resuscitation. The FAST examination is important at this stage of the evaluation, especially in hemodynamically unstable patients, where a positive FAST exam would be an immediate indication for emergency laparotomy.
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To assess disability, complete a brief and focused neurologic examination to document the patient's current mental status. The examination should include an assessment of pupillary size and reactivity, a determination of the patient's Glasgow Coma Scale score, and notation of any focal neurologic deficits such as unilateral weakness or poor muscle tone. Ideally, assessment of disability should be performed before administering pain medications, sedatives, or paralytics.
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In order to complete a thorough secondary survey, the patient must be fully exposed. Completely undress the patient while taking precautions to prevent or recognize and correct associated hypothermia. Begin a more thorough secondary survey, including logrolling the patient and examining all skin folds, the back, and axillae for any signs of trauma (eg, contusions, hematomas, abrasions, or penetrating wounds). Attempt to identify ...