Abdominal Trauma

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Initial Evaluation of the Patient with Blunt Abdominal Trauma Oliver ]. McAnena, MGh, FRGSI, * Ernest E. Moore, MD, FAGS, t and]ohn A. Mqrx, MD, FAGEP:j:

Approximately 10% of civilian injuries that require operation are the result of blunt abdominal trauma. 39, 56 Unrecognized injury to intra-abdominal contents remains a distressingly frequent cause of preventable death. 29, 62. 91 The symptoms and signs of these injuries are notoriously unreliable and are often masked by head injury, major fractures, alcohol, or other toxins. As many as one third of patients with an initial benign abdominal examination will require emergency laparotomy. 12, 56 The appropriate management of blunt abdominal trauma depends on a careful initial evaluation, the timely use of diagnostic procedures, and vigorous therapy directed at immediate life-threatening problems. In contrast to penetrating trauma, the decision to perform laparotomy for blunt abdominal trauma is far more complex because structural injury is less obvious and associated multisystem trauma may demand more urgent operation. PATHOPHYSIOLOGY Management of the patient with blunt abdominal trauma requires an understanding of the injury mechanism. In general, injuries can be classified as either high or low energy, and several pathophysiologic processes are operational: (1) sudden, pronounced rise in intra-abdominal pressure cre*Fellow in Trauma Surgery, Denver General Hospital, Denver, Colorado; and Senior Registrar in Surgery, The Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland tProfessor and Vice-Chairman of Surgery, University of Colorado Health Science Center; and Chief, Department of Surgery, Denver General Hospital, Denver, Colorado *Assistant Director, Department of Emergency Medicine, Denver General Hospital; and Associate Professor of Surgery, University of Colorado Health Science Center, Denver, Colorado

Surgical Clinics of North America-Vol. 70, No.3, June 1990

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ated by outward forces can cause rupture of a hollow viscus or burst injury of a solid organ, (2) compression of abdominal viscera between the applied force to the anterior wall and the posterior thoracic cage or vertebral column can produce a crush injury, and (3) abrupt, shearing forces can cause a tear of organs or vascular pedicles. 16. 24 Motor-vehicle accidents account for 75% of cases of blunt abdominal trauma. The severity of mechanism is related to the force and duration of impact as well as the mass of the patient contact area. Deceleration injuries occur in high-speed vehicular accidents and in falls from great heights. On impact, the organs continue to move forward at the terminal velocity, tearing organs at their sites of attachment. Lap-belt restraints can be associated with a sudden elevation in intra-abdominal pressure, producing hollow visceral rupture. Table 1 outlines the relative incidence of injured structures encountered at emergent laparotomy over the past decade at the Denver General Hospital (DGH). The spleen was the organ most frequently injured, followed by liver, mesentery, urologic structures, and pancreas. The relatively greater incidence of mesenteric and hollow visceral perforation compared to older series 12 may be related to the increased use of seat belts.

HISTORY

As much information as possible should be obtained from the paramedics or flight nurses, firemen, police, other parties involved in the accident, and bystanders as soon as possible in the emergency department (ED). Specific details of the injury mechanism are critical. 56 In cases of an automobile accident, one should inquire into the size of the vehicle; the frequency of injury is higher in smaller cars.63 What was the position of the victim in the vehicle? A rear-seat passenger is less likely to have sustained impact against rigid objects within the interior of the car. What was the type of accident? Frontal impact, side impact (T-bone), sideswipe, rear impact, and rollover have their own unique patterns of injury.24 Was the victim wearing a restraint device, and if so, what type? Lap seat belts (twopoint fixation) are associated with injuries distinct from those associated Table 1. Pattern of Injury Encountered at Laparotomy Following Blunt Trauma ORGAN

RELATIVE INCIDENCE

Spleen Liver Mesentery Urologic Pancreas Small bowel Colon Duodenum Vascular Stomach Gallbladder

46% 33%

10% 9% 9% 8%

7% 5% 4%

2% 2%

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with a lap seat belt combined with a shoulder harness. 92 In lateral-impact collisions, the seat belt is less effective in protecting wearers from severe or abdominal injuries. 2 On the other hand, ejection from the vehicle frequently results in life-threatening injuries. 21 Auto-pedestrian victims, particularly adults, are also at significant risk for abdominal injury.86 The patient or a third-party witness may be able to provide information regarding the patient's level of consciousness at the scene of the accident and whether or not the patient has been taking drugs or alcohol. It is also important to know the patient's medications, past medical history, and chronic medical conditions. The patient may be allergic to contrast media, and knowledge of this may alter the clinician's selection of radiologic investigations.

