Abdominal and Pelvic Trauma

Mechanism of injury is vitally important in the assessment of abdominal trauma. Blunt trauma can present without any external physical signs, and life-threatening intraabdominal injuries may be overlooked during initial assessment and treatment. In penetrating trauma, it is important to determine whether the peritoneum was violated, as well as the likely path of the penetrating object.

The EP must consider anatomic site, number of wounds, type and size of weapon, and the angle of approach of the weapon. Projectiles often have unpredictable paths and therefore surgical exploration is frequently necessary for assessment of the extent of injury. Because of the characteristics of the diaphragm and its changing position with respiration, penetrating injuries occurring below the nipple line anteriorly and the tip of the scapula posteriorly may directly involve the abdominal cavity. Knife or gunshot wounds may enter the abdomen, traverse the diaphragm, and enter the thorax, or vice versa. Blunt trauma may cause fracture of the pelvis, which may lead to significant hemorrhage. Bladder or urethral injuries may occur in both blunt and penetrating trauma.

Causes

• Main causes of blunt abdominal trauma are from motor vehicle accidents and automobile-pedestrian accidents.
• Common Etiologies include falls and industrial or recreational accidents.

Signs

• Hemodynamic instability (up to 20% with benign examination)
• Abrasions, contusions
• Penetrating wounds (must log roll)
• Guarding
• Distention
• Hematemesis
• Hematochezia
• Hematuria

Treatment

External hemorrhage rarely is associated with blunt abdominal trauma. If present, control the hemorrhage with direct pressure. Note any signs of inadequate systemic perfusion. Consider intraperitoneal hemorrhage whenever evidence of hemorrhagic shock is found in the absence of external hemorrhage. Initiate volume resuscitation with crystalloid solution; however, never delay patient transport while IV lines are inserted. En route, administer a fluid bolus of lactated Ringer or normal saline solution to patients with evidence of shock.

Acquire expeditious and complete spinal immobilization on patients with multisystem injuries and on patients with a mechanism of injury that has potential for spinal cord trauma. The pneumatic antishock garment may have a role for treating shock resulting from a severe pelvic fracture.