Diagnostic options for blunt abdominal trauma

Abstract

Purpose

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

Methods

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

Results

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

Conclusions

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient’s injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

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References

  1. 1.

    Iaselli F, et al. Bowel and mesenteric injuries from blunt abdominal trauma: a review. Radiol Med. 2015;120(1):21–322.

    PubMed  Google Scholar 

  2. 2.

    Norcross ED, et al. Application of American College of Surgeons’ field triage guidelines by pre-hospital personnel. J Am Coll Surg. 1995;181(6):539–44.

    CAS  PubMed  Google Scholar 

  3. 3.

    Rossaint R, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20(1):100.

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Vailas MG, et al. Seatbelt sign in a case of blunt abdominal trauma; what lies beneath it? BMC Surg. 2015;15:121.

    PubMed  PubMed Central  Google Scholar 

  5. 5.

    McStay C, et al. Hollow viscus injury. J Emerg Med. 2009;37(3):293–9.

    PubMed  Google Scholar 

  6. 6.

    Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997;63(10):885–8.

    CAS  PubMed  Google Scholar 

  7. 7.

    Jones EL, et al. Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours. J Trauma Acute Care Surg. 2014;76(4):1020–3.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Allgower M, Burri C. “Shock index”. Dtsch Med Wochenschr. 1967;92(43):1947–50.

    CAS  PubMed  Google Scholar 

  9. 9.

    Liu N, et al. An intelligent scoring system and its application to cardiac arrest prediction. IEEE Trans Inf Technol Biomed. 2012;16(6):1324–31.

    PubMed  Google Scholar 

  10. 10.

    Mitra B, et al. Trauma patients with the ‘triad of death’. Emerg Med J. 2012;29(8):622–5.

    PubMed  Google Scholar 

  11. 11.

    Wang SY, et al. An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study. BMC Surg. 2014;14:24.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Ibrahim I, et al. Is arterial base deficit still a useful prognostic marker in trauma? A systematic review. Am J Emerg Med. 2016;34(3):626–35.

    CAS  PubMed  Google Scholar 

  13. 13.

    Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma. 1998;45(5):873–7.

    CAS  PubMed  Google Scholar 

  14. 14.

    Mutschler M, et al. Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU(R). Crit Care. 2013;17(2):R42.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Johansson PI, et al. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med. 2009;17:45.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007;13(6):680–5.

    PubMed  Google Scholar 

  17. 17.

    Hunt H, et al. (2015) Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015;2:CD010438.

    Google Scholar 

  18. 18.

    Greenfield RH, Bessen HA, Henneman PL. Effect of crystalloid infusion on hematocrit and intravascular volume in healthy, nonbleeding subjects. Ann Emerg Med. 1989;18(1):51–5.

    CAS  PubMed  Google Scholar 

  19. 19.

    Stamler KD. Effect of crystalloid infusion on hematocrit in nonbleeding patients, with applications to clinical traumatology. Ann Emerg Med. 1989;18(7):747–9.

    CAS  PubMed  Google Scholar 

  20. 20.

    Genoa Update on Colorectal Polyp. Proceedings of the advanced course in coloproctology: the colorectal polyps, from genetics to surgery. Genoa, Italy, 11–12 March 2004. Tech Coloproctol, 2004. 8 Suppl 2: p. s239–314.

  21. 21.

    Thorson CM, et al. Admission hematocrit and transfusion requirements after trauma. J Am Coll Surg. 2013;216(1):65–73.

    PubMed  Google Scholar 

  22. 22.

    Mahajan A, et al. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014;45(9):1384–93.

    PubMed  Google Scholar 

  23. 23.

    Sabzghabaei A, et al. The accuracy of urinalysis in predicting intra-abdominal injury following blunt traumas. Emerg (Tehran). 2016;4(1):11–5.

    Google Scholar 

  24. 24.

