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Introduction   

Traumatic abdominal injuries can stem from various causes and may lead to life-threatening conditions, multi-organ system dysfunction, and death. Blunt abdominal trauma (BAT) most often arrives at emergency departments as the result of motor vehicle collisions (MVC) [1]. Other less common causes include falls from heights, bicycle injuries, sports-related injuries, and industrial accidents [1]. In children, the most common causes are motor vehicle injuries and bicycle accidents [1]. 

BAT results from direct impact, compression (secondary or direct) against fixed objects (e.g., steering wheel), or deceleration forces [2]. Abdominal trauma can cause considerable damage to internal organs, including the spleen, liver, small bowel, kidneys, bladder, colorectum, diaphragm, and pancreas, leading to internal bleeding, contusions, and visceral damage [1][3]. Traumatic abdominal injuries can result in hemorrhage, peritonitis, and contamination with visceral contents, often accompanied by associated pelvic injuries [4]. 

Missed abdominal injuries are a leading cause of preventable death in patients who have experienced trauma [5]. Initial management principles emphasize detecting abdominal injuries and determining the need for urgent intervention. Diagnostic tools such as the Focused Assessment with Sonography in Trauma (EFAST) and computed tomography (CT) scans are critical for identifying injuries and guiding assessment and treatment [12]. 

Diagnosis and Assessment 

Diagnosing and managing blunt abdominal trauma (BAT) is challenging due to the lack of historical data, the presence of distracting injuries, or altered mental status from head injuries or intoxication. Patients with BAT often sustain both abdominal and extra-abdominal injuries, complicating their initial ED presentation [6]. Common symptoms of BAT include increased abdominal pain or swelling, nausea, and vomiting [1][3].  

Blunt abdominal trauma constitutes 22% of injuries in major trauma cases and presents challenges in diagnosis and management. It also represents 7-10% of trauma-related hospital admissions [7]. Maintaining a high index of suspicion is crucial for multi-trauma patients when the mechanism of injury suggests significant abdominal injury. While penetrating injuries are often isolated, they can cause severe organ or vessel disruption and rapid bleeding, necessitating immediate control of bleeding and securing breathing.  

The evaluation of any patient who has experienced trauma starts with assessing the airway, breathing, and circulation. The American College of Surgeons’ Advanced Trauma Life Support (ATLS) promotes the primary survey sequence as airway, breathing, circulation, disability, and exposure (ABCDE) [8]. The imaging and diagnosis of intra-abdominal injury following blunt trauma depends on the hemodynamic status of the patient. If the patient is stable from a hemodynamic perspective, a CT scan is the ideal test for detecting solid organ injuries in the abdomen and pelvis. The primary advantage of CT scanning is its high specificity and its ability to guide the nonoperative management of solid organ injuries [9].  

For unstable patients, clinicians may perform an ultrasound (Extended Focused Assessment with Sonography for Trauma, or eFAST) or diagnostic peritoneal lavage, though both methods carry a high rate of false negatives and positives [10][11]. Indications for trauma ultrasound include blunt or penetrating trauma to the torso where there is suspicion of intraperitoneal hemorrhage, pericardial tamponade, and hemothorax [12].  

The FAST exam includes the following views (with eFAST views in parentheses): 

• Right Upper Quadrant (RUQ): Evaluates for free fluid in Morison’s pouch or the hepatorenal space, the lower pole of the kidney, and the space below the diaphragm on the right [13].  

• Cardiac View: Uses a subcostal or other cardiac view to visualize both the anterior and posterior pericardium for fluid [14][15].  

• Left Upper Quadrant (LUQ): Visualizes the diaphragm and the entire spleen. It checks above the diaphragm for signs of free fluid in the left hemithorax [14][15].  

• Pelvis (Bladder): Visualizes the interface with the rectum, prostate, or uterus. Clinicians can view additional images in a longitudinal plane [12].  

• (eFAST Anterior Thoracic View): Bilateral anterior chest (Pleural Sliding Views). A normal lung shows pleural sliding with reverberation artifacts (A-lines) [16]. 

Epidemiology 

Motor vehicle collisions are the most common cause of blunt abdominal trauma (BAT), with the spleen and liver being the most injured solid organs [1]. Delayed splenic rupture can also occur, posing a significant risk [17]. Injuries to the pancreas, bowel, mesentery, and diaphragm, though less common, are dangerous and more difficult to diagnose than solid organ injuries because these injuries often present with subtle or nonspecific symptoms and lack of clear imaging findings [6][7][18].  

