Urgent considerations

See Differentials for more details

Hemorrhagic shock

The abdominal cavity is a large potential space for hemorrhage that offers little opportunity for a tamponade effect to arise due to its tendency to distend. Abdominal vascular, splenic, and hepatic injuries can rapidly result in hemodynamic instability and shock. Similarly, renal injuries can quickly hemorrhage significant volumes into the retroperitoneal space. It is therefore critical that initial evaluation and management are carried out in a timely manner.

Hemorrhagic shock is a condition of reduced perfusion with inadequate oxygen delivery caused by acute blood loss. It may present with hypotension; tachycardia; oliguria; tachypnea; diminished or absent pulses; altered sensorium; and pale, cold, clammy skin. Urgent consultation with a surgeon and anesthetist is advisable. Patients in hemorrhagic shock require aggressive fluid resuscitation, blood transfusions, and control of the hemorrhage. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be taken emergently for laparotomy.[7][14]​​

European guidelines recommend that patients should undergo an immediate bleeding control procedure if they have an obvious source of bleeding, or if they present with hemorrhagic shock in extremis and have a suspected source of bleeding.[15]​ Patients with gunshot wounds, major stab wounds, or shrapnel wounds typically fall into this category. Blood should be drawn for crossmatch and multiple units of packed red blood cells prepared in anticipation of a transfusion. 

Patients with profound hemorrhagic shock

Suggested by extreme hypotension and a severely reduced mental status (i.e., coma). These patients require an immediate uncrossmatched blood transfusion. Pressure delivery and blood warming devices can be helpful in situations of profound hemorrhage. With large volume transfusions, coagulation may be affected and this needs to be monitored and treated with fresh frozen plasma and platelets as necessary. These patients require at least two functioning large-bore peripheral intravenous lines for fluid administration and a Foley catheter to allow accurate monitoring of urine output. If peripheral lines are difficult to place, a short, large-caliber femoral or subclavian central line is recommended. Long double- or triple-lumen central lines should be avoided as fluid cannot be infused rapidly through these catheters.

The US guidelines recommend protocols that target blood product ratios (fresh frozen plasma: platelet: packed red blood cells) of 1:1:1 or 1:1:1.5 to reduce mortality.[16][17]​​ The UK guidelines suggest a 1:1 ratio of red blood cells to fresh frozen plasma (FFP).[18][19]

Evidence from a small, randomized trial suggests that coagulation factor concentrates may be more effective than fresh frozen plasma in patients with trauma-induced coagulopathy.[20]

Consult local protocols for managing major hemorrhage in hemodynamically unstable trauma patients.[17][18][19]​​

Time to laparotomy

Delay in performing a laparotomy in an abdominal trauma patient with intra-abdominal bleeding increases morbidity and mortality.[21] European guidelines recommend serum lactate testing to estimate and monitor the extent of bleeding and tissue hypoperfusion.[15]​ Base-deficit, calculated from arterial blood gas measurement, may be used as an alternative; however, lactate levels more specifically reflect the degree of tissue hypoperfusion.[15]​​

Antifibrinolytics

Such as tranexamic acid, should be considered in all trauma patients with acute severe hemorrhage as soon as possible, as they have been shown to increase survival when given within 3 hours of injury.[22][23] A meta-analysis found that among patients with traumatic bleeding or postpartum hemorrhage, immediate treatment with tranexamic acid greatly increased the odds of survival, with the survival benefit decreasing by about 10% for every 15 minutes of treatment delay until 3 hours, after which there was no benefit.[24]

Hemorrhagic shock with unidentified source of bleeding

Patients presenting with hemorrhagic shock and an unidentified source of bleeding (as may occur with blunt trauma) should undergo immediate further assessment by a focused assessment by sonography in trauma (FAST) exam.[25][26]​

FAST is a useful tool for the rapid diagnosis of intra-abdominal hemorrhage.[27][28]​ The FAST exam uses a bedside ultrasound to provide images of the right upper quadrant, left upper quadrant, and pelvis to assess for intra-abdominal hemorrhage.[25]​ The sensitivity and specificity of point of care sonography is 68% and 95% for adults and children with abdominal trauma.[29]

If a FAST exam is unavailable or unreliable, a diagnostic peritoneal lavage (DPL) may be performed to assess for intraperitoneal bleeding.[30] DPL involves making a small midline incision below the umbilicus and using a needle and small catheter to aspirate intraperitoneal fluid to assess for blood or bile. If the aspirate is found to contain 10 mL of gross blood or bile, an exploratory laparotomy is indicated. In the absence of gross blood or bile, DPL requires 1 liter of fluid to be infused into the peritoneum and then drained. The effluent should be sent to the lab and evaluated. Laboratory criteria for a positive DPL are:

  • >100,000 red blood cells/mm³

  • >500 white blood cells/mm³

  • Presence of bacteria, bile, or food particles.