PHYSICAL EXAMINATION

Inspection for ecchymoses and abrasions provides clues to internal hemorrhage in the patient with blunt abdominal trauma. Gentle pressure over the lower ribs helps establish whether or not rib fractures are present; lower rib fractures are associated with hepatic or splenic injury. The examiner should note the contour of the abdomen prior to proceeding to superficial and deep palpation to elicit guarding, tenderness, and rebound. In the series by Davis et al,12 the physical findings most often associated with internal injury were abdominal tenderness and guarding, occurring in 75% of patients with positive physical findings. Peritoneal signs of rebound tenderness and rigidity occurred in 28%. Pain or blood on rectal examination, although helpful, was uncommon (3%). Of 437 patients studied, however, 43% had neither complaints nor signs of an intra-abdominal injury; however, 44% of these patients were ultimately explored, and 77% of them had a documented injury requiring repair. This re-emphasizes the unreliability of the initial abdominal examination following acute blunt trauma. The flanks should be palpated and the iliac crest and symphysis pubis compressed to establish the possibility of a pelvic fracture. The hip joints should also be internally and externally rotated. Absence of discomfort on performing these maneuvers usually excludes a major pelvic fracture,84 but signs may be masked by shock, head injury, or intoxicants. 56, 60 Sphincter tone, integrity of the rectal wall, and the presence of blood are primary components of the rectal examination. The presence of a high-riding or non palpable prostate supports the diagnosis of postmembranous disruption of the urethra. The presence or absence of blood at the penile meatus should be noted became this is an indication for urethrography prior to passage of a urethral catheter. The testes should be examined for injury, and in the setting of a pelvic fracture, a perineal or vaginal laceration must be excluded. Abdominal and thoracic trauma should be considered together in the initial evaluation because the dome of the diaphragm can rise to the fourth intercostal space during full expiration. There is a 20% chance of splenic injury and a 10% chance of hepatic injury with fractures of the left and right lower six ribs, respectively. 39, 56

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LABORATORY INVESTIGATION Hematologic and blood chemistry values are oflimited use immediately following blunt abdominal trauma, but baseline tests are important because subsequent changes may be the first sign of occult injury. Hematocrit reflects a balance of acute blood loss, endogenous plasma refill, and administration of crystalloid. 34 Serial measurements are helpful in monitoring continued hemorrhage. A leukocytosis following blunt abdominal trauma is common and generally nonspecific. Serum amylase lacks sensitivity and specificity for intra-abdominal injury.65 A normal level does not exclude major pancreatic injury, and isoenzymes do not improve diagnostic accuracy.4 Conversely, elevations may occur following trauma to the parotid gland, proximal small bowel, and the genitourinary tract. 56 For patients hospitalized with major trauma, baseline serum levels of electrolytes and renal and liver function are appropriate. A preliminary blood coagu1ation screen is important in patients who require massive transfusions or who have concomitant hepatic disease. Arterial blood gases are warranted in intubated patients or those who are at risk for subsequent pulmonary decompensation. Urinalysis should be an integral part of the work-up for all patients with blunt abdominal trauma to detect otherwise asymptomatic urologic trauma. tJ rinalysis for toxic drug metabolites is also appropriate in select patients.

RAD10LOGY Radiologic procedures in the stable patient with blunt abdominal trauma may be helpful when physical examination and laboratory investigations are inconclusive. However, trained personnel must supervise and monitor any patient suspected of having a serious injury, as the abandonment of a patient in the radiology department for even a brief period can have disastrous consequences. Anteroposterior chest radiographs provide clues to associated thoradc and diaphragmatic injury. Malposition of the nasogastric tube is often the first sign of a ruptured left diaphragm. Small amounts of free intraperitoneal or retroperitoneal air may be detectable in patients with gastric, duodenal, small Bowel, or colonic perforations. 3 • 25 A search should be made for rib, pelvic, vertebral body, and transverse spinous process fractures, as these warrant special consideration for nearby visceral damage. At least 800 ml of intraperitoneal blood is required to be evident on plain abdominal radiograph. 39 The following supportive findings may be observed: (1) the flank-stripe sign is a fluid-dense zone separating the ascending or descending colon from a distinctly outlined lateral peritoneal wall, and the colon is displaced medially; (2) the dog-ear's sign results from accumulations of blood that gravitate between the pelvic viscera and side walls on each side of the bladder; and (3) the hepatic-angle sign is loss of definition of the usually distinct inferior and right lateral borders of the liver as blood accumulates between the hepatic angle. and the right peritoneal wall. 3 • 25 With extensive hemoperitoneum, small bowel may float

