The work-up of a patient with abdominal trauma has always been perplexing. In the ever-changing medical environment, the surgeon must evaluate these patients in an efficient, cost-effective manner. On the other hand, the surgeon must be careful not to miss injuries and must be aware of the hazards of delayed or missed diagnoses. The patient is the most important factor in the equation. What is the most comfortable way to work up this patient? At Barnes-Jewish Hospital we are grappling with this dilemma.
The ultimate in abdominal evaluation, celiotomy is the gold standard. Celiotomy must be considered for each patient. Not every patient needs an operation, but no test or study is better for evaluating the abdomen. With celiotomy, the risk of missing a significant injury decreases almost to zero. The drawback of celiotomy is the nontherapeutic operation. Nontherapeutic laparotomy was once thought of as a benign procedure. Complications of nontherapeutic laparotomies range from 15% to 50%. The average hospital stay is a little more than 5 days.1 Therefore, a nontherapeutic celiotomy is not a benign procedure. Our approach is to avoid overutilizing celiotomy.
Patients with unstable penetrating abdominal wounds must be taken expeditiously to the operating room. Advanced Trauma Life Support protocol should be followed in the emergency room. Two large-bore IVs should be started, and blood drawn for pertinent labs, including type and match. O positive blood should be available. If the patient needs blood immediately, we give O negative blood to women of child-bearing age and O positive to everyone else.
We have not adopted delayed fluid resuscitation for penetrating torso trauma. Mattox2 proposed delaying fluid resuscitation until the patient reaches the operating room. Once in the operating room, the patient is resuscitated. Their study found a significantly decreased mortality rate in the group of patients who had delayed resuscitation. Because no other human data exist on delayed fluid resuscitation, we would like to see this protocol repeated before we adopt it for our trauma patients.
The key in this group of patients is speed. Quickly getting the patient to the operating room is paramount. When the length of time a patient is unstable is shortened, overall mortality and morbidity are decreased .
Most patients with unstable blunt trauma are motor vehicle crash victims. These patients have multisystem trauma. The focus should be quickly narrowed to only those systems that may be causing hypotension. Usually hypotension is caused by blood loss into the abdomen, the chest, into a large bone fracture (pelvis, femur, open tibia/fibula), or from a large, open wound. Severe head injuries can also cause hypotension.
We consider only three modalities safe and effective for evaluating abdominal trauma in an unstable patient: ultrasound, diagnostic peritoneal lavage, and celiotomy. Ultrasound has been used in Europe for years to evaluate patients with abdominal trauma. Only recently have we become aware of the benefits of ultrasound in evaluating unstable patients. Rapid abdominal ultrasound has several advantages. First, learning how to perform an ultrasound for abdominal trauma is not difficult. The diagnostician looks only for fluid, not organ architecture or function. Furthermore, in the unstable patient, this is not a small amount of fluid, but enough fluid to cause the patient's hypotension, a grossly positive lavage. Microscopic evidence for abdominal trauma is important, but should not cause a patient to remain unstable.
Celiotomy, as mentioned earlier, is still an excellent way to evaluate the abdomen. In areas where ultrasound is not available in the emergency room and severe abdominal trauma is rarely seen, diagnostic peritoneal lavage equipment may not be readily available. A rapid celiotomy may be the best course of action before obtaining further testing.
Evaluation of patients with abdominal trauma remains a complex issue. There is no one right way to evaluate a patient. Every surgeon must take his or her own surgical skills and hospital's resources into account when determining the best procedure for a patient.
1. Sosa JL, Baker M, Puente I, et al. Negative laparotomy in abdominal gunshot wounds: Potential impact of laparoscopy. J Trauma. 1995; 38: 194-197.
2. Bickell WH, Wall MJ, Matthew Jr J, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994; 331: 1105-1109.
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