AMC: Trauma Practice Management Guideline: Blunt Abdominal Trauma, Hollow Viscus Injury

Original: 2/2018 Reviewed: 1/2019 AMC: Trauma Practice Management Guideline: Blunt Abdominal Trauma, Hollow Viscus Injury

PURPOSE: To develop evidence based approach for the diagnosis and management of blunt abdominal trauma with the emphasis on hollow viscus injury

SUPPORTIVE DATA:

Definitions:

- blunt abdominal trauma refers to non-penetrating blunt force injury resulting in visceral injury to the abdomen. While the abdomen includes thoracoabdominal, pelvic, retroperitoneal and intraperitoneal anatomic locations this document will focus primarily on the diagnosis and management of hollow viscus injury

- hollow viscus injury refers to blunt force injury specific to the gastrointestinal system extending from the gastroesophageal junction, stomach, small and large intestine including the rectum. Any-rectal injury will be outlined in a separate guideline.

Background:

The evaluation and management of blunt abdominal trauma is among the most challenging issue in trauma care. Mechanisms of injury and associated injuries may raise the suspicion for significant intra-abdominal injury however no clinical or diagnostic modality consistently and definitively rule in or rule out injury that may require surgical intervention. Serial clinical examination is unreliable in the presence of significantly altered mental status associated with traumatic brain injury, extremes of age, and drug or alcohol intoxication. CT scan of the abdomen and pelvis in patients with blunt hollow viscus injury are associated with a significant false negative rate and while the addition of clinical and physical examination parameters to CT scan may in the form of a bowel injury prediction score may reduce the false negative rate, these tools have yet to be prospectively evaluated. What is known is that there is up to a 20% missed hollow viscus injury rate and significant delays in surgical intervention are associated with significant morbidity and mortality.

PROCEDURES / THERAPEUTIC INTERVENTIONS / GUIDELINE RECOMMENDATIONS:

Level 1:

1. Laparotomy is indicated in patients presenting with evidence of peritonitis, evisceration or hemodynamic instability that is not responsive to aggressive volume resuscitation 2. CT scanning with intravenous contrast of the chest, abdomen and pelvis is indicated in the hemodynamically stable patients and patients with impaired mental status and patients with high risk associated injuries such as TBI, thoracic injury, pelvic fractures, major long bone fractures and truncal abrasions such as seatbelt sign in patients with blunt force trauma.

Level 2:

1. Focal abdominal tenderness, intestinal thickening, mesenteric hematoma, significant intraperitoneal fluid in the absence of solid organ injury increases the concern for hollow viscus injury. Serial clinical examination, repeat FAST, DPL and / or CT scan is indicated with low threshold for laparotomy.

Original: 2/2018 Reviewed: 1/2019 AMC: Trauma Practice Management Guideline: Blunt Abdominal Trauma, Hollow Viscus Injury

Hemodynamically Stable

Physical Exam FAST

Negative Positive

Tandem CT Scan Hollow Viscus Distracting Injury Injury Yes No

No Yes  Free Fluid Free Fluid Laparotomy  Mesenteric Injury  Bowel Wall Abnormality  Admit No Yes Yes No  Serial Exam  +/- Repeat FAST  Admit Yes Solid Organ No  Serial PE Injury

 Serial Exam  Possible Laparotomy

Hemodynamically Unstable

Potential Alternative Option

Ultrasound DPL

 Aspiration of Gross Blood  RBC >100K/mm3 No Free Fluid Identified? Yes Yes  WBC >500/mm3 No  Particulate Matter  Bile  Other  Continue Resuscitation Exploratory Laparotomy  Continue Resuscitation  Evaluate Other Potential  Evaluate Other Potential Sources of Shock Sources of Shock  Repeat Ultrasound  Repeat DPL  DPL

Original: 2/2018 Reviewed: 1/2019 AMC: Trauma Practice Management Guideline: Blunt Abdominal Trauma, Hollow Viscus Injury

REFERENCES:

1. Practice Management Guidelines: Blunt Abdominal Trauma, Eastern Association for the Surgery of Trauma 2002. East.org 2. Jones EL, Stovall RT, Jones TS, et al. Intra-abdominal injury following blunt trauma becomes clinically apparent with 9 hours. J Trauma Acute Care Surg. 2014;76:1020-1023. 3. Rostas J, Cason B, Simmons J, et al. The validity of abdominal examination in blunt trauma patients with distracting injuries. J Trauma Acute Care Surg. 2015;78:1095-1101. 4. Cho Y, Judson R, Gumm K., et al. Trauma Service Guidelines: Blunt Abdominal Trauma. The Royal Melborne Hospital 2012/2013. 5. Watts DD, Fakhry SM. Incidence of Hollow Viscus Injury in Blunt Trauma: An Analysis of 275,557 trauma admissions from the EAST Multi-institutional Trial. J Trauma.2003;54:289-294.

Original: 2/2018 Reviewed: 1/2019