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toward the center of the abdomen with the production of a "ground-glass" appearance. There may also be loss of the psoas shadow or renal shadow in cases of retroperitoneal hemorrhage. The injured spleen may cause displacement of the gastric bubble medially or indentation of the splenic flexure of the colon.

DIAGNOSTIC PERITONEAL LAVAGE Initial physical examination of the abdomen often fails to detect significant intra-abdominal injury. 12, 66, 79, 82 Delay in diagnosis results in increased morbidity ahd mortality, more hospitalization time, and higher health care costs. On the other hand, unnecessary laparotomies are associated with a definable risk. 39 The introduction of diagnostic peritoneal lavage (DPL) by Root et al. in 196572 provided a rapid, inexpensive, aCcurate, and relatively safe adjunctive diagnostic modality in the management of patients with blunt abdominal trauma. We believe DPL remains an integral part of the evaluation of the seriously injured patient. There are three fundamental methods of introducing the DPL catheter into the perittmeal cavity. The closed approach consists of inserting the catheter in a blind percutaneous fashion; the major problem is uncontrolled depth of penetration, rendering the underlying intraperitoneal or retroperitoneal structures at risk for perforation. The open procedure, transversing the abdominal wall under direct visualization, is safer but more time consuming and introduces air into the peritoneal cavity. We prefer the semi-open technique performed at the infraumbilical ring as a compromise; this approach is rapid, safe, and extremely reliable. 21, 59, 73, 8~ The same approach can be employed in the patient with a major pelvic fracture because the enlarging anterior hematoma is limited by the infraumbilical ring. Before lavage, the stomach and bladder are decompressed with a nasogastric tube and a Foley catheter, respectively. The periumbilical area is shaved,' prepped with povidone-iodide solution, and draped sterilely. The area is infiltrated generously with local anesthesia (1 % xylocaine without epinephrine). A gently curved incision is made to one side of the umbilicus, at the level of the infraumbilical ring (Fig. 1). The advantages of making the incision at this site include relative avascularity, paucity of pre peritoneal fat, and adherence of the peritoneum resulting from obliteration of the umbilical arteries and urachus. 59 The incision is carried down to the linea alba, ensuring meticulous hemostasis. A 5-mm incision is made in the linea alba, and the free edges are grasped with towel clips. While elevating the abdominal wall by traction on the towel clips, a standard dialysis cathl:lter with the trocar is inserted toward the pelvis. Once the peritoneum is punctured; the trocar is withdrawn and the catheter is advanced into the pelvic floor. the tap is considered positive if greater than 10 ml of blood is aspirated. Otherwise, 1 L of warmed 0.9% sodium chloride is infused (15 ml/kg in children). If the clinical condition permits, the patient is rolled from side to side, and the bottle lowered to the floor for the return of lavage fluid by siphonage. A minimum of 75% of lavage efHuent is required for the test to be considered valid. The fluid is sent for laboratory analysis

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Figure 1. Diagnostic peritoneal lavage in the adult is performed using the semi-open technique at the infraumbilical ring. The free edges of the incised fascia are elevated with towel clips to eliminate contact between the trocar and the underlYing abdominal viscera.

of red and white blood cell counts, amylase (LAM) and alkaline phosphatase (LAP) levels, and examination for the presence of bile. The criteria for positive DPL are outlined in Table 2. In the context of blunt abdominal trauma, visceral damage is present in more than 95% of patients in whom the red blood cell count is greater than l00,000/mm 3 but less than 5% of those in whom the red blood cell count is less than 20, 000/mm 3 • 1, 6, 21, 26, 33, 41,53,80 Red blood cell counts between 20 and 100,OOO/mm3, however, may reflect serious injury in 15 to 25% of cases and merit further diagnostic evaluation; our current preference is abdominal computed tomographic (CT) scanning (Fig. 2). Occasionally, elevated white blood cells (>5001 mm 3), LAM,I, 45 or LAP50, 52 will signal an otherwise occult intestinal injury, when the sensitivity of DPL based on laboratory red blood cell criteria is Table 2. Criteria for Diagnostic Peritoneal Lavage Following Blunt Abdominal Trauma INDEX

