208 Abdominal Trauma
The acutely injured patient requires a rapid, systematic, and thorough evaluation.1,2 The goals of this initial evaluation are to detect and treat immediately life-threatening injuries and then to move to a more thorough assessment of less serious injuries and preexisting conditions. Minute-to-minute management must be guided by the patient’s hemodynamic status (physiology) and anatomic injuries. Abnormal physiology kills trauma patients: hypotension, respiratory distress, hypoxemia, and so on. Do not focus on defining every anatomic injury in an unstable patient; find and correct the etiology of the abnormal physiology. The trauma patient admitted to the intensive care unit (ICU) generally has multiple injuries, many of which are threats to life or limb. Prioritization of the management of these injuries is based on treatment of the most immediate threat to life first. In blunt trauma victims, central nervous system injury accounts for 60% of deaths; hemorrhage and its consequences account for 30% of trauma deaths.1 Deaths resulting from penetrating abdominal trauma are from bleeding or sepsis. The most common etiology of hemorrhagic shock in the trauma patient is intraabdominal bleeding. Early deaths from abdominal injury are from bleeding. Late deaths are from intraabdominal sepsis, most often from hollow organ injury.1 Remember that injuries rarely occur in isolation; injuries occur as a component of a pattern of injuries.
Initial Assessment of the Trauma Patient
Advanced Trauma Life Support (ATLS) course principles should be followed in the assessment of any trauma patient1 (Table 208-1). Immediate threats to life are identified and treated during the primary survey. Do not move beyond the primary survey until the patient has been stabilized. The resuscitation phase of the trauma patient generally occurs simultaneously with the primary survey. Intravenous lines are placed, and fluid resuscitation is initiated. The secondary survey is started after the patient has been stabilized. This is a head-to-toe survey defining all anatomic injuries. Remember that if a trauma patient deteriorates or does not respond as you expect, start over with the primary survey.
| Primary survey | Identify and treat immediate threats to life. This is a physiologic and not a temporal event. Stabilize patient before moving to the secondary survey. |
| Resuscitation | Establish at least two large-bore intravenous lines. Resuscitate to specific endpoints. |
| Secondary survey | Perform head-to-toe examination of patient. Order radiographic studies. |
| Definitive care | Move patient from emergency department to intensive care unit or operating room as quickly as possible. |
The trauma patient who arrives in the ICU and later becomes unstable generally has a derangement in circulation. Hypotension, tachycardia, and oliguria are obvious signs of hypoperfusion. On the other hand, even with normal vital signs, as many as 75% of trauma patients in the ICU have compensated shock with tissue hypoperfusion.3,4 Biochemical indices of perfusion such as base deficit or lactate levels should be determined to assess global perfusion.5,6 In the trauma patient, ongoing blood loss is the most common etiology for hypoperfusion. The source of the hemorrhage must be expeditiously identified and stopped. Sources for blood loss in the trauma patient include the abdomen, chest, pelvis, long bones, or externally via open wounds. The gastrointestinal tract is rarely the source of initial blood loss in the trauma patient. Any delay in control of hemorrhage increases morbidity and mortality.
