■ Diaphragmatic injuries misinterpreted as a hemothoraxmay be treated
inappropriately with tube thoracostomy. CXR following NG tube place-
ment will usually show the location of the stomach.
■ An association has been identified between diaphragmatic injuries and
aortic injuries and pelvic fractures. Consider them when you see diaphrag-
matic injuries.
Hollow Viscus
MECHANISMS
■ Injuries can range from bowel contusions to lacerations/rupture.
■ Signs of hemoperitoneum can result if there are tears of the mesentery.
■ Small-bowel injuries, which may be caused by compression of bowel
between seat belt and spine, are particularly hard to find on CT, but may
be suggested on physical exam by abdominal wall contusion (seat belt
sign).
■ Approximately one-third of patients with a seat-belt sign will have intra-
abdominal injuries.
■ The jejunum is the most commonly injured section of bowel.
SYMPTOMS
■ Unlike solid organ injuries, which present with signs of blood loss, hollow
viscus injuries tend to cause peritoneal signs due to bacterial contamina-
tion or irritation from gastric contents.
■ On initial exam, peritoneal signs may be absent.
DIAGNOSIS
■ Although only present occasionally, on CXR look for free air under the
diaphragm indicating hollow viscus injury.
■ CT is the preferred modality for evaluating bowel injuries.
TREATMENT
Bowel perforations should undergo laparotomy, while contusions can be
observed.
Solid Organs
In blunt trauma, the spleen is the most often injured organand two-thirds of
the time the only injured organ. The liver is the second most commonly injured
organ. Renal injuries are less common.
DIAGNOSIS
■ CT with IV contrast is confirmative.
■ Lipase and amylase levels are neither sensitive nor specific for pancreatic
injury (injured may be normal, uninjured high); however, they can be
used in conjunction with other tests and trended.
TREATMENT
■ The majority of liver and splenic injuries are treated expectantly rather
than surgically.
■ Surgery for splenic injuries grade III or higher and in patients <55 years
TRAUMAManagement of solid organ
injury is based on
hemodynamic status, not
grade.The three abdominal injuries
in blunt trauma that are
difficult to diagnose with CT
imaging are diaphragm,
pancreas, and bowel.