    Scalea TM, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma. 1999;46(3):466–72.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749–57.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Montoya J, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2016;42(2):119–26.

    CAS  PubMed  Google Scholar 

  27. 27.

    Surgeons, A.C.o., Advanced Trauma Life Support. Vol. 9. 2014: Urban and Fischer Verlag/Elsevier.

  28. 28.

    Unfallchirurgie, D.G.f., S3—Leitlinie Polytrauma und Schwerverletztenversorgung. 2016: AWMF.

  29. 29.

    Stawicki SP. Trends in nonoperative management of traumatic injuries: a synopsis. Int J Crit Illn Inj Sci. 2017;7(1):38–57.

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11–7.

    PubMed  Google Scholar 

  31. 31.

    Nandipati KC, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center. Injury. 2011;42(5):511–4.

    PubMed  Google Scholar 

  32. 32.

    Wherrett LJ, et al. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma. 1996;41(5):815–20.

    CAS  PubMed  Google Scholar 

  33. 33.

    Hoffmann R, et al. Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: a prospective analysis of 291 patients. J Trauma. 1992;32(4):452–8.

    CAS  PubMed  Google Scholar 

  34. 34.

    Jehle D, Guarino J, Karamanoukian H. Emergency department ultrasound in the evaluation of blunt abdominal trauma. Am J Emerg Med. 1993;11(4):342–6.

    CAS  PubMed  Google Scholar 

  35. 35.

    Branney SW, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39(2):375–80.

    CAS  PubMed  Google Scholar 

  36. 36.

    Stawicki SP, et al. Portable ultrasonography in mass casualty incidents: The CAVEAT examination. World J Orthop. 2010;1(1):10–9.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Soyuncu S, et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury. 2007;38(5):564–9.

    CAS  PubMed  Google Scholar 

  38. 38.

    Healey MA, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma. 1996;40(6):875–83.

    CAS  PubMed  Google Scholar 

  39. 39.

    McGahan JP, Richards J, Gillen M. The focused abdominal sonography for trauma scan: pearls and pitfalls. J Ultrasound Med. 2002;21(7):789–800.

    PubMed  Google Scholar 

  40. 40.

    Carter JW, et al. Do we really rely on fast for decision-making in the management of blunt abdominal trauma? Injury. 2015;46(5):817–21.

    PubMed  Google Scholar 

  41. 41.

    Blackstock U, Munson J, Szyld D. Bedside ultrasound curriculum for medical students: report of a blended learning curriculum implementation and validation. J Clin Ultrasound. 2015;43(3):139–44.

    PubMed  Google Scholar 

  42. 42.

    Dubois L, Leslie K, Parry N. FACTS survey: focused assessment with sonography in trauma use among Canadian residents training in general surgery. J Trauma. 2010;69(4):765–9.

    PubMed  Google Scholar 

  43. 43.

    Ma OJ, et al. Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels. Am J Emerg Med. 2001;19(4):284–6.

    CAS  PubMed  Google Scholar 

  44. 44.

    Ollerton JE, et al. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma. 2006;60(4):785–91.

    CAS  PubMed  Google Scholar 

  45. 45.

    Wydo SM, et al. Portable ultrasound in disaster triage: a focused review. Eur J Trauma Emerg Surg. 2016;42(2):151–9.

    CAS  PubMed  Google Scholar 

  46. 46.

    Stengel D, et al. (2015) Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev. 2015;9:CD004446.

    Google Scholar 

  47. 47.

    Miele V, et al. Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma. Br J Radiol. 2016;89(1061):20150823.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Zhang Z, et al. Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis. Sci Rep. 2017;7(1):4446.

    PubMed  PubMed Central  Google Scholar 

  49. 49.

    Sessa B, et al. Blunt abdominal trauma: role of contrast-enhanced ultrasound (CEUS) in the detection and staging of abdominal traumatic lesions compared to US and CE-MDCT. Radiol Med. 2015;120(2):180–9.

