Emergency Medicine

ABDOMINAL AND PELVIC TRAUMA

Surgical Emergencies 239

(ii) Pelvis X-ray: a fractured pelvis may be associated with major

intra-abdominal or retroperitoneal injuries.

(iii) Plain abdominal film is usually of little value, and rarely

performed

(a) look for loss of the psoas shadow, transverse process fracture,

abnormal renal outlines and free gas within the peritoneal

cavity on a lateral decubitus view.

MANAGEMENT

1 Give high-f low oxygen. Transfuse initially with crystalloid such as normal
saline or Hartmann’s (compound sodium lactate), then blood when
available.

2 Pass a nasogastric tube to drain the stomach.

3 Insert a urethral catheter to measure the urine output and to look for
haematuria.
(i) Omit this if a urethral injury is suspected from blood at the
meatus, a scrotal haematoma or a high-riding prostate on rectal
examination.

4 Consider the need for an immediate laparotomy, call the surgeon if not
present and alert theatre. Indications include:
(i) Persistent shock.
(ii) Rigid, silent abdomen.
(iii) Radiological evidence of free gas or ruptured diaphragm.

5 Commonly there are no immediate indications for laparotomy and further
investigation is needed:
(i) Ultrasound
(a) focused assessment by sonography for trauma (FAST)
ultrasound is ideal for unstable patients unable to be
transferred for CT evaluation
(b) it is rapid, repeatable at the bedside, non-invasive and
highly sensitive for free intraperitoneal fluid, i.e. blood
from a haemoperitoneum. It can also demonstrate cardiac
tamponade
(c) however, it is operator dependent, and may miss hollow
viscus, diaphragmatic and retroperitoneal injuries.
(ii) CT scan
(a) patients must be stable. CT scanning takes time and the
patient must be transported out of the resuscitation room
(b) CT provides anatomical information on the intra-abdominal
organs injured allowing non-operative management
(c) CT also visualizes the retroperitoneum, pelvis and
lower chest, although it may still miss hollow viscus and
diaphragmatic injuries.