Blunt Abdominal Injury

Written on 13/08/2025
tok.ilman609
2

Injury to intra-abdominal solid organs, hollow viscus, mesentery, and retroperitoneal structures after blunt force (RTC, pedestrian struck, fall, crush, handlebar). Mortality and morbidity are driven by hemorrhage and missed bowel/mesenteric injury (BBMI). 
 

Who to suspect?:

  • Significant torso trauma, seat-belt sign, lower chest wall injuries (lower-rib fractures), pelvic fractures, hypotension without obvious external bleeding.

     

Red flags for bowel/mesenteric injury:

  • Seat-belt sign or abdominal wall ecchymosis; evolving tenderness/guarding; persistent tachycardia; rising WBC/lactate.

  • CT: free fluid without solid organ injury, mesenteric stranding/hematoma, bowel wall thickening/hypoenhancement, inter-loop fluid, pneumoperitoneum, extraluminal contrast, active mesenteric bleeding.

     

Bowel Injury Prediction Score (BIPS): 1 point each → WBC ≥17,000, abdominal tenderness, CT mesenteric injury grade ≥4 (contusion/hematoma with bowel wall thickening or inter-loop fluid). Score ≥2 = high risk for BBMI requiring surgery. 

 

Remember:

  • eFAST rapidly detects free fluid but cannot exclude BBMI. A negative eFAST ≠ safe discharge. Use CT in stable patients.

  • Modern multi-detector CT with IV contrast is the gold standard for stable patients; oral contrast is not routinely required. 
     

 

Quick Algorithms
 

Unstable → eFAST

  • Positive → OR/AE.

  • Negative but high suspicion → repeat eFAST, adjuncts (pelvis), escalate to control.


Stable → CT with IV contrast

  • Definitive hollow viscus signs (free air, extraluminal contrast) → OR.

  • High-risk but not definitive (free fluid w/o solid organ injury, mesenteric hematoma/stranding, bowel wall thickening, inter-loop fluid) or BIPS ≥2 → early surgical exploration (laparoscopy/laparotomy).

  • Clean CT → discharge or observe per SBS/mechanism + clinical trajectory.
     

 

1. Rapid Clinical Assessment & Stabilization

ABCDE with hemorrhage focus

  • Unstable (SBP <90, poor perfusion): activate massive hemorrhage protocol; eFAST at bedside. If positive → expedited OR/angio per institutional pathway. If negative but high suspicion, repeat eFAST, consider pelvic binder/REBOA pathway, and don’t delay definitive hemorrhage control. 

  • Analgesia, warmed crystalloids, blood early; TXA per major hemorrhage policy. Correct coagulopathy, hypothermia, acidosis.

  • Nil by Mouth (NBM) and early general surgery consult for any peritonism or concerning trajectory.
     


2. Imaging & Tests

  • CT Abdomen & Pelvis with IV contrast promptly. Add chest CT if mechanism warrants; tailor for pancreas/duodenum when suspicion. 

  • Labs: baseline FBC, VBG/ABG (lactate), urea/creatinine, LFTs, amylase/lipase (pancreatic/duodenal concern), type & screen.

  • Serial exams & vitals q2–4h if observed; trend WBC and lactate.

  • Equivocal CT + clinical concern → repeat CT in 6–8 h or diagnostic laparoscopy with low threshold if deterioration. 



3. Condition-Directed Management


> Solid organ injury (liver/spleen/kidney) – stable patient

  • Default = Non-operative management (NOM) with monitored setting. Indications for angioembolization include active contrast extravasation (“blush”), high-grade injury (AAST IV–V), or ongoing transfusion needs despite stability.

     

> Bowel/mesenteric injury

  • Operate now if: peritonitis, free intraperitoneal air or extraluminal contrast on CT, or hemodynamic instability from suspected abdominal source. 

