Blunt Abdominal Trauma Patients Are at Very Low Risk for Intra-Abdominal Injury after Emergency Department Observation

Abstract

IntroductionPatients are commonly admitted to the hospital for observation following blunt abdominal trauma (BAT), despite initially negative emergency department (ED) evaluations. With the current use of screening technology, such as computed tomography (CT) of the abdomen and pelvis, ultrasound, and laboratory evaluations, it is unclear which patients require observation. The objective of this study was to determine the prevalence of intra-abdominal injury (IAI) and death in hemodynamically normal and stable BAT patients with initially negative ED evaluations admitted to an ED observation unit and to define a low-risk subgroup of patients and assess whether they may be discharged without abdominal/pelvic CT or observation.MethodsThis was a retrospective cohort study performed at an urban level 1 trauma center and included all BAT patients admitted to an ED observation unit as part of a BAT key clinical pathway. All were observed for at least 8 hours as part of the key clinical pathway, and only minors and pregnant women were excluded. Outcomes included the presence of IAI or death during a 40-month follow-up period. Prior to data collection, low-risk criteria were defined as no intoxication, no hypotension or tachycardia, no abdominal pain or tenderness, no hematuria, and no distracting injury. To be considered low risk, patients needed to meet all low-risk criteria.ResultsOf the 1,169 patients included over the 2-year study period, 29% received a CT of the abdomen and pelvis, 6% were admitted to the hospital from the observation unit for further management, 0.4% (95% confidence interval [CI], 0.1%–1%) were diagnosed with IAI, and 0% (95% CI, 0%–0.3%) died. Patients had a median combined ED and observation length of stay of 9.5 hours. Of the 237 (20%) patients who met low-risk criteria, 7% had a CT of the abdomen and pelvis and 0% (95% CI, 0%–1.5%) were diagnosed with IAI or died.ConclusionMost BAT patients who have initially negative ED evaluations are at low risk for IAI but still require some combination of observation and CT. A subgroup of BAT patients may be safely discharged without CT or observation after the initial evaluation.

Complementary exams in blunt torso trauma. Perform only radiographs and fast: is it safe?

“…These findings are consistent with other studies in literature which show the safety of treating patients without tomography scanning as a tracking method 3 . There are other issues in literature that reinforce the safety of the conduct of cases through conventional studies, leaving the CT as an supplementary examination.…”

Catastrophic necrotizing fasciitis after blunt abdominal trauma with delayed recognition of the coecal rupture – case report

“…Patients who have sustained BAT and have undergone otherwise negative diagnostic evaluation in the emergency department (ED) will also undergo CT of the abdomen and pelvis, admission to the hospital for an extended observation period, or both, in order to be evaluated for occult IAI. [10,11] However, the incidence of IAI in patients who are otherwise hemodynamically stable and have initially negative diagnostic evaluations in the ED is quite low, probably occurring in less than 1%. [11] The frequency of NF is about 0.40 cases per 100.000 and is correlated with inadequate oxygenation and nutrition of tissue.…”

“…[10] Diagnostic evaluation of patients with BAT include physical examination, focused ultrasonography, computed tomography (CT), diagnostic peritoneal lavage, laparoscopy, laparotomy, laboratory tests, and observation. Patients who have sustained BAT and have undergone otherwise negative diagnostic evaluation in the emergency department (ED) will also undergo CT of the abdomen and pelvis, admission to the hospital for an extended observation period, or both, in order to be evaluated for occult IAI.…”

Missed mesenteric injury in blunt abdominal trauma: A potentially lethal error

“…However, the incidence of significant intraabdominal injuries in these patients is relatively low, and this has been reported to be less than 1% of cases. [9]. Although protocols and the duration of observation vary between units, some have argued that clinical observations longer than 24 hours solely to attempt identifying the small proportion of missed injuries may not be justified.…”