POSITIVE

EQUIVOCAL

Aspirate Blood Fluid

>lOml Enteric contents

>5ml

Lavage Red blood cells White blood cells

> lOO,OOO/mm3 >500/mm3 (confirmed by

>50,OOO/mm3 >200/mm3

Enzyme Bile

repeat DPL) Amylase ~20 IU/L, and alkaline phosphatase ~3 IU Confirmed biochemically

Abbreviation: DPL = diagnostic peritoneal lavage.

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12 hours after injury) with isolated abdominal trauma or of the child who arrives hemodynamically stable following a minor mech~nism of injury (sports injury).73 In fact, Uthoff et alB5 reported sUPerior results with nuclear scintigraphy compared to CT scanning in a prospective study of blunt abdominal trauma. Abdominal aortography and splanchnic ap.giography are rarely warranted for the evaluation of acute abdominal trauma, but they may be of value as adjuncts for selective viscer;:tl embolization suggested by CT scanning. Occasionally, lumbar arterial embolization is useful for massive retroperitoneal bleeding associated with unstable thoracolumbar spine fractures. 75 Pelvic angiography with selective embolization via the hypogastric artery is an integral part of the management of active hemorrha~ associated with major pelvjc fractures. 60 The details of this complex subject, however, are beyond the scope of this article. Magnetic resonance imaging (MRI) is extremely accurate in anatomic definition of structural injury, but logistics virtually eliminate its practical application in the evaluation of acute abdominal trauma. lO Similarly, a number of other diagnostic tests, such as biliary31 and labeled red blood cell68 scintigraphy, are primarily employed for delayed complications of abdominal trauma.

EVALUATION OF THE CHILD WITH BLUNT ABDOMINAL TRAUMA Trauma is the leading cause of death in children 1 to 14 years of age, and blunt trauma causes 90% of these critical injuries. 19. 71 Aut~obile and auto-pedestrian accidents account for the majority of injuries, although the role of child abuse is increasing. 9 Injuries inconsistent with the history provided, or not in keeping with the child's level of physical maturity, should alert the physician to the possibility of child abuse. Because the child's abdomen has poorly developed musculature and a relatively smaller anteroposterior diameter, the abdominal contents are more vulnerable to injury. The rib cage is extremely resilient in children and less prone to fractures, but it nonetheless provides only partial protection for intraperitoneal contents. The initial assessment of pediatric patients is frequently made more difficult by age-related difficulties in communication, fearinduced uncooperative behavior, or concomitant head injury. The trauma surgeon must be familiar with the normal physiologic range of vital signs adjusted for age (Table 3). Decompressive nasogastric tubes are particularly important to aid abdominal examinatiop., as children are prone to aerophagia. Children are also more susceptible to hypothermia resulting from the administration of unwarmed fluids and blood products. The use of overhead heated lamps, blood warmers, and prewarmedintravenous fluids minimizes this complication.

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Table 3. Physiologic Indices in the Normal Child AGE

WEIGHT

(yr)

(kg)

SYSTOLIC BLOOD PRESSURE

HEART RATE

RESPIRATION

HEMATOCRIT

(%)

