1.  Name of the condition: Blunt abdominal trauma

2.  When to suspect/ recognize?

a.     Introduction: Blunt abdominal trauma (BAT) is an increasingly common problem encountered in the emergency department. The usual causes of BAT include vehicular accident, assault, falls, sports injuries and natural disasters.

b.     Case definition: BAT is suspected in any patient involved in above situations and presents with abdominal pain, distention or shock. It should be looked for in patients of polytrauma.

3.  Incidence of the condition: One study has reported 2.1% incidence of BAT amongst all surgical patients admitted to a tertiary hospital during 1 year.

4.   Differential diagnosis: Abdominal trauma forms a differential diagnosis of any patient presenting with acute abdomen.

5.   Prevention and counseling: Use of appropriate safety measures during various activities associated with BAT can significantly reduce its incidence.

6.  Optimal diagnostic criteria, investigations, treatment and referral criteria:

I.   Clinical diagnosis: This is based on

a.    High level of suspicion of intra-abdominal injury

b.    Presence of wounds/ bruising on the abdomen

c.    Abdominal guarding/ tenderness

d.    Presence of free gas/ fluid in the peritoneal cavity

e.       Presence of fracture of lower ribs and/ or pelvis increases the likelihood of intraabdominal injury

f.      Note should be made of altered mental state, drug or alcohol intoxication and distracting injuries which may mask the features of BAT

g.    Repeated examination increases the accuracy of diagnosis

II.   Investigations:

a.     All hemodynamically stable patients with suspected BAT should undergo Focused Abdominal Sonography in Trauma (FAST)or Diagnostic Peritoneal Lavage (DPL)

b.       Urgent laparotomy is indicated in patients with evidence of BAT who remain hemodynamically unstable despite initial resuscitation

III.    Treatment (Standard operating procedure):

a.    Inpatient:

i.    All patients should have initial cervical stabilization and resuscitation, if required

ii.      Initial fluid resuscitation should be done with 2L warmed Ringer Lactate solution infused rapidly through 2 peripheral lines

iii.      A nasogastric tube and a Foley catheter should be put

iv.      Laparotomy should be done, if indicated on the basis of clinical features, FAST or DPL

v.     Laparotomy should be done through a long midline incision

vi.         Bleeding should be controlled by clamping/ packing till definitive control is possible

vii.       Hollow viscus should be repaired

viii.         In case the intra-abdominal injuries are extensive, patient is very sick and OT facilities/ surgeon’s experience is suboptimal, Damage Control Surgery may be done. Definitive surgery should be done subsequently under improved circumstances or at a higher center.

b.    Outpatient: Not indicated

c.    Day care: Not indicated

IV.     Referral criteria: After Damage Control Surgery if the local facilities are inadequate.