Rosen & Barkin's 5-Minute Emergency Medicine Consult by Jeffrey J. Schaider, Adam Z. Barkin, Roger M. Barkin, Philip Shayne, Richard E. Wolfe, Stephen R. Hayden, Peter Rosen Page B

the back.
Lap-belt abrasions can be indicative of significant intra-abdominal injuries.
Bowel sounds may be absent from peritoneal irritation (late finding).
Foley catheter (if no blood at the meatus, no perineal hematoma, and normal prostate exam) to obtain urine and record urinary output
Plain film of the pelvis:
Fracture of the pelvis and gross hematuria may indicate genitourinary injury.
Further evaluation of these structures with retrograde urethrogram, cystogram, or IV pyelogram
CT most useful in assessing need for operative intervention and for evaluating the retroperitoneal space and solid organs:
Patient must be stable enough to make trip to scanner.
Also useful for suspected renal injury
Focused abdominal sonography for trauma (FAST) to detect intraperitoneal fluid:
US is rapid, requires no contrast agents, and is noninvasive.
Operator dependent
Diagnostic peritoneal lavage (useful for revealing injuries in the intrathoracic abdomen, pelvic abdomen, and true abdomen) primarily indicated for unstable patients:
Positive with gross blood, RBC count of >100,000/mm 3 , WBC count of 500/mm 3 , or presence of bile, feces, or food particles
DIAGNOSIS TESTS & NTERPRETATION
Lab
Hemoglobin/hematocrit, which initially may be normal owing to isovolemic blood loss
Type and screen is essential. Cross-match PRBC units for unstable patients.
Urinalysis for blood:
Microscopic hematuria in the presence of shock is an indication for genitourinary evaluation.
ABG:
Base deficit may suggest hypovolemic shock and help guide the resuscitation.
Imaging
    See “Essential Workup.”
Diagnostic Procedures/Surgery
    See “Essential Workup”
DIFFERENTIAL DIAGNOSIS
    Lower thoracic injury may cause abdominal pain.
TREATMENT
PRE HOSPITAL
Titrate fluid resuscitation to clinical response. Target SBP of 90–100 mm Hg
Normal vital signs do not preclude significant intra-abdominal pathology.
INITIAL STABILIZATION/THERAPY
Ensure adequate airway:
Intubate if needed.
O 2 100% by nonrebreather face mask
2 large-bore IV lines with crystalloid infusion
Begin infusion of PRBCs if no response to 2 L of crystalloid.
If patient is in profound shock, consider immediate transfusion of O-negative blood.
ED TREATMENT/PROCEDURES
Continue stabilization begun in field.
Nasogastric tube to evacuate stomach, decrease distention, and decrease risk of aspiration:
May relieve respiratory distress if caused by a herniated stomach through the diaphragm
MEDICATION
Tetanus toxoid booster: 0.5 mL IM for patients with open wounds
Tetanus immunoglobulin: 250 U IM for patients who have not had complete series
IV antibiotics: Broad-spectrum aerobic with anaerobic coverage such as a 2nd-generation cephalosporin
Pediatric Considerations
Crystalloid infusion is 20 mL/kg if patient is in shock.
PRBC dose is 1 mL/kg.
FOLLOW-UP
DISPOSITION
Admission Criteria
Postoperative cases
Equivocal findings on diagnostic peritoneal lavage, FAST exam, or CT
Many blunt abdominal trauma patients benefit from admission, monitoring, and serial abdominal exams.
Discharge Criteria
    No patient in whom you suspect intra-abdominal injury should be discharged home without an appropriate period of observation, despite negative exam or imaging studies.
PEARLS AND PITFALLS
Do not delay blood products when patient is in obvious shock despite normal Hct.
Avoid overaggressive resuscitation with crystalloids.
Obtain a pregnancy test in all females of childbearing age.
Do not transport unstable patients to CT for diagnostic imaging.
ADDITIONAL READING
Amoroso TA. Evaluation of the patient with blunt abdominal trauma: An evidence based approach.
Emerg Med Clin North Am
. 1999;17:63–75.
Holmes JF, Offerman SR, Chang CH, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries.
Ann Emerg Med
. 2004;43(1):120–128.
Kendall JL, Faragher J, Hewitt GJ, et al. Emergency department ultrasound is not a sensitive detector of solid organ injury.
West J Emerg