A perspective on the early management of abdominal trauma

Blunt trauma in Australia is most commonly due to road accidents and is often multisystem in its effect on the body. Whereas some cases of intra-abdominal injury result in massive bleeding, and may be readily diagnosed clinically, many abdominal injuries are difficult to diagnose on initial clinical examination. Delays in treatment can result in otherwise avoidable morbidity and mortality, and the practice of diagnosis by repeated clinical examination over long periods of time is to be condemned in principle. All abdominal injuries can (and should) now be diagnosed and treatment commenced within 2-4 h of admission to hospital. Diagnostic peritoneal lavage (DPL) is the most sensitive indicator of intraperitoneal blood after trauma, and if employed early, and interpreted with a low threshold for positivity, early treatment of all intraperitoneal organ disruption can be undertaken. The best organ-imaging technique available for abdominal trauma is computerized tomography (CT) scan, but it is not as sensitive as DPL in the diagnosis of haemoperitoneum, and its accuracy in defining bowel injury is not proved. Several factors dictate the choice of DPL or CT scan in difficult trauma cases, and these include the stability of the patient, the availability of CT scan, the experience of the treating physician with either modality, the organs most at risk of injury in any case, and the decision to attempt conservative or operative management. In a small number of cases, doubt may still exist after CT and/or DPL, and an early laparotomy remains the 'gold standard' of diagnosis in such situations. In penetrating trauma, laparotomy is indicated if wound exploration shows penetration of the peritoneum.