Patients found to have significant free intra-abdominal fluid on FAST exam (or DPL) and hemodynamic instability should undergo urgent surgery.

Guideline recommendations

The Eastern Association for the Surgery of Trauma makes the following recommendations with regard to managing penetrating abdominal trauma.[14]

  • Take patients who are hemodynamically unstable or who have diffuse abdominal tenderness for urgent laparotomy

  • Perform exploratory laparotomy or further diagnostic investigation for intraperitoneal injury in patients who are hemodynamically stable but have an unreliable clinical exam (e.g., patients with severe head injury, spinal cord injury, severe intoxication, or need for sedation or anesthesia)

  • Routine laparotomy is not indicated in hemodynamically stable patients with:

    • Abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness (away from the wound site) in centers with surgical expertise

    • Abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs

    • Penetrating injury isolated to the right upper quadrant with stable vital signs, reliable exam, and minimal to no abdominal tenderness.

  • Consider abdominopelvic computed tomography (CT) in patients who are initially managed nonoperatively

  • Diaphragmatic lacerations and peritoneal penetration may be evaluated with diagnostic laparoscopy

  • Serial physical exams can reliably detect significant injuries if performed by experienced clinicians and the same team

  • Most patients managed nonoperatively can be discharged after 24 hours of observation if the abdominal exam is reliable and they have minimal or no abdominal tenderness.

European guidelines recommend using contrast-enhanced whole-body CT (WBCT) to detect and identify the type of injury and the potential source of bleeding.[15] ​Usually, patients with penetrating trauma and signs of hemodynamic instability undergo surgery without CT; however, WBCT while continuing resuscitation, regardless of hemodynamic status may be considered.[26][31][32][33][34]

Missed or delayed diagnosis of intra-abdominal organ injury

Whole-body CT occasionally identifies unexpected significant injuries and its underuse may result in missed or delayed diagnoses.[16]​ Clinical judgement and local protocols should be used when deciding whether to use whole-body versus selective CT to evaluate patients with blunt trauma.[16]

Injuries to the spleen, liver, and abdominal vasculature

Significant intra-abdominal hemorrhage and hemodynamic instability may result from abdominal vascular, splenic, and hepatic injuries. A FAST exam and abdominal CT scan with contrast should be initiated promptly when these injuries are suspected.

Pancreatic injury

Diagnosis of pancreatic injuries is difficult due to the retroperitoneal location of the pancreas, resulting in delay in the development of signs and symptoms. Vague abdominal pain radiating to the back and abdominal tenderness usually do not appear until some hours after the traumatic event. An abdominal CT scan is key to making the diagnosis, as serum amylase and serum lipase may only later become elevated. Magnetic resonance cholangiopancreatography is recommended to definitively exclude pancreatic parenchymal and ductal injuries.[9]

Diaphragmatic injury

Missed diaphragmatic injuries are associated with significant morbidity from herniation and strangulation of abdominal viscera. There is a high incidence of diaphragmatic injury in thoracoabdominal penetrating trauma.[13]​ The patient may complain of chest pain, abdominal pain, or shortness of breath. There may be hemodynamic instability when the patient lies supine. Typically, there are diminished breath sounds on the affected side, with bowel sounds audible over what would normally be the lung fields. Thoracoabdominal CT is a good choice for diagnosing diaphragmatic injuries related to blunt trauma, but laparoscopy is a more appropriate tool for detecting diaphragmatic injuries relating to penetrating trauma.[13][35][36]​​​​

Stomach and small bowel injuries

Significant morbidity and mortality accompany a missed or delayed diagnosis of small bowel injury. Patients often do not have signs of peritonitis in the early period and small bowel injury may be missed. This may happen in the context of blunt abdominal trauma, where a small bowel injury is not suspected, or when a stab wound to the anterior abdomen is misdiagnosed as not having penetrated the posterior abdominal fascia. Stomach injury often results in a rapid onset of burning epigastric pain, followed by rigidity and rebound sensitivity. Classically, free air under the diaphragm is seen on erect chest x-ray with perforation of a hollow viscus, although this is not always seen and diagnosis may also require abdominal CT and DPL, along with careful evaluation of the clinical and laboratory findings.[37][38]

Mesenteric injury

There is a high rate of delayed diagnosis of mesenteric injury after blunt abdominal trauma as patients may be initially asymptomatic, and CT has a high false-negative rate.[39]​ Delayed diagnosis can result in bowel ischemia.[40]​ Maintaining a high level of clinical suspicion, along with FAST exam and abdominal CT, is important in ensuring the diagnosis is not missed.

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