The abdomen is a particularly challenging area to evaluate for several reasons. First, except in cases of evisceration or obvious peritonitis, the history and physical exam findings that suggest intraabdominal injury are usually subtle.7 Second, severely injured patients often have an altered mental status from concurrent brain injury, shock, or intoxicating agents that can mask symptoms and signs. Third, more obvious injuries such as complex open extremity fractures can distract providers and focus attention away from occult torso injuries. Finally, adjuncts to the history and physical, though numerous and ever evolving, still have weaknesses in sensitivity, specificity, and positive or negative predictive value.8–18
As noted, both speed and completeness are critical in evaluating the abdomen. Delays in diagnosis and treatment have been shown to affect morbidity and mortality.19 It is essential to recognize that a trauma patient requires a laparotomy with hard signs or positive diagnostic tests (focused assessment with sonography for trauma [FAST] or diagnostic peritoneal lavage [DPL]). It is not necessary, and in fact hazardous to the patient, to persist in defining the specific anatomy injury in a patient with indications for laparotomy. For patients who present in shock, after airway control, support of inadequate ventilation, and control of external hemorrhage, attention should be immediately turned to finding and treating the cavitary hemorrhage. In the majority of patients with torso trauma, the cause of shock will be bleeding. Tension pneumothorax, pericardial tamponade, spinal cord injury, and medical causes of shock will constitute a minority of cases. It is important for the resuscitation team to keep this in mind, and every maneuver should be performed while seeking the most likely causes of shock. Thus, for the critically injured patient, early intubation may be beneficial to avoid the need for emergency intubation further along in the resuscitation. Early chest tube placement should be considered as a potential diagnostic as well as therapeutic maneuver, particularly in patients who present in extremis. Laboratory tests drawn should be routine and performed in order of importance. A specimen for blood for type and crossmatch is vital, since transfusion is highly likely in this group of patients. Arterial blood gas analysis machines are now ubiquitous in resuscitation units and can provide a rapid assessment of the patient’s physiologic status. A specimen should be drawn as early as practical. Venous access must be accomplished expeditiously. Initially, the most experienced personnel should perform these procedures in the critically injured patient. Less experienced providers can provide essential support by procuring and setting up supplies and equipment, coordinating team activities at the direction of the team leader, and providing accurate documentation of the resuscitation.
Blunt Abdominal Injury
Physical examination alone will miss as many as 45% of abdominal injuries, so for patients who present with evidence of shock but respond to initial resuscitation with fluid replacement, more adjuncts can be employed in initial evaluation. Radiographs of the chest and pelvis are helpful to demonstrate hemothorax, pneumothorax, diaphragmatic rupture, or complex fractures. Abdominal radiographs are not helpful in the evaluation of blunt abdominal trauma. The FAST exam was popularized in the 1990s and has gained acceptance as a screening test for diagnosis of significant hemoperitoneum.13,14 Its major advantage is bedside availability, speed, and noninvasiveness. Because of this ready availability, FAST should be employed in all severely injured blunt trauma patients with a potential abdominal injury. Ultrasound is most helpful for the hypotensive patient with blunt torso trauma and a positive FAST.8,14 In this circumstance, the patient can be taken promptly to the OR for laparotomy. Significant drawbacks remain the relatively low sensitivity for peritoneal blood (68%) and the fact that the test cannot be used to detect diaphragm, hollow viscus, or retroperitoneal injuries.8,14,20 In addition, one cannot use FAST to grade solid-organ injury severity. Ultrasound is less useful in evaluating penetrating trauma. However, because of its ability to detect hemopericardium, it can be useful to direct the initial operative approach and incision placement in thoracoabdominal penetrating trauma.
For hemodynamically stable blunt trauma patients, computed tomography (CT) is the standard diagnostic tool.16,17,21 It is particularly accurate in diagnosis of solid-organ injury. It does lack sensitivity and specificity for pancreatic, hollow viscus, and diaphragm injuries, especially early in the clinical course when the initial study is usually performed.18,22–26
DPL is a study used much less frequently since FAST has been shown to reliably detect hemoperitoneum. However, DPL is useful for further evaluation of the abdomen when FAST is negative in unstable patients or in the evaluation of the abdomen in the patient who requires emergency operation for an injury remote from the abdomen.26 The test is relatively simple and rapid, but it is invasive, and complications such as bowel injury are well described. More importantly, similar to FAST, DPL lacks sensitivity for retroperitoneal and diaphragm injuries. In addition, DPL is nonspecific. Thus, exploratory laparotomy based on DPL may be nontherapeutic in 25% of cases.