  • High-risk but not definitive (e.g., free fluid without solid organ injury, significant mesenteric hematoma/stranding, thickened bowel wall, BIPS ≥2): early surgical exploration (diagnostic laparoscopy or laparotomy) is favored over prolonged observation. Delay increases sepsis and mortality. 

  • Antibiotics: broad-spectrum coverage when hollow viscus injury is suspected/confirmed.



> Seat-belt sign (SBS)

  • High association with HVI. If high-quality CT is completely negative, many can be safely discharged with clear return precautions; otherwise 12–24 h observation with serial exams. Older patients warrant lower discharge threshold.




4. Disposition & Observation


> ED Discharge (selective):

  • Normal vitals, pain controlled, CT negative (no free fluid, no mesenteric/bowel signs), reliable follow-up, no SBS or SBS with negative high-quality CT and clinician comfort. Provide strict return advice. 



> Short-stay observation (12–24 h) with serial exams:

  • Mild tenderness with equivocal CT, SBS with any minor CT abnormalities, rising WBC/lactate without explanation. Repeat CT if symptoms evolve. 



> Admit/OR:

  • Any CT-proven visceral injury needing intervention, ongoing transfusion needs, hemodynamic lability, peritonism, BIPS ≥2, or polytrauma disposition drivers.





References

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  2. Coccolini, F., Coimbra, R., Ordonez, C., Kluger, Y., Vega, F., Moore, E. E., Biffl, W., Leppaniemi, A., Fraga, G. P., Bala, M., Marzi, I., Sartelli, M., Peitzman, A., Picetti, E., Manfredi, R., Kirkpatrick, A. W., Pereira, B. M., Pereira, J., Chiarugi, M., … Catena, F. (2020). Liver trauma: WSES 2020 guidelines. World Journal of Emergency Surgery, 15, 24. https://doi.org/10.1186/s13017-020-00302-7 BioMed CentralPubMed

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  4. Faget, C., Taourel, P., Charbit, J., Ruyer, A., Alili, C., Molinari, N., & Millet, I. (2015). Value of CT to predict surgically important bowel and/or mesenteric injury in blunt trauma: Performance of a preliminary scoring system. European Radiology, 25(12), 3620–3628. https://doi.org/10.1007/s00330-015-3771-7 

  5. McNutt, M. K., Chinapuvvula, N. R., Beckmann, N. M., Camp, E. A., Pommerening, M. J., Laney, R. W., West, O. C., Gill, B. S., Kozar, R. A., Cotton, B. A., Wade, C. E., Adams, P. R., & Holcomb, J. B. (2015). Early surgical intervention for blunt bowel injury: The Bowel Injury Prediction Score (BIPS). Journal of Trauma and Acute Care Surgery, 78(1), 105–111. https://doi.org/10.1097/TA.0000000000000471 

  6. Smyth, L., Bendinelli, C., Lee, N., Reeds, M. G., Loh, E. J., Amico, F., Balogh, Z. J., Di Saverio, S., Weber, D., ten Broek, R. P., Abu-Zidan, F. M., Campanelli, G., Beka, S. G., Chiarugi, M., Shelat, V. G., Tan, E., Moore, E., Bonavina, L., Latifi, R., … Catena, F. (2022). WSES guidelines on blunt and penetrating bowel injury: Diagnosis, investigations, and treatment. World Journal of Emergency Surgery, 17, 13. https://doi.org/10.1186/s13017-022-00418-y 

  7. Wandling, M., Cuschieri, J., Kozar, R., O’Meara, L., Celii, A., Starr, W., Cothren Burlew, C., Todd, S. R., de Leon, A., McIntyre, R. C., Urban, S., Biffl, W. L., Bayat, D., Dunn, J., Peck, K., Rooney, A. S., Kornblith, L. Z., Callcut, R. A., Lollar, D. I., … McNutt, M. (2022). Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries. Injury, 53(1), 122–128. https://doi.org/10.1016/j.injury.2021.07.026