Blunt abdominopelvic trauma

Initial Approach (Primary Survey)

• Assess ABCDEs immediately.
• Establish large-bore IV access (two 14- or 16-gauge needles) or intraosseous (IO) access.
• Initiate resuscitation with IV fluids (warmed crystalloids) or Massive Transfusion Protocol (MTP) if in hemorrhagic shock.
• Determine hemodynamic status:
  • Hemodynamically Unstable: SBP < 90 mmHg, HR > 120 bpm, cool/clammy extremities, altered mental status, or failure to respond to initial 1L fluid bolus.
  • Hemodynamically Stable: SBP ≥ 90 mmHg with adequate tissue perfusion.

---

Hemodynamically Unstable Patient Algorithm

• Step 1: Bedside FAST Scan (Focused Assessment with Sonography for Trauma).
  • Evaluates 4 spaces: Hepatorenal (Morison’s pouch), splenorenal, pelvis (rectovesical/rectouterine), pericardium.
• If FAST (+) (free fluid detected):
  • Proceed to Immediate Exploratory Laparotomy (Ex-Lap). Do NOT send to CT (unstable patients must never leave the resuscitation bay).
• If FAST (-) or equivocal:
  • Search for other sources of hemorrhagic shock (chest, pelvis, long bones).
  • Obtain emergency pelvic X-ray and CXR.
  • If pelvic fracture is suspected, apply a pelvic binder immediately.
  • Perform Diagnostic Peritoneal Lavage (DPL) if intra-abdominal hemorrhage is still highly suspected but FAST is negative or unavailable.
    • If DPL (+): Proceed to Ex-Lap.
    • If DPL (-): Search for extra-abdominal causes of shock.

Hemodynamically Stable Patient Algorithm

• Step 1: Physical Examination & FAST.
  • Note: A normal FAST does not rule out intra-abdominal injury in stable patients (it misses retroperitoneal bleeding, hollow viscus injury, and low-grade solid organ laceration).
• Step 2: Contrast-Enhanced CT of Abdomen and Pelvis (CTAP).
  • CTAP is the gold standard diagnostic test for stable patients.
• Step 3: Management based on CTAP findings:
  • Solid Organ Injury (Spleen/Liver/Kidney):
    • Grade I-III (no active bleed/contrast extravasation): Conservative/non-operative management (serial Hgb/Hct, bed rest, ICU observation).
    • Active contrast extravasation (“blush”): Proceed to Angioembolization.
    • Grade IV-V or hemodynamic deterioration during observation: Proceed to Ex-Lap.
  • Hollow Viscus Injury (Bowel/Mesentery):
    • Suggested by free air (pneumoperitoneum), bowel wall thickening, or mesenteric hematoma.
    • Management: Proceed to Ex-Lap.