Penetrating Abdominal Injury
Gunshot Wounds
Gunshot wounds which violate the peritoneal cavity generally mandate exploratory laparotomy. The likelihood of visceral injury requiring repair is 80% to 95%.27,28 After a rapid primary survey, the entire body must be inspected for penetrating wounds by rolling the patient on both sides. Special attention must be paid to hidden areas such as the axillae, skin folds, body creases, and the perineum. The number of bullet wounds should be noted. Radiographs are taken of any body areas which may have been in the path of bullet trajectory. This is a critical maneuver to identify all bullets, possible trajectory, and thus structures at risk. Remember that bullets often do not travel in a straight line and may ricochet off bony structures; trajectory cannot be determined with complete confidence. The number of external wounds plus bullets found within the patient (usually on radiographs) must equal an even number; an odd number means that a bullet has not been found and other body cavities are at risk.
Abdominal Stab Wounds
The likelihood of finding an injury which requires operative repair in a patient with an anterior stab wound is only 25% to 33%.29 Indications for immediate exploration include hypotension, peritonitis, and evisceration. In the absence of these signs, selective management is appropriate, provided a surgeon and an OR are immediately available. In the stable patient with a reliable physical examination, the surgeon may simply decide to perform serial abdominal examination (selective management). The need for exploratory laparotomy is then based on change in abdominal examination, vital signs (especially temperature or heart rate), or white blood cell count.29,30
In the setting of anterior abdominal stab wounds, local wound exploration (LWE) can be helpful.31,32 This is a formal surgical procedure usually performed in the resuscitation room. Using sterile technique and under local anesthesia, the anterior abdominal stab wound is elongated with a scalpel, and the underlying fascia is exposed with sharp dissection. Penetration of the anterior fascia suggests the possibility of peritoneal penetration and usually warrants further operative intervention, usually laparotomy or DPL. A recent multicenter trial suggested that anterior abdominal stab wounds without evisceration, hemodynamic instability, or peritonitis could be triaged based upon the results of LWE.32 In some centers, diagnostic laparoscopy is performed when FAST, DPL, or LWE are equivocal. Laparoscopy in this setting has been challenged because of the difficulty in detecting small intestinal injuries, but it can be very helpful in evaluating the diaphragm in left thoracoabdominal stab wounds. In the stable patient, knife wounds of the flank and back may be evaluated by CT to assess trajectory of the weapon and possible visceral injury.
Solid-Organ Injury
Liver
The majority of liver injuries do not require an operation.33–35 Indeed, 86% of all isolated liver injuries were managed nonoperatively in a recent National Trauma Data Bank review.35 The speed and accuracy of CT has greatly enhanced the ability to detect and accurately grade solid-organ injuries. The key decision point is hemodynamic stability for CT imaging. If they are stable enough for CT, the majority of these patients can be observed. Conversely, 25% of liver injuries will require an intervention for a complication (bleeding, abscess, bile leak, biloma). Thus, interventional radiology has a critical role in the management of solid-organ injury.36 This has facilitated the study of the natural history of liver injuries treated nonoperatively. It has been shown that the grade of injury is an important predictor of success of nonoperative management, but even high-grade liver injuries can be successfully managed in this way.
The key to favorable outcomes in liver injury is recognition of failure of nonoperative management, as evidenced by ongoing bleeding. Signs of bleeding such as progressive anemia, hypotension, tachycardia, and failure to correct base deficit with volume resuscitation must be addressed in the setting of known liver injury. Angiographic embolization of hepatic arterial branches may avoid laparotomy if utilized immediately following recognition of arterial bleeding on the initial CT or early in the resuscitation phase.37 It must be emphasized that the hemodynamically unstable patient with a liver injury must undergo immediate operation.
Both operative and nonoperative liver trauma patients in the ICU must be monitored for several potential problems. As nonoperative management of liver trauma has become commonplace, complications related to the liver are recognized in as many as 14% to 25% of high-grade injuries.37–39 Ongoing or recurrent bleeding must be carefully excluded. Hepatic and perihepatic abscesses may be amenable to percutaneous drainage and antibiotic therapy. Biliary complications including bile leaks, biliary fistula, biloma, and bile peritonitis occur in proportion to severity of the liver injury. Percutaneous drainage of bile collections is usually the first step. Endoscopic retrograde cholangiography with bile duct stenting can be added for high-volume or persistent leaks.
