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■ High-grade liver injuries have a higher likelihood of requiring surgical

intervention; however, these can be managed nonoperatively as long as

the patient is hemodynamically stable.

■ Interventional radiology is taking on an increasingly greater role in the

treatment of solid organ injury, using embolization to help delay or pre-

vent surgical intervention.

PENETRATING ABDOMINAL TRAUMA

Seventy percent of anterior stab wounds penetrate peritoneum, and 50% of

those cause organ damage. A lower chest stab wound has a 15% chance of

causing intra-abdominal injury.

The most commonly injured organs in penetrating trauma are:

■ Stab wound: Liver first, then small bowel (both have large surface areas)

■ Gunshot wound: Small bowel, then colon, then liver

TREATMENT

■ Penetrating trauma with peritonitis requires immediate surgery.

■ Stab wounds to the abdomen may be evaluated using local wound explo-

ration(a surgical procedure).

■ Digital probing or injection of contrast is not recommended.

■ Triple contrast CT scans (CT with PO, IV, and rectal contrast) can be

used to evaluate a penetrating abdominal injury, especially if direct explo-

ration is not possible or is inconclusive.

■ Observation with serial exams without imaging is an acceptable method of eval-

uating penetrating abdominal trauma with a low likelihood of significant injury.

Studies in Abdominal Trauma

FOCUSEDASSESSMENTWITHSONOGRAPHY FORTRAUMA

■ Four views:

■ Hepatorenal (Morison’s) space (see Figure 3.13)

■ Splenorenal space

■ Pelvis (Pouch of Douglas or rectovesicular pouch)

■ Pericardium (see Figure 3.14)

■ In hypotensive victims of blunt trauma, a positive FAST suggests intra-

abdominal hemorrhage and the need for exploratory laparotomy.

■ In patients who are not hypotensive, a positive FAST may serve as a triage

tool to expedite diagnostic evaluation and surgical consultation.

■ In general, a FAST exam does not determine where the injury lies, only

that there is an injury. The location of fluid does not correlate with the

injured organ.

■ FAST exams do not exclude intra-abdominal injury. Observe or CT scan

patients with suspected injuries who have a negative FAST exam.

■ False-positive FAST exams may be found in patients who have cirrhosis

and in females who may have a small amount of physiologic free fluid in

the pouch of Douglas.

DIAGNOSTICPERITONEALLAVAGE(DPL)

■ DPL can be performed at the bedside with an open or a closed technique.

■ DPL in patients with pelvic fractures should be done open and above the

umbilicus to prevent false-positives due to pelvic hematomas.

TRAUMA

Positive DPL:

10 cc of blood on initial draw

> 100,000 RBC/μL after

putting 1 L of NS into

abdomen