Management of blunt abdominal trauma

Key points.

• Blunt abdominal trauma is a significant cause of morbidity and mortality

• Timely intervention and individualized treatment strategies are required to optimize patient outcomes

• Most patients with significant blunt abdominal trauma have multi-organ injuries

• Blunt abdominal trauma should be managed through a combination of operative intervention, angiographic techniques, and non-operative management

• In patients who are operated on, the primary operative decision point is determining whether a definitive or damage control operation is required

Introduction

Blunt abdominal trauma (BAT) is a significant cause of morbidity and mortality after injury. This article describes a structured approach to the assessment and management of BAT, underscoring timely intervention and individualized treatment strategies to optimize patient outcomes.

Initiating the assessment of BAT aligns with the Advanced Trauma Life Support (ATLS) framework, which prioritizes rapid evaluation and stabilization through the ABCDE (airway/breathing/circulation/disability/exposure) approach. Figure 1 demonstrates an initial approach to BAT. Physical examination, plain radiographs, and focused assessment with sonography for trauma (FAST) serve as primary tools in promptly identifying life-threatening injuries and determining the treatment and trajectory of unstable patients (that is operating theatre, or pelvic packing, angioembolization). Stable patients may undergo further evaluation.

Fig. 1.

Evaluation of blunt abdominal trauma: haemodynamic status dictates management

Free fluid in the absence of solid organ injury should be considered for hollow viscus injury. FAST, focused assessment with sonography for trauma; OR, operating room.

Damage control (or haemostatic) resuscitation constitutes a cornerstone in BAT management. This resuscitation strategy incorporates early administration of balanced resuscitation (whole blood and/or balanced component ratios), limiting the use of crystalloids, and allowing for permissive hypotension. This approach helps to prevent or minimize (and promptly address) coagulopathy, allowing the surgeon to focus on achieving rapid surgical haemostasis¹. The use of damage control resuscitation has been shown to prevent the progression of the lethal triad—hypothermia, acidosis, and coagulopathy—significantly enhancing patient survival and minimizing morbidity.

Traumatic injuries are managed through a combination of operative intervention, angiographic techniques, and non-operative management (NOM). In BAT, exploratory laparotomy facilitates direct inspection of internal organs and enables control of haemorrhage and contamination. The primary operative decision point is determining whether this is a definitive (single procedure) or damage control operation. Patients who may benefit from damage control laparotomy demonstrate signs of the lethal triad and physiological exhaustion and will likely need resuscitation in the ICU to optimize patient stability before definitive repair.

In the realm of trauma management, particularly in cases of BAT, patients rarely present with isolated injuries to a single organ system. Instead, they often present with a complex interplay of injuries affecting multiple organs simultaneously. While this article discusses the management of organ-specific injuries, it is crucial to recognize the inherent challenges posed by concomitant and competing injuries in real-world scenarios.

Liver

Hepatic injuries are common after BAT. Operative management is dictated by the patient’s haemodynamic stability, not necessarily injury grade.

Melloul et al.³ conducted a systematic review on managing blunt hepatic injuries, comparing operative versus non-operative approaches and assessing the role of selective arterial embolization. Surgical strategies, such as perihepatic packing, hepatorrhaphy, and non-anatomic resection, were most common. Of patients who underwent surgical management, 12–28% required post-operative transarterial embolization (TAE) for persistent or recurrent bleeding. Complications post-surgery were bile leakage, liver failure, abscess, and pulmonary complications. Overall mortality was significant at 31%³. NOM is the accepted strategy in haemodynamically stable patients. The success rate in this series was 92%, with only 1–5% requiring TAE due to recurrent bleeding. Biliary complications from hepatic trauma occurred in 4% of non-operative cases, with 2–5% requiring operation. The overall 90-day mortality rate after NOM was 5%, with liver-related death at 1%. TAE was successful in 93% of patients, with 9–30% requiring a laparotomy for abdominal compartment syndrome (ACS), haemorrhage, or biliary complications. Liver-related mortality after TAE ranged from 0% to 10%³.

Spleen

The management of splenic injuries is contingent upon patient stability, with management options including observation, splenic artery embolization, or splenectomy. Patients at higher risk of failure of NOM include those greater than 55 years old, those with a high injury severity score, those requiring red cell transfusions, those on anticoagulant therapy, those with human immunodeficiency virus (HIV) disease, those with cirrhosis, and those with drug addiction⁴. In stable patients with high-grade splenic injuries, splenic artery angioembolization (SAE) is an effective adjunct to NOM. When readily available, early angiography and SAE can be considered when contrast extravasation or vascular injuries are detected at admission using CT and can be considered for high-grade splenic injuries, even without contrast extravasation. Patients who require more blood transfusions in the first 24 h after injuries and those who undergo massive transfusion are at higher risk of failure of SAE⁵.