Spleen
Similar to liver injury, splenic trauma has seen a significant trend toward nonoperative management. Approximately 76% of splenic injuries are currently managed without operation.35,40–50 Successful management again requires recognition of signs of failure of a nonoperative strategy. In the case of the spleen, this is almost exclusively due to bleeding. Although hemodynamic instability remains the only clear indication for operative intervention, several studies have demonstrated risk factors for failed nonoperative management including greater injury severity score, splenic injury grade, volume of hemoperitoneum, higher injury severity score, and older age.49,50
These risk factors are highlighted to emphasize that all patients initially selected for nonoperative management must be monitored carefully. Angiographic embolization is an adjunct in the management of splenic injury with evidence of contrast extravasation on CT, but this strategy should not be chosen in the unstable patient or in the patient with other indications for laparotomy.48 Complications of angioembolization of the spleen include continued bleeding and splenic abscess. Unlike the liver, the spleen is not essential to life. Although splenectomy following a trial of nonoperative management is considered a “failure,” it is certainly preferable to a preventable mortality from bleeding.44,47,51,52 This should be borne in mind when nonoperative management is chosen in the first place. “Successful” nonoperative management of an injured spleen that requires constant bedside attention and blood product replacement while waiting for the bleeding to stop should not be viewed as superior to initial planned splenectomy. Indeed, if operation is performed early, splenic repair and salvage can sometimes be considered.
Kidneys
The kidneys lie in a relatively protected region of the retroperitoneum, with spine, ribs, paraspinous muscles, and the intraperitoneal organs and tissues offering protection. The kidneys are thus less commonly injured than either the liver or spleen. Similar to the liver and spleen, the majority of blunt renal injuries are managed nonoperatively. In the national review by Tinkoff et al., only 8% of isolated kidney injuries required operation compared to 14% of liver and 24% of spleen injuries.35 Severity of injury does correlate with rates of nephrectomy and, in blunt trauma, rates of dialysis and mortality.53 Even if a laparotomy is performed for other reasons, the kidneys do not have to be explored unless there is an expanding retroperitoneal hematoma. In penetrating trauma, however, any hematoma around the kidney should prompt exploration, owing to the significant risk of major renal vascular injury and collecting system disruption. Repair or partial nephrectomy is usually preferred to nephrectomy in the non-exsanguinating patient. Palpation of a normal contralateral kidney should be done prior to nephrectomy. Complications of nonoperative management and partial nephrectomy include bleeding, urinoma, and infection.
Pancreas
Injury to the pancreas is unusual in most trauma series. It is well protected in the retroperitoneum. In blunt trauma, its position overlying the lumbar spine contributes to injury in that compression against the spine by a seatbelt, handlebar, ski pole or similar object can result in contusion or transection.55 Pancreatic injuries are notable for difficulty in diagnosis.54–56 The common diagnostic studies used in the evaluation of abdominal trauma—CT, FAST, and DPL—all fail to accurately assess the pancreas.54–57 CT can demonstrate transection and peripancreatic inflammation and fluid; it is the best of the three modalities to detect pancreatic trauma, but a recent multi-institutional study demonstrated that modern 64-slice CT missed almost 50% of pancreatic ductal injuries.57 Serum amylase and lipase levels are also unreliable in the diagnosis of pancreatic injury. Thus a high index of suspicion must be maintained when a mechanism of injury or commonly associated injury is present. Lumbar Chance fractures, duodenal hematoma, and direct epigastric blow should prompt suspicion and frequent reassessment.54
Pancreatic trauma from penetrating mechanisms is often complicated by injuries to surrounding structures, most importantly the aorta, vena cava, and portal vein, as well as the stomach, duodenum, and liver. These injuries can be devastating and commonly necessitate damage control techniques described later. Control of hemorrhage and enteric perforations take precedence; pancreatic resectional procedures are rarely indicated during the initial procedure except for the unusual isolated tail injury, which may be amenable to distal pancreatectomy.56,58,59 Generous drainage of the retroperitoneum is employed in all patients discovered to have pancreatic injury at the time of operation.