2 4 6 8 10

12 16 20 24 29

90 94 96 104 llO

120 llO 100 96 90

35 31 26 23 21

37 38 39 39 40

The management of blunt abdominal trauma in children has changed radically over the past decade. 20. 40. 42. 44. 55. 64. 90 Recognition of overwhelming postsplenic sepsis revolutionized the approach to splenic injury, which was once considered a mandatory indication for laparotomy as well as splenectomy. As the impetus for splenic salvage grew, it was observed that bleeding from minor splenic lacerations in children had often ceased at the time of abdominal exploration. This phenomenon has been ascribed to a greater capsule-to-parenchyma ratio in younger individuals. 57 The pioneering work of Simpson et a}2o, 90 and the subsequent studies of other groups40. 42, 44, 55, 64 established that the majority of isolated splenic injuries in the child heal without surgical intervention. The advent of double-contrast CT scanning of the abdomen added further confidence in the nonoperative management of solid visceral injury. The timely recognition of major pancreatic injury or hollow visceral perforation is problematic. The penalty for delayed recognition of these injuries is severe. Although the incidence of blunt intestinal disruption in children is considered low, recent clinical reviews have indicated a rate as high as 18%.7. 27, 83 Our study73 and others88 confirm the high risk of pancreatic transection in acutely injured children. Diagnostic peritoneal lavage may miss isolated injury of these organs owing to the relative insensitivity oflavage effiuent amylase and the delay in peritoneal leukocytic response. Computed tomography has been largely unsuccessful in visualizing small bowel perforation; its accuracy in the evaluation of 'acute pancreatic trauma in the child has also been disappointing. Enzyme analysis of free intraperitoneal blood may prove valuable for a selective laparotomy policy in the child. The aspiration of intraperitoneal blood formerly mandated celiotomy; thus, further characterization of this collection has received vanishing attention. The recent concept of nonoperative management for stable patients with grossly bloody aspirate presumes isolated injury to the liver or spleen. Submitting this aspirate to amylase and alkaline phosphatase measurement may help assure integrity of the pancreas and hollow viscera. Prior study supports this hypothesis. 50. 73 Assessment of diagnostic methods should carefully consider the qualifications of the specific institution. The ability to perform CT accurately in children is compromised by their lack of cooperation as well as their paucity of retroperitoneal fat. The role of DPL in children at high risk for abdominal injury has been reconsidered favorably by several groups with extensive experience in managing pediatric trauma. 19, 70, 71 We believe the best

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approach is to combine DPL and scanning to determine the need for laparotomy. Diagnostic peritoneal lavage is a rapid, sensitive test to confirm the presence of intraperitoneal blood. In the child younger than 10 years of age, the Seldinger wire/closed technique of DPL is particularly useful owing to the paucity of omentum and mesenteric fat.73 The need for laparotomy can be further clarified by scanning. We have adhered to a protocol at DGH designed to avoid life-threatening complications from delayed abdominal exploration and, at the same time, to reduce the number of unnecessary laparotomies (Fig. 3). Diagnostic peritoneal lavage is performed in children at high risk for abdominal injury, particularly following major multisystem insults, and in those in whom physical examination is compromised. If the DPL is grossly positive by aspiration of free blood and the child demonstrates clinical instability, laparotomy is performed. Selective observation is permitted when DPL is positive for blood, depending upon Memodynamic and clinical parameters and corroborative CT findings. Laparotomy is mandatory for DPL effluent positive by criteria other than blood. In the stable child with DPL positive by blood or red blood cell count alone, laparotomy is done if the scans fail to demonstrate suspected hepatosplenic injury or if hollow visceral disruption or major pancreatic injury is identified. Selective nonoperative management of pediatric trauma requires frequent abdominal examinations, monitoring of vital signs, frequent laboratory tests, and close monitoring by nursing personnel experienced in pediatric intensive care. 47

EVALUATION OF BLUNT ABDOMINAL TRAUMA DURING PREGNANCY Trauma is the leading cause of death in women of child-bearing age. 51, 62 Accidental injuries occur in 5 to 10% of all pregnancies. As the pregnancy progresses, the incidence of minor trauma increases. By the third trimester, minor trauma occurs more frequently than at any other time during female adulthood. The most common cause of fetal death is maternal death. Therefore, initial resuscitation efforts are directed primarily toward the mother. The approach to the injured pregnant patient is the same as for the nonpregnant person. Prehospital information is critical; the more significant the injury mechanism, the more concerned and aggressive the physician must be in patient care. Rothenberger74 reviewed 103 cases of blunt maternal trauma and found successful pregnancy outcome in only 39% of cases associated with major maternal injuries, 73% of cases with minor injuries, and 100% of cases with insignificant maternal injuries. A knowledge of the physiologic processes unique to pregnancy is important to interpret the pregnant woman's response to the stress of trauma (Table 4). During the first trimester, the mother's physiology is only mildly altered. By the tenth week, the mother's cardiac output has reached 7 Limin, and this level is maintained throughout the remainder of pregnancy. In the third trimester, however, cardiac output can be transiently lowered by inferior vena cava compression from the gravid uterus. This so-called supine hypotensive syndrome also can cause placental abrup-

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BLUNT ABDOMINAL ( TRAUMA

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Aspirate GI contents Lavage enzymes High risk'

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.. I Aspirate blood Lavage RBC

