Stabilization of Trauma in the ER

General Approach to Abdominal Trauma The initial evaluation of the injured abdomen looks for hemorrhage or spillage of bowel content. Other injuries, such as pancreatic or biliary injury, are not acutely life-threatening and are therefore less urgent. Despite the multitude of intraabdominal organs, and the wide variation of presentation of injured patients, the question is: Is there blood or peritoneal contamination? Evaluate the abdomen during the secondary survey. The primary goal is to decide if surgery is necessary. If you find no need for immediate surgery, further evaluation of the abdomen can wait until other urgent problems are treated. No abdominal problem, including evisceration, takes precedence over the evaluation and stabilization measures of the primary survey! Abdominal evaluation presents special problems. The unconscious patients exam provides virtually no clues. Even in alert patients, the level of pain and the reaction to palpation are of little help in differentiating severe from trivial injury during the critical early period following injury. Peritoneal signs may not develop for one to four hours. And the abdomen contains a multitude of organs whose function is largely invisible, and whose pain response to injury helps very little in identifying the injured organ. The physician approaches the injured abdomen in a simplistic fashion: If the abdomen is tender or if the patient has a decreased level of consciousness, assume significant injury. If the patient is hypotensive, or will undergo urgent surgery for a

non-abdominal problem, perform peritoneal lavage. If the patient is sufficiently stable and other problems are not emergent, order a CT scan of the abdomen. Tender Abdomen or Decreased LOC Hypotensive on arrival or Emergency non-abdominal surgery Peritoneal Lavage (+/- Abd x-rays) Stable, no urgent conditions Abd x-rays, CT scan Exact, organ-specific diagnosis is often not possible, nor wise. The patient who has free air on abdominal x-ray needs rapid laparotomy, rather than an attempt to localize the organ rupture. Similarly, the patient with hypotension, left upper quadrant pain, and a positive peritoneal lavage needs surgery now. Assume a ruptured spleen. If it turns out to be a bruised left abdomen and a laceration of the mesenteric blood vessels, so what? Your goal is to identify the need for surgery. The exam notes the location and relative severity of tenderness, and seeks any clues such as broken ribs, or a steering wheel mark across the abdomen. If any evidence of injury is present, make a decision about further evaluation after the secondary survey, when the patients other problems are known. All gunshot wounds will require surgical exploration. Some knife wounds are managed conservatively. X-rays and peritoneal lavage may be used to screen for bowel laceration or major bleeding. Stabilization of Abdominal Injury Complete the primary (ABC) survey. Infuse fluid rapidly for

the patient with evidence of shock. Examine the abdomen during the secondary survey. Place an NG tube and foley catheter. Cover any open wounds to protect the viscera. The abdominal compartment of anti-shock trousers must NOT be inflated if the patient is pregnant, if there is an open abdominal wound, or if rupture of the diaphragm is suspected. Rupture of the diaphragm is more common than realized. It should be anticipated with any patient with a penetrating wound of the upper abdomen or lower chest. Back to Top