Intestinal Injury
Hollow visceral injury is commonly the result of penetrating abdominal injury, small intestine most often. These injuries are generally found during routine exploration of the abdomen for gunshot injury. Bowel injury from blunt trauma is relatively uncommon and difficult to diagnose.22–2560 Full-thickness intestinal injury may be present despite normal findings by CT, FAST, and routine laboratory studies. CT may miss 15% to 30% of intestine injury. A seatbelt mark or Chance fracture may be associated with intestinal or mesenteric injury in 25% to 30% of patients.24,25
Diaphragm Injury
Blunt diaphragmatic injury is important to diagnose, as 60% to 90% of these patients have an associated intraabdominal injury. The chest radiograph is diagnostic in 25% of cases, abnormal but not diagnostic in 50% of cases (blunting of the diaphragm, haziness or infiltrate at the lung base), and normal (even in retrospect) in 25% of cases.61 Diaphragmatic injury is more common on the left side. Acute injury to the diaphragm is repaired through the abdomen rather than the chest because of the high likelihood of associated abdominal injury. Diaphragmatic injuries from penetrating trauma are very difficult to diagnose because the hole is generally small. Penetrating thoracoabdominal wounds, particularly on the left side, may result in hernias which entrap intestine years later. If the trajectory of a penetrating injury suggests the possibility of a diaphragmatic injury on the left, either laparoscopy or laparotomy is generally indicated.
Genitourinary Injury
Hematuria is the hallmark of genitourinary injury. Gross hematuria mandates further evaluation of the genitourinary tract, usually with a cystogram to evaluate the bladder and CT to evaluate the kidneys. Microscopic hematuria is further evaluated in the blunt trauma patient with hypotension, lower rib fractures, flank ecchymosis or tenderness, spine fractures, or high injury severity score (multiple injuries).2,53 A straddle injury or anterior pelvic rami fracture may be associated with a urethral injury, particularly in males. Signs of urethral injury include blood at the meatus, inability to void, perineal hematoma, or high-riding prostate gland on examination. A retrograde urethrogram should be obtained prior to placement of a bladder catheter in this patient.
Damage Control
The concept of damage control has gained considerable popularity over the last 20 years. Damage control refers to truncated surgical operations to control immediately life-threatening problems, followed by a period of vigorous ongoing resuscitation in the ICU and subsequent return to the OR for definitive repair of injuries.2,62–68 Recognition that prolonged heroic efforts at complete correction of anatomic abnormalities often resulted in technically adequate repairs in patients who were physiologically exhausted and often died from irreversible shock, acidosis, or coagulopathy led to widespread acceptance of this alternative approach.
Damage control can be applied appropriately to virtually any initial operation in trauma. Although laparotomy is the prototypical operation suited to abbreviation, thoracotomy, craniotomy, vascular repairs, and orthopedic procedures can all be performed in a lifesaving but incomplete manner in the setting of profound acidosis, hypothermia, and coagulopathy. This so-called bloody, vicious cycle is the hallmark indication to abort efforts at definitive surgical repair.63
Exploratory laparotomy is the operation in which damage control is most frequently employed. Rapid control of hemorrhage and enteric contamination, followed by temporary closure of the abdomen, all ideally performed in 1 hour or less, should be the goals. Vascular injuries are ligated or shunted, liver injuries are packed, the injured spleen is removed, kidney injuries are packed or nephrectomy performed, and hollow viscus injuries are controlled with rapid suture or staple techniques.62–68 A variety of devices or techniques have been used to rapidly cover and protect the abdominal viscera for ongoing ICU resuscitation. These include sterile plastic intravenous fluid bags, skin-only closure, and vacuum suction devices. The patient is scheduled to return to the OR within 24 to 48 hours for definitive repairs. These operations may include removal of packs, resection of devitalized tissue, permanent vascular repairs, bowel anastomoses or stoma creation, feeding tube placement, and abdominal wall closure. Occasionally a patient must be returned to the OR sooner if significant bleeding persists or recurs. Immediate postoperative resuscitation might also include angioembolization. Arterial bleeding from liver injuries or associated with pelvic fractures is sometimes amenable to this treatment strategy, but it must be remembered that the typical angiography suite is ill equipped to manage these critically ill patients, and necessary resources must be mobilized. Appropriate anesthesia services, sufficient monitoring capabilities, and coordinated blood product acquisition must be available. Essentially, the resources of the trauma OR must be present in the radiology suite.
