Guideline sources The following summarized guidelines for the evaluation and management of blunt abdominal trauma are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the European Association of Urology (EAU 2022), the World Society of Emergency Surgery (WSES 2022; 2020; 2017), the World Society of Emergency Surgery (WSES/AAST 2020; 2019), the Eastern Association for the Surgery of Trauma (EAST 2019; 2012), the American Urological Association (AUA 2014), and the American College of Emergency Physicians (ACEP 2011). 1 2 3 4 5 6 7 8 9 10 11 12 13 Guidelines 1. Diagnostic investigations Initial evaluation: https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 1/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway As per WSES 2022 guidelines, obtain a primary survey, extended FAST, perform a physical examination, obtain a secondary survey, blood chemistry, check for vital signs followed by contrast-enhanced abdominal CT in awake and oriented patients with blunt abdominal trauma. A Show 4 more As per WSES 2017 guidelines, decide on diagnostic technique at admission based on the hemodynamic status of the patient. A Show 2 more As per ACEP 2011 guidelines, obtain bedside U/S, when available, as the initial diagnostic modality to identify the need for emergent laparotomy in hemodynamically unstable patients (systolic BP 90 mmHg) with blunt abdominal trauma. B Computed tomography: As per WSES 2022 guidelines, obtain CT in the presence of a seatbelt sign (a high index of suspicion for bowel injury). A Show 3 more As per WSES 2017 guidelines, obtain CT with IV contrast as the gold standard in hemodynamically stable or stabilized patients with trauma. A Show 2 more As per EAST 2012 guidelines, obtain abdominal CT with IV contrast in hemodynamically stable patients with blunt abdominal trauma without peritonitis, to identify and assess the severity of injury to the spleen. B As per ACEP 2011 guidelines, avoid obtaining CT in patients with isolated abdominal trauma suspected for occult abdominal injury, if the following are absent: abdominal tenderness hypotension altered mental status (GCS < 14) costal margin tenderness abnormal CXR hematocrit < 30% hematuria. D Angiography: Consider obtaining angiography in patients with AAST grade > III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding. C Consider obtaining angiography either as an adjunct to nonoperative management in patients with splenic injury thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms posing a risk for delayed hemorrhage. C 2. Diagnostic procedures https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 2/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway Diagnostic laparoscopy: Consider performing diagnostic laparoscopy in hemodynamically compensated patients with highly sensitive findings of bowel injury on CT. C Consider treating bowel injuries laparoscopically, based on the surgeon experience and logistics of the trauma center, if identified during diagnostic laparoscopy. C Diagnostic peritoneal lavage: consider performing diagnostic peritoneal lavage as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkers. C 3. Medical management Non-operative management: As per ACC 2022 guidelines, initiate anti-impulse therapy, if clinically tolerated, and obtain repeat imaging within 24-48 hours of the initial imaging to reduce the risk of injury progression in patients with grade 1-2 blunt traumatic abdominal aortic injury without malperfusion. B As per EAST 2012 guidelines: Consider offering nonoperative management in patients with splenic injuries only in an environment providing capabilities for monitoring, serial clinical evaluations and an operating room available for urgent laparotomy. C Recognize that the following factors are not contraindications for attempting a trial of nonoperative management in hemodynamically stable patients with splenic injuries: severity of injury (as suggested by CT grade or degree of hemoperitoneum) neurologic status age > 55 presence of associated injuries. B Thromboprophylaxis: consider administering pharmacologic prophylaxis to prevent VTE in patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although insufficient evidence on the optimal timing of safe initiation. C 4. Inpatient care Serial clinical and laboratory assessment: As per WSES 2022 guidelines, admit patients with high-risk mechanisms (handlebar, seatbelt sign) and non-specific CT findings for observation including serial clinical examination. B As per WSES 2017 guidelines, obtain clinical and laboratory observation associated to bed rest in the first 48-72 hours of follow-up in patients with moderate and severe splenic injury. B Serial imaging assessment: As per WSES 2017 guidelines, consider obtaining repeated CT during the admission in patients with splenic injury with: https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 3/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway moderate and severe lesions or in decreasing hematocrit in the presence of vascular anomalies or underlying splenic pathology or coagulopathy neurological impairment. B As per EAST 2012 guidelines, use the following to decide on frequency of and need for follow- up imaging in patients with blunt splenic injury: clinical factors, such as persistent systemic inflammatory response increasing/persistent abdominal pain otherwise unexplained drop in Hgb. B As per EAST 2012 guidelines, use the following to decide on frequency of and need for follow- up imaging in patients with blunt splenic injury: clinical factors, such as persistent systemic inflammatory response increasing/persistent abdominal pain otherwise unexplained drop in Hgb. B 5. Therapeutic procedures Resuscitative endovascular balloon occlusion of the aorta: As per ACC 2022 guidelines: Insufficient evidence regarding the usefulness of the routine use of REBOA for hemorrhage control in patients with blunt traumatic abdominal aortic injury, and even it may cause harm in some