Blunt abdominal trauma — assessment and disposition

The primary survey is completed first. The C, the A and the B are addressed. The patient is borderline-unstable (BP 95/60, HR 110, pale) — the circulation is the concern.

Abdominal assessment: inspect for the distension, the bruising (the seat-belt sign — raises the risk of the hollow viscus and the mesenteric injury), the penetrating wounds. Palpate for the tenderness, the guarding and the rigidity. The perineum and the rectal examination are performed.^[1]

FAST scan: the bedside ultrasound in the four views. If the FAST is positive (free fluid in the Morrison pouch or the splenorenal recess) and the patient is unstable or borderline-unstable, the indication is for the theatre — the damage-control laparotomy — because the free fluid in the hypotensive blunt trauma patient is the intra-abdominal bleeding until proven otherwise. If the FAST is negative, the borderline-unstable patient still needs the CT (if they can be stabilised with the fluid and the blood) or the close observation with the serial examinations, because the hollow viscus and the retroperitoneal injuries may not produce the free fluid on the FAST.^[1]

Disposition: this patient is borderline. If the FAST is positive — theatre. If the FAST is negative and the patient stabilises with the resuscitation — the CT of the abdomen and the pelvis with the intravenous contrast, followed by the admission and the serial examinations for the evolving hollow viscus injury (the seat-belt sign predicts the bowel and the mesenteric injury). The CT evaluates the solid organ, the mesenteric and the retroperitoneal injury. The patient is observed for 24 to 48 hours for the delayed presentation of the bowel injury.^[1]