    PubMed  Google Scholar 

  50. 50.

    Valentino M, et al. Contrast-enhanced ultrasound for blunt abdominal trauma. Semin Ultrasound CT MR. 2007;28(2):130–40.

    PubMed  Google Scholar 

  51. 51.

    Pinto F, et al. The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations. Acta Radiol. 2014;55(7):776–84.

    PubMed  Google Scholar 

  52. 52.

    Wongwaisayawan S, et al. Trauma ultrasound. Ultrasound Med Biol. 2015;41(10):2543–61.

    PubMed  Google Scholar 

  53. 53.

    Pinto F, et al. The role of CEUS in the assessment of haemodynamically stable patients with blunt abdominal trauma. Radiol Med. 2015;120(1):3–11.

    PubMed  Google Scholar 

  54. 54.

    Deunk J, et al. Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm. Ann Surg. 2010;251(3):512–20.

    PubMed  Google Scholar 

  55. 55.

    Kokabi N, et al. Specific radiological findings of traumatic gastrointestinal tract injuries in patients with blunt chest and abdominal trauma. Can Assoc Radiol J. 2015;66(2):158–63.

    PubMed  Google Scholar 

  56. 56.

    Corwin MT, et al. Utilization of a clinical prediction rule for abdominal-pelvic CT scans in patients with blunt abdominal trauma. Emerg Radiol. 2014;21(6):571–6.

    PubMed  Google Scholar 

  57. 57.

    Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology. 2012;265(3):678–93.

    PubMed  Google Scholar 

  58. 58.

    Marek AP, et al. CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma. Injury. 2014;45(1):116–21.

    PubMed  Google Scholar 

  59. 59.

    Hefny AF, et al. Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital. Injury. 2015;46(1):100–4.

    PubMed  Google Scholar 

  60. 60.

    Gonser-Hafertepen LN, et al. Isolated free fluid on abdominal computed tomography in blunt trauma: watch and wait or operate? J Am Coll Surg. 2014;219(4):599–605.

    PubMed  Google Scholar 

  61. 61.

    Park MH, Shin BS, Namgung H. Diagnostic performance of 64-MDCT for blunt small bowel perforation. Clin Imaging. 2013;37(5):884–8.

    PubMed  Google Scholar 

  62. 62.

    Yu J, et al. Blunt bowel and mesenteric injury: MDCT diagnosis. Abdom Imaging. 2011;36(1):50–61.

    PubMed  Google Scholar 

  63. 63.

    Fu CJ, et al. Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma. Diagn Interv Radiol. 2015;21(5):361–7.

    PubMed  PubMed Central  Google Scholar 

  64. 64.

    Wallace GW, et al. Imaging the pregnant patient with abdominal pain. Abdom Imaging. 2012;37(5):849–60.

    PubMed  Google Scholar 

  65. 65.

    Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499–505.

    PubMed  PubMed Central  Google Scholar 

  66. 66.

    Arnold M, Moore SW. Paediatric blunt abdominal trauma - are we doing too many computed tomography scans? S Afr J Surg. 2013;51(1):26–31.

    CAS  PubMed  Google Scholar 

  67. 67.

    Panda A, et al. Evaluation of diagnostic utility of multidetector computed tomography and magnetic resonance imaging in blunt pancreatic trauma: a prospective study. Acta Radiol. 2015;56(4):387–96.

    PubMed  Google Scholar 

  68. 68.

    Tharakan SJ, et al. Laparoscopy in Pediatric Abdominal Trauma: A 13-Year Experience. Eur J Pediatr Surg. 2016;26(5):443–8.

    PubMed  Google Scholar 

  69. 69.

    Johnson JJ, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013;205(3):317–20.

    PubMed  Google Scholar 

  70. 70.

    Sitnikov V, et al. The role of video-assisted laparoscopy in management of patients with small bowel injuries in abdominal trauma. Surg Endosc. 2009;23(1):125–9.