Open Abdomen
One of the consequences of abdominal damage control is an open abdomen, which refers to the unapproximated abdominal wall fascia. The concept of the open abdomen resulted from the recognition that massive swelling and edema of the abdominal viscera in critically injured patients resulted in increased intraperitoneal pressures and resultant organ dysfunction. This is now referred to as abdominal compartment syndrome.2,69 Excessive crystalloid resuscitation may be a major factor contributing to abdominal compartment syndrome. The open abdomen is an integral part of a damage control strategy. It facilitates damage control because it shortens the duration of the initial operation and simplifies reexploration. At least as importantly, it also prevents abdominal compartment syndrome by creating a protected but flexible space for the enlarged viscera.
However, the open abdomen can be seen as a major tradeoff. On the one hand, many patients who may have previously died when definitive repairs and abdominal wall closure were always practiced, now survive with damage control techniques and an open abdomen. On the other hand, management of the open abdomen is not straightforward and carries significant morbidity.62 The most serious complications of the open abdomen are enterocutaneous, or “enteroatmospheric,” fistulas and giant ventral hernias. Because of these complications, multiple strategies to close the abdominal wall fascia as soon as possible after initial operation have been employed. These include sequential suturing, negative-pressure dressings, proprietary fascial approximation devices, spanning the fascial defect with biological or permanent mesh materials, and plastic surgical techniques of separating and advancing the fascial layers of the abdominal wall.64 None of these techniques has been universally successful, and optimal management of the open abdomen remains an area of active research. One area of controversy is the relative safety and efficacy of enteral nutritional support during open abdomen management. Dissanaike and colleagues demonstrated that immediate enteral feeding in patients with open abdomens significantly lowered pneumonia incidence, without affecting abdominal closure rate.70
Key Points
Rozycki GS, Root HD. The diagnosis of intraabdominal visceral injury. J Trauma. 2010;68:1019-1023.
A current review of the diagnostic tools available for the accurate evaluation of abdominal injury.
Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207:646-655.
Kozar RA, Moore JB, Niles SE, et al. Complications of nonoperative management of high-grade blunt hepatic injuries. J Trauma. 2005;59:1066-1071.
An important analysis of the complexities in the management of liver injury.
Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma. 2006;61:1113-1118.
Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin Crit Care. 2006;12:346-350.
A thorough review of the critical steps in damage control from patient selection to ICU management.
1 American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Manual. Chicago: American College of Surgeons; 2001.
2 Demetriades D, Velmahos G. Indications for laparotomy. In: Moore EE, Feliciano DV, Mattox KL, editors. Trauma. New York: McGraw-Hill; 2004:593.
3 Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and survival following injury. J Trauma. 1993;35:584.
4 Claridge JA, Crabtree TD, Pelletier SJ, et al. Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. J Trauma. 2000;48:8.
5 Davis JW, Parks SN, Kaups KL, et al. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma. 1996;41:769.
6 Rixen D, Raum M, Bouillon B, et al. Base deficit development and its prognostic significance in post-trauma critical illness. Shock. 2001;15:83.
7 Enderson BL, Maull KI. Missed injuries: The trauma surgeon’s nemesis. Surg Clin North Am. 1991;71:399.
8 Soffer D, Schulman CI, McKenney MG, et al. What does ultrasonography miss in blunt trauma patients with a low Glasgow Coma Score (GCS)? J Trauma. 2006;60:1184.
9 Rozycki GS, Root HD. The diagnosis of intraabdominal visceral injury. J Trauma. 2010;68:1019.
10 Nagy KK, Roberts RR, Joseph JT, et al. Experience with over 2500 diagnostic peritoneal lavages. Injury. 2000;31:479.
11 Himmelman RG, Martin M, Gilkey S, et al. Triple-contrast CT in penetrating back and flank trauma. J Trauma. 1991;31:852.