Pancreas

Blunt pancreatic injuries (BPI) pose diagnostic and therapeutic challenges due to the retroperitoneal location of the pancreas and the rarity of such injuries. Up to 40% of patients with BPI undergo initial CT that indicates a normal result². Therefore, diagnosing BPI requires high clinical suspicion and repeat axial imaging is warranted when clinical concerns remain. Management of BPI hinges on the location of the injury (to the left versus right of the superior mesenteric vein) and the presence or absence of a main pancreatic duct injury (see Fig. 2). Grade I and II pancreatic injuries are low-grade injuries, involving contusions and lacerations without affecting the pancreatic duct, and can be managed non-operatively with low complication rates (4–14%). Grade III–V pancreatic injuries are high-grade injuries, requiring surgical intervention due to damage to the main pancreatic duct or pancreatic head. The aim of treating high-grade injuries is to prevent duct-related complications, which have a morbidity rate of up to 60%².

Fig. 2.

Organ-specific management

*Application of pancreatoduodenectomy in trauma is controversial, but sometimes necessary, and, when performed, may be associated with better outcomes than drainage alone². DCL, damage control laparotomy; SMV, superior mesenteric vein; w/o, without.

Kidney/bladder

Renal injuries are predominantly managed non-operatively. Surgical intervention is reserved for haemodynamically unstable patients or those with expanding haematomas. The advent of angioembolization has improved the success rate of NOM for renal trauma of all grades; 89% for the first time and 82% when repeated⁶. Intraperitoneal bladder injuries necessitate surgical repair. Extraperitoneal bladder injuries can typically be managed with a Foley catheter, with 2.4% requiring surgical intervention. However, in cases where orthopaedic pelvic repair requires exposure of the bladder, surgeons might choose to address an extraperitoneal bladder injury concurrently to limit the exposure of orthopaedic hardware to urine⁷.

Diaphragm

Traumatic diaphragm injury, a relatively rare occurrence (occurring in 1–7% of patients with blunt abdominal trauma), is typically associated with severe trauma due to the significant intra-abdominal pressure required to cause such injuries⁸. These injuries usually happen on the weaker left posterolateral side of the diaphragm. Right-sided injuries are associated with high mortality due to the greater force needed and the potential accompanying hepatic and vascular damage. Intraoperatively recognized diaphragm injuries should be repaired. Typically, this involves a primary repair with non-absorbable sutures, although, with larger injuries, prosthetic meshes can be considered, depending on the level of contamination and other associated injuries⁸.

Hollow viscus

The prevalence of traumatic hollow viscus and mesenteric injuries after blunt trauma is about 1% and these injuries require prompt diagnosis and management due to the significant risk of increased mortality associated with delay⁹. Diagnosis is challenging, especially in patients with multiple injuries and altered mental status. Various predictive scores, such as the Bowel Injury Prediction Score (BIPS), help surgeons decide on the necessity of surgery. Patients with signs of peritonitis, significant CT findings (bowel wall thickening or hypoenhancement), or seat belt marks should lead to suspicion of blunt bowel and mesenteric injuries. Haemodynamically unstable patients, or those with findings on cross-sectional imaging, warrant immediate surgical intervention via exploratory laparotomy. For stable patients without signs of bowel injury, NOM includes regular monitoring and gradual diet reintroduction. Ongoing assessment is essential to detect any deterioration, which may necessitate surgical intervention⁹.

Abdominal vascular injury

Major abdominal vascular injuries occur in 5–10% of patients with BAT¹⁰. These injuries are associated with a high mortality rate of 20–60%. Retroperitoneal bleeding management varies by the affected zone: zone 1 (central vessels), zone 2 (renal vessels), and zone 3 (iliac vessels). Immediate exploration is necessary for all zone 1 injuries and selective for zone 2 or 3 injuries. The repair method depends on the extent of the injury and the patient’s overall condition. Patients in physiologic extremis should undergo vascular shunting with delayed reconstruction. Endovascular repair is increasingly used, especially for aortic injuries, highlighting its growing role in managing traumatic vascular injuries¹⁰.

Funding

The authors have no funding to declare.

Disclosure

B.A.C. was a paid consultant to and was a scientific advisory board member at Haemonetics Corporation and was an advisory board member at Teleflex, Cerus, and Velico (all unrelated to this work). The authors declare no other conflict of interest.