Blunt abdominal trauma (BAT) accounts for 80 percent of abdominal injuries seen in emergency departments (ED), contributing to morbidity and mortality [6]. Blows to the abdomen account for 15 percent of cases, while falls contribute to 6 to 9 percent of cases [6]. Occult BAT may also occur in cases of child abuse and domestic violence [19].  

Thirteen percent of patients presenting to the ED with BAT have intra-abdominal injuries [6]. Patients with seatbelt signs, despite the overall minimal risk of injury, face a higher risk for hollow viscus injury and are associated with a distinctive injury profile known as “seat belt syndrome,” which increases the likelihood of intra-abdominal injury eightfold [20]. 

 Pathophysiology  

Blunt or penetrating trauma can lacerate or rupture intra-abdominal structures [1]. Blunt injury may cause a hematoma in a solid organ or the wall of a hollow viscus [1]. Hollow viscus lacerations often cause low-volume hemorrhage with minimal physiologic consequences. More serious injuries may cause massive hemorrhage, leading to shock, acidosis, and coagulopathy, which require rapid intervention [21]. 

Abdominal hemorrhage is often internal, except for the lesser amounts of external hemorrhage caused by body wall lacerations from penetrating trauma [22]. Internal hemorrhage can occur intra or retroperitoneal [22]. Laceration or rupture of a hollow viscus allows gastric, intestinal, or bladder contents to enter the peritoneal cavity, causing peritonitis, and complications from abdominal injuries can include hematoma rupture, intra-abdominal abscess, bowel obstruction or ileus, biliary leakage and/or biloma, and abdominal compartment syndrome [23][24].  

Treatment may lead to complications such as abscess, bowel obstruction, abdominal compartment syndrome, and delayed incisional hernia. Hematomas can resolve without intervention over days to months, depending on size and location. Splenic hematomas and, less often, hepatic hematomas may rupture within the first few days after injury, sometimes up to months later, causing significant delayed hemorrhage.  

Intestinal wall hematomas sometimes perforate within 48 to 72 hours after injury, releasing intestinal contents and causing peritonitis without significant hemorrhage [25][26]. Intestinal wall hematomas can cause intestinal stricture months to years later, although there are cases of bowel obstruction as early as two weeks after blunt trauma [26]. Intra-abdominal abscesses can result from undetected hollow viscus perforation but may also follow laparotomy. The rate of abscess formation ranges from 0% after nontherapeutic laparotomies to about 10% after therapeutic laparotomies and as high as 50% after surgery to repair severe liver lacerations [27]. Bowel obstruction can develop weeks to years after injury due to intestinal wall hematoma or adhesions from intestinal serosal or mesenteric tears [26].  

Etiology 

Clinicians categorize abdominal trauma by the mechanism of injury: blunt, penetrating or decelerating [28]. 

Clinical Signs and Symptoms  

Following blunt abdominal trauma, clinicians should suspect severe injury if they observe a seatbelt injury, rebound tenderness, hypotension (BP <90 mmHg), abdominal distension, abdominal guarding, or a concomitant femur fracture [29].  

Patients with abdominal trauma often experience abdominal pain, but it is often mild and overshadowed by more painful injuries including fractures or by altered sensorium from head injury, intoxication, or shock. Pain from a splenic injury may radiate to the left shoulder, while pain from a small intestinal perforation starts as minimal but worsens [29]. Patients with renal injuries may notice hematuria.  

During the initial examination, vital signs may indicate hypovolemia, such as tachycardia and narrow pulse pressure, or shock, characterized by dusky color, diaphoresis, altered sensorium, oliguria, and hypotension. Clinicians must inspect the abdomen buttocks, perineum, flank, and lower chest when firearms or explosive devices are involved.  

Cutaneous lesions from these injuries are often small with minimal bleeding, though larger wounds with evisceration can occur. Although abdominal pain and tenderness increase the likelihood of intra-abdominal injury, their absence does not exclude injury. The presence of altered sensorium or painful extra-abdominal injuries should raise suspicion for abdominal injury even without suggestive symptoms or signs. 