12 Fischer RP, Beverlin BC, Engrav LH, et al. Diagnostic peritoneal lavage: Fourteen years and 2586 patients later. Am J Surg. 1978;136:701.
13 Rozycki G, Ochsner M, Schmidt J, et al. A prospective study of surgeon performed ultrasound as the primary adjunct modality for injured patient assessment. J Trauma. 1995;39:492.
14 Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: Lessons learned from 1450 patients. Ann Surg. 1998;228:557.
15 Catre MG. Diagnostic peritoneal lavage versus abdominal computed tomography in blunt abdominal trauma: A review of prospective studies. Can J Surg. 1995;38:117.
16 Meredith JW, Ditesheim JA, Stonehouse S, et al. Computed tomography and diagnostic peritoneal lavage. Am Surg. 1992;58:44.
17 Pevec WC, Peitzman AB, Udekwu AO, et al. Computed tomography in the evaluation of blunt abdominal trauma. Surg Gynecol Obstet. 1991;173:262.
18 Root HD, Hauser CW, McKinley CR, et al. Diagnostic peritoneal lavage. Surgery. 1965;57:633.
19 Choi KC, Peek-Asa C, Lovell M, et al. Complications after therapeutic trauma laparotomy. J Am Coll Surg. 2005;201:546.
20 Mutabagani KH, Coley BD, Zumberge N, et al. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: Is it useful? Pediatr Surg. 1999;34:48.
21 Deunk J, Brink M, Dekker HM, et al. Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm. Ann Surg. 2010;251:512.
22 Mostafa A, Hanson JM, Grinblat L, et al. Surgically important bowel and/or mesenteric injury in blunt trauma: accuracy of multidetector CT for evaluation. Radiology. 2008;249:524.
23 Ekeh AP, Saxe J, Walusimbi M, et al. Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology—are results better? J Trauma. 2008;65:354.
24 Watts DD, Fakhry SM. EAST Multi-institutional hollow viscus injury research group: Incidence of hollow viscus injury in blunt trauma: An analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma. 2003;54:289.
25 Fakhry SM, Brownstein M, Watts DD, et al. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: An analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma. 2000;48:408.
26 Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma. 2009;67:330.
27 Frankel HL, Boone DC, Peitzman AB. Abdominal trauma. In: Peitzman AB, Rhodes M, Schwab CW, et al, editors. The Trauma Manual. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002:236.
28 Moore EE, Moore JB, Van Duzer-Moore S. Mandatory laparotomy for gunshot wounds penetrating the abdomen. Am J Surg. 1980;140:847.
29 Shorr RM, Gottlieb MM, Webb K, et al. Selective management of abdominal stab wounds. Arch Surg. 1988;123:1141.
30 Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68:721.
31 Boyle EMJr, Maier RV, Salazar JD, et al. Diagnosis of injuries after stab wounds to the back and flank. J Trauma. 1997;42:260.
32 Biffl WL, Kaups KL, Cothren CC, et al. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma. 2009;66:1294.
33 Malhotra AK, Fabian TC, Croce MA, et al. Blunt hepatic injury: A paradigm shift to nonoperative management in the 1990s. Ann Surg. 2000;231:804.
34 Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: A 25-year perspective. Ann Surg. 2000;232:324.
35 Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, liver and kidney, validation based on the National Trauma Data Bank. J Amer Coll Surg. 2008;207:646.
36 Carrillo EH, Spain DA, Wohltmann CD, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. 1999;46:619.
37 Johnson JW, Gracias VH, Gupta R, et al. Hepatic angiography in patients undergoing damage control laparotomy. J Trauma. 2002;52:1102.
38 Kozar RA, Moore FA, Moore EE, et al. Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 2009;67:1144.
39 Kozar RA, Moore JB, Niles SE, et al. Complications of nonoperative management of high-grade blunt hepatic injuries. J Trauma. 2005;59:1066.
