EVALUATION OF THE PATIENT WITH BLUNT ABDOMINAL TRAUMA: AN EVIDENCE BASED APPROACH

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Emergency patients frequently are required to evaluate patients who have sustained blunt abdominal trauma from a variety of mechanisms. The management of these patients is an ongoing challenge to the emergency physician (EP). Blunt abdominal trauma usually occurs in the setting of multisystem injury following a motor vehicle collision (MVC), fall, or other high-speed energy transfer. The high incidence of concomitant CNS injury makes traditional methods of diagnosis (e.g., history, physical examination) unreliable. Proper diagnosis and management usually require the application of a number of complementary diagnostic modalities.

It has been estimated that about 6% of all patients presenting with blunt abdominal trauma from any mechanism will have injuries requiring laparotomy; this reflects to some extent a changing pattern of “need for laparotomy” because more injuries, especially to the frequently injured liver and spleen,1 can be managed nonoperatively. Both operative and nonoperative management require an acute assessment of not only the presence of injury to the organs affected but also the nature and extent of the injuries. As a result, the demands on a diagnostic modality to be not only sensitive, but specific, are increasing.

This article examines the evidence underlying the use of CT scanning, diagnostic peritoneal lavage (DPL), and ultrasonography (US) for the diagnosis and immediate management of the patient with blunt abdominal trauma. It is also the purpose of this article to formulate an evidenced-based protocol for managing the patient with blunt abdominal trauma in the initial stages of the trauma resuscitation.

Section snippets

MATERIALS AND METHODS

A MEDLINE search was conducted using the keywords abdominal trauma, diagnosis, blunt; an additional search was conducted using nonpenetrating instead of blunt after examination of the associated MeSH (Medical Search Headings) terms revealed that this search might be more comprehensive. The search was limited to English language articles and was limited to the years 1993 to 1998. This search yielded a total of 230 articles meeting the search criteria. The abstracts of these articles were then

Historical Context

Early in the history of trauma resuscitation, physical examination alone was used to assess for the presence or absence of intra-abdominal injury. This soon proved unreliable, and soon afterward four-quadrant paracentesis was added to the armamentarium of the trauma surgeon. Root et al34 described the use of DPL in 1965. It was envisioned that this “minilaparotomy” with saline lavage of the peritoneum would confirm or deny a suspicion of injury with higher accuracy, and decrease negative

FUTURE DIRECTIONS

The proper place for ultrasound scanning in the management of the trauma patient remains in question. Minimal training standards remain in question; these will become paramount in further studies in which sonograms are done by nonradiologists. The exact significance of a positive finding on ultrasound examination, and of specific sonographic signs of intraperitoneal fluid, is uncertain. How much fluid is enough to require laparotomy? Head-to-head comparison of sonography and DPL is needed to

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    Address reprint requests to Thomas A. Amoroso, MD, Division of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215

    *

    Division of Emergency Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts

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