    PubMed  Google Scholar 

  71. 71.

    Nicolau AE, et al. Small bowel perforation caused by compound pelvic fracture found in diagnostic laparoscopy. Chirurgia (Bucur). 2006;101(4):423–8.

    CAS  Google Scholar 

  72. 72.

    Uranus S, Dorr K. Laparoscopy in Abdominal Trauma. Eur J Trauma Emerg Surg. 2010;36(1):19–24.

    PubMed  Google Scholar 

  73. 73.

    Kindel T, et al. Laparoscopy in trauma: An overview of complications and related topics. Int J Crit Illn Inj Sci. 2015;5(3):196–205.

    PubMed  PubMed Central  Google Scholar 

  74. 74.

    Becker HP, Willms A, Schwab R. Laparoscopy for abdominal trauma. Chirurg. 2006;77(11):1007–133.

    CAS  PubMed  Google Scholar 

  75. 75.

    Khubutiya M, et al. Laparoscopy in blunt and penetrating abdominal trauma. Surg Laparosc Endosc Percutan Tech. 2013;23(6):507–12.

    PubMed  Google Scholar 

  76. 76.

    Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma? Chirurgia (Bucur). 2011;106(1):59–66.

    CAS  Google Scholar 

  77. 77.

    Lee PC, et al. Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma. Surg Innov. 2014;21(2):155–65.

    PubMed  Google Scholar 

  78. 78.

    Kaban GK, et al. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov. 2008;15(1):26–31.

    PubMed  Google Scholar 

  79. 79.

    Gaines BA, Rutkoski JD. The role of laparoscopy in pediatric trauma. Semin Pediatr Surg. 2010;19(4):300–3.

    PubMed  Google Scholar 

  80. 80.

    Gregoric PD, et al. Laparoscopy in the evaluation of blunt abdominal trauma. Acta Chir Iugosl. 2010;57(4):33–8.

    PubMed  Google Scholar 

  81. 81.

    Addeo P, Calabrese DP. Diagnostic and therapeutic value of laparoscopy for small bowel blunt injuries: A case report. Int J Surg Case Rep. 2011;2(8):316–8.

    PubMed  PubMed Central  Google Scholar 

  82. 82.

    Fuentes S, et al. Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age. Cir Pediatr. 2011;24(2):115–7.

    CAS  PubMed  Google Scholar 

  83. 83.

    Van Kerschaver O, et al. An unusual case of blunt abdominal trauma: A bleeding and ruptured gall-bladder managed by laparoscopy. Acta Chir Belg. 2006;106(4):417–9.

    PubMed  Google Scholar 

  84. 84.

    Kovachev S, et al. Open laparoscopy–a modified Hasson technique. Akush Ginekol (Sofiia). 2015;54(4):52–6.

    CAS  Google Scholar 

  85. 85.

    Marwan A, et al. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma. 2010;69(4):761–4.

    PubMed  Google Scholar 

  86. 86.

    Lin HF, et al. Value of diagnostic and therapeutic laparoscopy for patients with blunt abdominal trauma: A 10-year medical center experience. PLoS ONE. 2018;13(2):e0193379.

    PubMed  PubMed Central  Google Scholar 

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Correspondence to Achatz Gerhard.

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Achatz Gerhard, Schwabe Kerstin, Brill Sebastian, Zischek Christoph, Schmidt Roland, Friemert Benedikt and Beltzer Christian declare that there is no conflict of interest regarding this paper and topic.

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For this study there were no test or experiments to humans or animals.

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Gerhard, A., Kerstin, S., Sebastian, B. et al. Diagnostic options for blunt abdominal trauma. Eur J Trauma Emerg Surg (2020). https://doi.org/10.1007/s00068-020-01405-1

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Keywords

  • Blunt abdominal trauma
  • FAST
  • MSCT
  • Radiography
  • Diagnostic laparoscopy
  • Hollow viscus injury