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The Rational Clinical Examination | Clinician's Corner

Does This Adult Patient Have a Blunt Intra-abdominal Injury?

Daniel K. Nishijima, MD, MAS; David L. Simel, MD, MHS; David H. Wisner, MD; James F. Holmes, MD, MPH
JAMA. 2012;307(14):1517-1527. doi:10.1001/jama.2012.422.
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Context Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma.

Objective To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma.

Data Sources We conducted a structured search of MEDLINE (1950–January 2012) and EMBASE (1980–January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography.

Study Selection We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction.

Data Extraction Critical appraisal and data extraction were independently performed by 2 authors.

Data Synthesis The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than −6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup.

Conclusions Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.

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Figures

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Figure 1. Seat Belt Sign
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Linear abrasion and ecchymosis across abdominal wall from lap portion of safety restraint.

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Figure 2. Focused Assessment With Sonography for Trauma (FAST) Examination Positions for Assessment of Intra-abdominal Injuries
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The FAST examination uses bedside ultrasonography for the rapid identification of intra-abdominal and intrapericardial hemorrhage in trauma patients. A, Locations of transducer placement for the evaluation of intra-abdominal injury and B, corresponding ultrasound views demonstrating intra-abdominal free fluid (arrowheads). Transducer planes shown are approximate. The examiner tilts the transducer as necessary to detect free fluid around tissues. A complete FAST examination also includes a pericardial ultrasound view (not shown) to assess pericardial effusion. See video of all 4 FAST ultrasound views.

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