cases. I Insufficient evidence regarding the usefulness of the routine use of REBOA for hemorrhage control in patients with blunt traumatic abdominal aortic injury, and even it may cause harm in some cases. I 6. Surgical interventions Indications for laparotomy: As per WSES 2022 guidelines, perform prompt surgical exploration in the presence of highly specific CT findings such as extraluminal air, extraluminal oral contrast, or bowel-wall defects. A As per EAST 2012 guidelines: Perform urgent laparotomy in patients with diffuse peritonitis and in hemodynamically unstable patients after blunt abdominal trauma. A Do not perform routine laparotomy in hemodynamically stable patients without peritonitis presenting with an isolated splenic injury. D Vascular injury repair: as per ACC 2022 guidelines, initiate anti-impulse therapy, if clinically tolerated, and obtain repeat imaging within 24-48 hours of the initial imaging to reduce the risk of https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 4/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway injury progression in patients with grade 1-2 blunt traumatic abdominal aortic injury without malperfusion. B Show 11 more 7. Specific circumstances Patients with liver trauma: As per WSES 2020 guidelines: Obtain extended FAST for rapid detection of intra-abdominal free fluid. A Obtain CT with IV contrast as the gold standard in hemodynamically stable patients with trauma A , and in patients considered for nonoperative management of liver trauma. B As per EAST 2012 guidelines: Obtain abdominal CT with IV contrast to identify and assess the severity of liver injury in hemodynamically stable patients with blunt abdominal trauma without peritonitis. B Obtain reevaluation with CT in patients with persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in Hgb. B Patients with pancreatoduodenal injury: obtain extended FAST for detecting free fluid and solid organ injury. A Show 15 more Patients with kidney injury: As per EAU 2022 guidelines, obtain multiphase CT in patients with traumatic injury and: visible hematuria non-visible hematuria and one episode of hypotension history of rapid deceleration injury and/or significant associated injuries clinical signs suggesting kidney trauma, such as flank pain, abrasions, fractured ribs, abdominal distension, and/or a mass and tenderness. A As per WSES 2019 guidelines, obtain extended FAST to detect intra-abdominal free fluid. A Recognize that extended FAST has low sensitivity and specificity in kidney trauma. B Show 2 more As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images in patients with suspected renal injury. B Show 7 more Patients with ureteral injury: As per EAU 2022 guidelines, suspect ureteral injury in patients with deceleration-type blunt trauma. A As per WSES 2019 guidelines: Suspect ureteral injury in patients with high-energy blunt trauma, particularly in deceleration injuries with multi-system involvement. B https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 5/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway Obtain IV contrast-enhanced CT with delayed phase in hemodynamically stable or stabilized patients with suspected ureteral injury. B As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with delayed imaging (urogram) in stable patients with trauma with suspected ureteral injuries. B Patients with bladder injury: As per EAST 2019 guidelines, obtain CT cystography for the diagnosis of bladder rupture in moderate-risk (gross hematuria) and high-risk (gross hematuria and pelvic fracture) patients. B Show 4 more As per WSES 2019 guidelines, recognize that IV contrast-enhanced CT with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries. B Show 9 more As per AUA 2014 guidelines, obtain retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. B Show 5 more 8. Follow-up and surveillance Discharge from hospital: discharge clinically stable patients with isolated blunt abdominal trauma after a negative result for abdominal CT with IV contrast, with or without oral contrast. B Follow-up: As per ACC 2022 guidelines: Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location in patients with blunt traumatic aortic injury undergone aortic repair. C Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with blunt traumatic aortic injury not undergone repair. C As per WSES 2022 guidelines, obtain long-term follow-up in patients with blunt abdominal trauma to identify the sequelae of mesenteric injuries. B As per ACEP 2011 guidelines, consider obtaining further observation, close follow-up, and/or imaging in selected patients based on clinical judgment. C Clinical findings Symptoms Vital signs Abdominal pain Hypotension Signs of shock Neurological exam Tachycardia Altered mental status Abdominal exam https://web.pathway.md/diseases/recNf2GjVlFbQ9tDb 6/8 6/29/23, 3:19 AM Blunt abdominal trauma Pathway Abdominal distension Musculoskeletal exam Abdominal guarding Concomitant femur fracture Abdominal tenderness Costal margin tenderness Lab findings Peritoneal findings Microscopic hematuria Rebound tenderness serum lactate Seat belt sign serum base deficit Integument exam Imaging findings Seatbelt sign Free intraperitoneal fluid Hematological findings Pneumoperitoneum WBC count hematocrit Likelihood Ratios Pertinent positives The following findings increase the probability of blunt abdominal trauma in adults. 13 Finding LR+ Value Presence of rebound tenderness 6.5 (1.8-24) Presence of seat belt sign 5.6-9.9 Presence of hypotension 5.2 (3.5-7.5) Presence of abdominal distension 3.8 (1.9-7.6) Show 5 more Pertinent negatives The following findings decrease the probability of blunt abdominal trauma in adults. 13 Finding LR- Value No history of abdominal pain 0.52 (0.34-0.79) Absence of seat belt sign 0.53-0.55 Absence of abdominal tenderness 0.61 (0.46-0.80) Absence of costal margin tenderness 0.74 (0.66-0.84) Show 5 more References 1. 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