Blunt abdominal trauma

The management of the patient with blunt abdominal trauma remains in continuous flux. The emergency physician cannot place undue reliance on physical examination, and plain radiography of the abdomen rarely adds to patient care. Laboratory tests, particularly elevated liver function tests or a large base deficit, may increase our suspicion for intraabdominal trauma. However, normal blood tests should never prevent further investigation as warranted by mechanism of injury or clinical picture. Ultrasound and laparoscopy are two diagnostic interventions that have been more extensively studied abroad than in the United States. With the advent of large clinical trials in our own country they should play a growing role in the diagnosis and management of abdominal trauma in the coming decade. DPL revolutionized the diagnosis of intraabdominal injury. It has an astoundingly impressive track record of 97% accuracy that is rivaled by few other tests in medicine. It has been criticized at times for being overly sensitive to trivial injuries, leading to nontherapeutic laparotomies. CT has the advantage of being relatively noninvasive and theoretically has the potential for decreasing nontherapeutic laparotomies, but is very reader-dependent and in many studies not as sensitive as peritoneal lavage. Both CT and DPL may miss critical intraabdominal injuries, but this is much less likely with lavage. Perhaps the greatest risk of CT is the delay it adds to performing a needed laparotomy. CT provides an excellent modality to screen for abdominal injury in the stable patient. However, the more critically injured a patient is, the greater the danger of delays introduced by CT. In these patients, greater emphasis should be placed on immediate DPL or direct transport to the operating room. The challenge in the 1990s will be to refine the diagnosis of intraabdominal trauma to allow for swift recognition of those injuries that require surgical intervention.