Blunt Abdominal Trauma Debriefing Notes
1. Recognize and respond appropriately to a patient with hemorrhagic shock.
Step 1: Effectively manage the airway and optimize oxygenation.
Step 2: Identify and control immediate threats to central perfusion.
Step 3: Identify and address severe intracranial injuries.
Step 4: Identify and control other potentially life-threatening thoracic and abdominal injuries.
Step 5: Identify and control potentially limb-threatening injuries.
Step 6: Identify and treat noncritical injuries.
Key points:
From a physiological standpoint, shock results when oxygen delivery is inadequate to meet tissue
demands. The correct approach to treating shock is to restore tissue perfusion rather than to simply
achieve a higher systolic blood pressure.
The presence of shock should never be simplistically equated with a systolic blood pressure
reading<90mmHg.
The recognition of clinical shock requires complex integration of numerous data points including the
mechanism of injury and patient’s overall appearance, vital signs, level of mentation, peripheral
perfusion and urine output.
These clinical parameters alone do not adequately quantify the degree of shock or the response to
shock therapy. This principle is especially pertinent in elderly patients and in those with limited
cardiovascular reserve.
In severely injured blunt trauma patient, clinical parameters should be coupled with objective makers of
tissue perfusion eg, serum lactate or base deficit.
The accurate diagnosis of the cause(s) of shock begins with a targeted physical examination and the
thoughtful use of diagnostic testing (including chest radiography, pelvis radiography, and ultrasound).
The use of objective serum makers of tissue perfusion (eg. serum lactate or base deficit) can be helpful
in identifying “subclinical” shock and in following the patient’s response to resuscitation. A point of care
H/H can be helpful as the results are available within minutes. An actual CBC should be obtained and
sent to the lab, but don’t delay resuscitation for those results.
If the patient reveals signs of hemorrhagic shock, they will need an immediate type and crossmatch for
6-8 units of blood. In patients requiring massive transfusion (defined as the administration of > 10 U of
PRBCs in 24 hours), institutional protocols defining blood product ratios have improved outcomes.
When massive transfusion is employed, use of PRBC to platelet to FFP ratio of approximately 1:1:1 may
result in decreased need for blood products. (Remember to give calcium as well in patients requiring
massive transfusion to prevent citrate toxicity).
In a severely injured polytrauma patient, if the patient is stable, the surgeon request a “pan CT” of the
head, neck, chest, abdomen, pelvis, and possibly lower extremities if fractures are evident.
. For initial evaluation purposes in an unstable patient, consider the following:
2. Assess the source of hemorrhage via bedside methods:
1. Chest radiography:
Look for tension pneumothorax or massive hemothorax.
Is there evidence suggestive of aortic injury?
2. Pelvis radiography:
Is there pelvic ring disruption?
3. Focused assessment with sonography for trauma (FAST):
Is there sonographic evidence of: Pneumothorax? Hemothorax? Hemopericardium?
Hemoperitoneum?
See UpToDate FAST Algorithm (attached)
Learn FAST by using Procedures Consult, EM US apps, Blue Phantom FAST Simulator, Vimedex
FAST Simulator and/or “real” people scanning.
If positive the patient needs an emergency laparotomy.
If negative, continue hemostatic resuscitation while seeking and treating other causes of
hemorrhage and shock.
FAST Facts:
a) FAST can reliably identify 200-250ml of intraperitoneal fluid; cannot reliably evaluate
retroperitoneum/hollow viscous injury
b) Sensitivity/specificity: 75%/98%, NPV: 94%; increased sens/spec with serial exams; 86-97%
accurate
c) FAST is performed using a curvilinear 2.5 or 3.5 MHz probe (set gain so fluid in heart is black)
d) 4 main views to obtain (stand at pt’s right):
 Cardiac (probe indicator to pt’s right): parasternal or subxiphoid, hepatocardiac
interface, cardiac wall motion, pericardial space
 RUQ (probe indicator cephalad, mid-axillary line, 11/12th ribs): hepatorenal interface
(Morrison’s Pouch), diaphragm, inferior pole of kidney
 LUQ (probe indicator cephalad, mid-axillary line, 10/11th ribs): splenorenal interface,
diaphragm, inferior pole of kidney, inferior tip of spleen
 Suprapubic (probe indicator to pt’s right, just cephalad to pubic bone): outline of
bladder, silhouette of uterus (females)
e) CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma.
CT is the Gold Standard
f) Unstable pt, + FAST = OR
g) Stable pt, + FAST = Abdominal CT
h) Stable pt, low mechanism of injury, - FAST = Observation, serial exams
4. Diagnostic peritoneal aspiration (DPA):
Is there hemoperitoneum?
Algorithm (text version):
Diagnostic peritoneal aspiration (DPA) can be performed following a negative FAST scan in the
setting of blunt abdominal trauma. A positive DPA is suggested by the aspiration of frank blood
If the DPA is positive, the patient needs: emergency laparotomy.
If the DPA is negative, then other causes of hemorrhage are likely (i.e. extra-abdominal), or nonhemorrhagic causes of hypotension. The six sites of bleeding to consider are: scalp and external,
chest, abdomen, long bones, pelvis and retroperitoneal (SCALPeR). However, patients who are
FAST negative and DPA negative following blunt abdominal trauma may still have a significant
intraperitoneal injury. Serial examination of the abdomen and serial FAST scans should be
performed in case of an evolving injury. If the patient stabilizes, a CT abdomen with IV contrast
will help determine the presence of a significant intraperitoneal organ injury retroperitoneal
injury, which may also necessitate operative intervention or interventional radiology.
3. Respond appropriately to evidence of intra-abdominal hemorrhage with initial management and
disposition
Indications for emergency laparotomy:
Peritonism
Free air under the diaphragm
Significant gastrointestinal hemorrhage
Hypotension with positive FAST scan or positive DPL
**Persistent or recurrent hypotension in the patient with hemoperitoneum is an indication for
immediate laparotomy.
If patient is hemodynamically stable, then options include:
Serial physical examinations +/- FAST scans and observation. CT abdomen with IV contrast (DPL is an
alternative if CT abdomen is not available) The choice depends on various factors: availability of
imaging; availability of experienced staff to perform serial examinations; patient preference following
informed consent; presence of other indications for definitive imaging e.g. seat belt sign, suspected
retroperitoneal injury, etc. CT abdomen is primarily used in a hemodynamically stable to identify
intraperitoneal injuries in the absence of significant hemorrhage. FAST scan can detect 250 mL of
intraperitoneal free fluid, depending on the operator. As such it is useful for identifying significant
intraperitoneal hemorrhage. However, ultrasound is not reliable for identifying specific organ injuries or
minor hemorrhage.
** An important point is that if the above discussed radiographic modalities and/or general surgeon
experienced in the care of trauma are not available in your institution, then the patient must be
transferred. Do not keep sick trauma patients if you do not have the resources to care for them.