40 Federle MP, Courcoulas AP, Powell M, et al. Blunt splenic injury in adults: Clinical and CT criteria for management with emphasis on active extravasation. Radiology. 1998;206:137.
41 Coburn MC, Pfeifer J, Deluca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg. 1995;130:332.
42 Konstatakos AK, Barnoski AL, Plaisier BR, et al. Optimizing the management of blunt splenic injury in adults and children. Surgery. 1999;126:805.
43 Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults: Multi-institutional study of the Eastern Association for the Surgery of Trauma. J Trauma. 2000;49:177.
44 Savage SA, Zarzaur BL, Magnotti LJ, et al. The evolution of blunt splenic injury: resolution and progression. J Trauma. 2008;64:1085.
45 Harbrecht BG, Zenati MS, Ochoa JB, et al. Evaluation of a 15-year experience with splenic injuries in a state trauma system. Surgery. 2007;141:229.
46 McCray VW, Davis JW, Lemaster D, et al. Observation for nonoperative management of the spleen: how long is long enough? J Trauma. 2008;65:1354.
47 Peitzman AB, Harbrecht BG, Rivera L, et al. Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences. J Am Coll Surg. 2005;201:179.
48 Moore FA, Davis JW, Moore EE, et al. Western Trauma Association (WTA) critical decisions in trauma: management of adult blunt splenic trauma. J Trauma. 2008;65:1007.
49 Watson GA, Rosengart MR, Zenati MS, et al. Nonoperative management of severe blunt splenic injury: are we getting better? J Trauma. 2006;61:1113.
50 Smith J, Armen S, Cook CH, et al. Blunt splenic injuries: have we watched long enough? J Trauma. 2008;64:656.
51 Zarzaur BL, Vashi S, Magnotti LJ, et al. The real risk of splenectomy after discharge home following nonoperative management of blunt splenic injury. J Trauma. 2009;66:1531.
52 Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt abdominal trauma: have we gone too far? Surg Infect (Larchmt). 2009;10:427.
53 Kuan JK, Wright JL, Nathens AB, et al. American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries. J Trauma. 2006;60:351.
54 Subramanian A, Dente CJ, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am. 2007;87:1515.
55 Stawicki PS, Schwab CW. Pancreatic trauma: demographics, diagnosis, and management. Am Surgeon. 2008;74:1133.
56 Seamon MJ, Kim PK, Stawicki P, et al. Pancreatic injury in damage control laparotomies: is pancreatic resection safe during the initial laparotomy? Injury. 2009;40:61.
57 Phelan HA, Velmahos GC, Jurkovich GJ, et al. An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study. J Trauma. 2009;66:641.
58 Smego DR, Richardson JD, Flint LM. Determinants of outcome in pancreatic trauma. J Trauma. 1985;25:771.
59 Patton JHJr, Lyden SP, Croce MA, et al. Pancreatic trauma: A simplified management guideline. J Trauma. 1997;43:234.
60 Nance ML, Peden GW, Shapiro MB, et al. Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma. J Trauma. 1997;43:618.
61 Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg. 1995;170:5.
62 Miller RS, Morris JA, Diaz JJ, et al. Complications after 344 damage-control open celiotomies. J Trauma. 2005;59:1365.
63 Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin Crit Care. 2006;12:346.
64 Fabian TC. Damage control in trauma: laparotomy wound management, acute to chronic. Surg Clin North Am. 2007;87:73.
65 Mattox KL. Introduction, background, and future projections of damage control surgery. Surg Clin North Am. 1997;77:753.
66 Morris JA, Eddy VA, Binman TA, et al. The staged celiotomy for trauma: Issues in unpacking and reconstruction. Ann Surg. 1993;217:576.
67 Burch JM, Ortiz VB, Richardson DJ, et al. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg. 1992;215:476.
68 Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control: An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35:375.
69 Ivatury RR, Sugerman HJ, Peitzman AB. Abdominal compartment syndrome: Recognition and management. Adv Surg. 2001;35:251.
70 Dissanaike S, Pham T, Shalhub S, et al. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg. 2008;207:690.