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(E) ___________---. Olsen WR: The serum amylase in blunt abdominal trauma. J Trauma 13:200, 1973 66. Olsen WfI., Redman fIC, Hildreth DH: Abdominal paracentesis and peritonealll\vage in blunt abdominal trauma. J Trauma 11:824, 1971 67. Oreskovich MR, Howard JD, Copass MK, et al: Geriatric trauma: Injury patterns and outcome. J Trauma 24:565, 1984 68. Orzel JA, Rudd TG, Oreskovich MR: Evaluation of traumatic mesenteric hemorrhage in a hemophiliac with Tc-99m labeled red blood cell scintigraphy. J Trfluma 26:1056, 1986 69. Philips LL, Skrodelis V, Taylor HC: Hemorrhage clue to fibrinolysis in abruptio placentae. Am J Obstet Gynecol 84:1447, 1962 70. Powell RW, Gref;!n JB, Ochsner MG, et al: Peritoneal lavage in pediatric patients sustaining blunt abdomillal trauma: A reappraisal. J Trauma 27:6, 1987 71. Ramenofsky ML, Morse TS: Standards of care for the critically injured pediatric patient. J Trauma 22:921, 1982 72. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal lavage. Surgery 57:633, 1965 73. Rothenberg S, Moore EE, Marx JA, et al: Selective management of blunt abdominal trauma in children-the triage role of peritoneal lavage. J Trauma 27:1101, 1987 74. Rothenberger DA, Quattlebaum FW, Zabel J, et al: Blunt maternal trauma: A review of . 103 cases. J Trauma 18:173, 1978 75. Scalea T, Goldstein A, Phillips T, et aI: An analysis of 161 falls from a height-the jumper syndrome. J Trauma 26:706, 1986 76. Sherck JP, McCort JJ, Oakes DD: Computed tomography in thoracoflbdominal trauma. J Trauma 25:1015, 1984 77. Sjogren H, Bjornstig U: Unintentional injuries among elderly people; Incidence, causes, severity, and costs. Accid Anal Prev 21:233, 1989 78. Snyder WH, Weigelt JH, Watkins WL, et al: The surgical management of duodenal trauma. Arch Surg 115:422, 1980 79. Thal ER: Evaluation of perjtoneallavage and local exploration in lower chest and abdoplinal stab wounds. J Trauma 17:642, 1977 80. ThaJ. ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. Am J Surg 125:64, 1973 81. Thompson JS, Moore EE: Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg Gynecol Obstet 153:861, 1981 82. Thompson JS, Moore EE, VanDllzer-Moore S, et al: The evolution of abdominal stab wound management. J Trauma 20:478, 1980 83. Traub AC, Perry JF: Injuries associated for splenic trauma. J Trauma 21:840, 1981 84. Trunkey DD, Chapman MW, Lim RC, et al: Management of pelvic fractures in blunt trauma injury. J Trauma 14:912, 1974 85. Uthoff LB, Wyffels PL, Adams CT, et al: A prospective study comparing nuclear scintigraphy and CAT in the initial evaluation of the trauma patient. Ann Surg 198:611, 1983 86. Vestrup JA, Reid JDS: A profile of urban adult pedestrian trauma. J Trauma 29:741, 1989 87, Ward RE, Miller P, Clark DG, et al: Angiography and peritoneal lavage in blunt flbdominal trauma. J Trauma 21:848, 1981 88. Warner RL, Othersen HB, Smith CD: Traumatic pancreatitis and pseudocyst in children: Current management. J Trauma 29:597, 1989 89. Weber CE: Postmortem cesarean section: Review of the literature and case reports. Am J Obstet Gynecol 110:158, 1971 90. Wesson DE, Filler RM, Ein SH, et l!i: Ruptured spleen: When to operate? J Pediatr Surg 16:267, 1981 91. West J, Trunkey DD, Lim RC: Systems of trauma care: A study of two counties. Arch Surg 114:455, 1979

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92. Woelfel GF, Moore EE, Cogbill TH, et al: Severe thoracic and abdominal injuries associated with lap-harness seatbelts. J Trauma 24:166, 1984 93. Wooley MM, Mahour GT, Sloan T: Duodenal hematoma in infancy and childhood. Am J Surg 136:8, 1978

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Initial evaluation of the patient with blunt abdominal trauma.

Unrecognized abdominal injury remains a distressingly frequent cause of preventable death following blunt trauma. Peritoneal signs are often subtle, o...
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