Intra-abdominal injuries can cause referred pain, such as Kehr’s sign (left shoulder pain from splenic injury) or right shoulder pain from liver injury [6]. The digital rectal examination (DRE) has poor sensitivity for detecting bowel injuries but warranted for suspected urethral or penetrating rectal injuries. DRE does not often provide additional accurate or useful information that alters management [30]. 

Classification 

Organ injury severity classification ranges from grade 1 (minimal) to grades 5 or 6 (massive), with higher grades correlating with increased mortality and a greater need for operative intervention. These scales assist in assessing injuries to specific organs, including the liver (Grades of Hepatic Injury), spleen (Grades of Splenic Injury), and kidneys (classification of renal injuries) [31][32]. 

Classification of Hepatic Injury  

Grade I 

• Hematoma: Subcapsular, <10% surface area 
• Laceration: Capsular tear, <1 cm parenchymal depth 

Grade II 

• Hematoma: Subcapsular, 10-50% surface area 
• Hematoma: Intraparenchymal, <10 cm diameter 
• Laceration: Capsular tear, 1-3 cm parenchymal depth, <10 cm length 

Grade III 

• Hematoma: Subcapsular hematoma covering more than 50% of the surface area, including ruptured subcapsular or parenchymal hematoma 
• Hematoma: Intraparenchymal, >10 cm 
• Laceration: Capsular tear, >3 cm parenchymal depth 
• Vascular Injury: Active bleeding contained within liver parenchyma. 

Grade IV 

• Laceration: Parenchymal disruption involving 25-75% of a hepatic lobe or 1-3 Couinaud segments 
• Vascular Injury: Active bleeding breaching the liver parenchyma into the peritoneum. 

Grade V 

• Laceration: Parenchymal disruption involving >75% of hepatic lobe 
• Vascular Injury: Juxta hepatic venous injuries (retro hepatic vena cava / central major hepatic veins) 

Classification of Splenic Injury  

Grade I 

• Subcapsular hematoma <10% of surface area 
• Parenchymal laceration <1 cm depth 
• Capsular tear 

Grade II 

• Subcapsular hematoma 10-50% of surface area 
• Intraparenchymal hematoma <5 cm 
• Parenchymal laceration 1-3 cm in depth 

Grade III 

• Subcapsular hematoma >50% of surface area 
• Intraparenchymal hematoma ≥5 cm 
• Parenchymal laceration >3 cm in depth 
• Ruptured subcapsular or intraparenchymal hematoma. 

Grade IV 

• Any injury with a splenic vascular injury or active bleeding confined within the splenic capsule. 
• Parenchymal laceration affecting segmental or hilar vessels, resulting in more than 25% devascularization. 

Grade V 

• Shattered spleen 
• Any injury with a splenic vascular injury and active bleeding extending beyond the spleen into the peritoneum. 

Classification of Renal Injury  

Grade I 

• Subcapsular hematoma and/or contusion without laceration 

Grade II 

• Superficial laceration ≤1 cm depth not involving the collecting system (no evidence of urine extravasation) 
• Perirenal hematoma confined within the perirenal fascia. 

Grade III 

• Laceration >1 cm depth not involving the collecting system (no evidence of urine extravasation) 
• Vascular injury or active bleeding confined within the perirenal fascia. 

Grade IV 

• Laceration involving the collecting system with urinary extravasation. 
• Laceration of the renal pelvis and/or complete ureteropelvic disruption 
• Vascular injury to segmental renal artery or vein 
• Segmental infarctions without associated active bleeding (due to vessel thrombosis) 
• Active bleeding extending beyond the perirenal fascia into the retroperitoneum or peritoneum 

Grade V 

• Shattered kidney 
• Avulsion of renal hilum or laceration of the main renal artery or vein, leading to devascularization of the kidney 
• Devascularized kidney with active bleeding 

Managing Unstable Patients with Blunt Trauma in the Abdomen 

In unstable patients with BAT, the primary focus is to identify intraperitoneal hemorrhage [33]. Immediate consultation with a trauma surgeon is essential. Perform a focused assessment with sonography for trauma (eFAST) exam if ultrasound is available. Surgeons may take unstable patients with a positive eFAST exam to the operating room for emergency laparotomy. If the eFAST exam is inconclusive and the patient remains unstable, the surgeon must decide whether to perform an emergency laparotomy based on the suspicion of intra-abdominal injury. For stable patients CT scans can assist in the evaluation. Diagnostic Peritoneal Lavage (DPL) is redundant, but Diagnostic Peritoneal Aspiration (DPA) remains useful for unstable patients when eFAST ultrasound results are inconclusive [34].  

