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- Discuss the incidence and epidemiology of abdominal trauma
- Review abdominal anatomy
- Discuss the mechanisms of injury for abdominal trauma
- Explain an abdominal assessment as part of a trauma exam
- Discuss prehospital management
- Identify emergency department care transfer and ED assessment tools
On a cold November afternoon in northern Wisconsin, Medic 4 is dispatched for a male patient who fell from his deer hunting tree stand and is reported as unresponsive. Based on the initial information, a medical helicopter is also dispatched to the scene. On arrival, the Medic 4 crew finds the patient awake and complaining of severe pain along his right flank and abdomen. After the patient is immobilized and moved into the ambulance, a full assessment is performed. Airway and breathing are patent and adequate, with no severe external bleeding. There is no gross neurological deficit. The patient's clothing is removed and a detailed exam finds bruising and tenderness along the right flank, as well as pain, rebound tenderness, guarding and distention of the right upper and right lower quadrants. There are no other physical exam findings. His vital signs are: HR 88, RR 20, BP 130/94, and skin warm, pale and dry.
As the helicopter lands on scene, the crew debates whether to transport the patient themselves to a local hospital or have him flown to the regional trauma center, a 23-minute flight away. The senior medic argues that the patient has no findings to warrant transport to the trauma center, but his partner thinks different. Who's right?
INCIDENCE AND EPIDEMIOLOGY
Blunt and penetrating abdominal trauma are major causes of morbidity and mortality in the United States, particularly because it can be very difficult to recognize clear symptoms early.1 In blunt force abdominal trauma, the spleen and liver are the most commonly injured organs, with a mortality rate of roughly 8.5%.2 Nearly three-quarters of all blunt abdominal trauma injuries involve vehicles.3 Almost two-thirds of injuries occur in males, with a peak incidence in patients between ages 14 and 30.
Penetrating abdominal trauma has a slightly higher mortality rate, depending on the mechanism of injury. It ranges up to about 12%, and is responsible for more than a third of urban trauma center admissions and 12% of rural trauma center admissions. Gunshot and stab wounds combine to cause 95% of penetrating abdominal injuries. Penetrating abdominal injuries have a significantly higher morbidity rate than blunt trauma, with the most serious morbidities arising from wound site infections and development of intra-abdominal abscesses.4
Pediatric patients warrant special mention because their abdominal anatomy differs from adults. Fewer than 10% of pediatric injuries are considered abdominal trauma in nature; however, more than 80% of pediatric abdominal injuries are caused by blunt force trauma.2 Be suspicious of pediatric abdominal injuries, as many are caused by abuse. Due to the unique pediatric anatomy, discussed later in this article, organ injury rates differ from adults.
The abdomen holds and protects major organs of the digestive, reproductive, genitourinary, vascular and endocrine systems, and can be defined as the space between the diaphragm pelvic bony structures on the superior and inferior aspects, respectively; the flanks along the lateral walls; the abdominal muscles anteriorly; and the vertebrae and back muscles along the posterior cavity wall.