Resuscitative endovascular balloon occlusion of the aorta (REBOA) can serve as a bridging therapy for controlling noncompressible hemorrhage in unstable BAT patients by temporarily stopping or limiting blood flow through the aorta until achieving definitive bleeding control through endovascular procedures or surgery [35]. However, this technique is associated with higher rates of mortality, acute kidney injury, and lower extremity amputation in studies [34]. In cases of major pelvic fractures, ultrasound cannot distinguish between blood and urine in the peritoneal cavity, so surgeons may need to further evaluate with a CT scan if they can stabilize the patient [11][36]. 

Stable Patient Management 

Management of stable BAT patients depends on their assessed risk for significant intra-abdominal injury. The approach varies based on factors such as patient age, comorbidities, mechanism of injury, examination findings, and available hospital resources. The evaluation of stable BAT patients includes diagnostic imaging and serial physical examinations [6]. Ultrasound alone may miss relevant injuries. If ultrasound detects intraperitoneal blood, an abdominal and pelvic CT scan with IV contrast should follow to delineate injuries and quantify hemoperitoneum [6].  

Clinical Indications for Laparotomy 

Nonoperative management remains standard for most BAT patients, but immediate laparotomy may be necessary for: 

• Unexplained blood loss or hypotension in an unstable patient who has a suspected intra-abdominal injury [2]. 
• Clear and persistent signs of peritoneal irritation [2]. 
• Radiologic evidence of pneumoperitoneum consistent with viscus rupture [2] 
• Evidence of diaphragmatic rupture [2]. 
• Persistent, significant gastrointestinal bleeding [2]. 

Special Considerations 

Pelvic Fracture 

For patients with pelvic fractures and ongoing bleeding, the presence or absence of hemoperitoneum directs management [36]. Ultrasound detection of free fluid or gross intraperitoneal blood identified by DPT indicates the need for emergency laparotomy. 

Multiple-System Injury 

Tailor management for patients with multiple life-threatening injuries and prioritize laparotomy for intraperitoneal hemorrhage over head or chest trauma. 

Closed Head Injury 

In patients with BAT and concomitant closed head injury, the neurologic examination and CT imaging results determine the need and timing for neurosurgical intervention. Immediate consultation with both a neurosurgeon and a trauma surgeon are essential. 

Pregnant Patient 

Trauma is the leading non-obstetric cause of maternal death during pregnancy, and major trauma carries a 40% to 50% risk of fetal death [37]. Management prioritizes assessing the extent of maternal injury and directing resuscitation efforts towards ensuring the mother’s survival. 

Geriatric Patient 

Signs and symptoms of abdominal injury often appear less pronounced in adults over 60 years old, necessitating a high index of suspicion for injuries in this population [6]. 

Patient With Obesity 

Class III obesity (BMI >40) correlates with a lower rate of hollow viscus injury but shows comparable rates of solid organ injury [38] [39]. In patients with obesity, the extended FAST (e-FAST) and physical examinations are less accurate, so clinicians should maintain a low threshold for obtaining CT imaging [39]. 

Conclusion

Blunt trauma in the abdomen presents a significant challenge in emergency medicine due to its varied etiology and potential for severe internal injuries [1]. The primary mechanisms include motor vehicle collisions, assaults, falls, and recreational accidents, all of which can result in substantial damage to organs such as the spleen, liver, and pancreas [1][3]. Rapid and accurate diagnosis is fundamental, as missed abdominal injuries are a leading cause of preventable death in patients who have experienced trauma. Utilizing diagnostic tools like the Focused Assessment with Sonography for Trauma (eFAST) and CT scans can identify injuries and guide the necessary treatment interventions [12].  

Effective management of BAT depends on a thorough assessment and a tailored approach to each patient’s condition. Evaluate stable patients with a combination of diagnostic imaging and serial physical examinations to rule out significant injuries. Those deemed at higher risk or presenting with concerning symptoms often undergo CT imaging to ensure the absence of internal damage. Unstable patients require immediate surgical consultation and emergent interventions. Pregnant women, the elderly, and those with obesity, require special considerations. By adapting management strategies to each scenario, clinicians can improve outcomes and reduce mortality associated with blunt abdominal trauma. 

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