Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma

background A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy. Methods This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between selfreported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy. results Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one. conclusion Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home. Level of evidence Level III, therapeutic/care management. IntroductIon Blunt abdominal trauma (BAT), most commonly resulting from motor vehicle accidents (MVA) and falls, is a mechanism of injury frequently encountered by both emergency physicians and trauma surgeons.1 2 Unlike penetrating abdominal injuries, unclear signs of traumatic injuries after BAT often leaves many treatment decisions to the acumen of the clinician.3–5 These challenges may result in a under triage and a delayed diagnosis of significant intra-abdominal injury (IAI) secondary to BAT, the consequences of which may potentially lead to severe morbidity and mortality.6–8 The estimated prevalence of IAI in patients with BAT presenting to the emergency department (ED) were reported at 13%; those with clinically significant injuries were reported at 4.7%.9 A thorough history and physical examination remains the primary initial step toward diagnosing IAI in patients with BAT; however, the reliability of this examination has been questioned.10 11 Studies suggest that in select situations, the physical examination alone may not be sufficient for excluding IAI.3 4 12–15 The utility of abdominal tenderness on physical examination as a screen for IAI was observed to be of limited sensitivity and specificity (ranging from 46% to 82% for sensitivity and 41% to 69% for specificity).12 13 16 Further, patients with trauma often present with altered mental status (AMS) and multisystem trauma resulting in distracting injuries, which may lead to an unreliable physical examination.2 4 9 12 CT has become an important adjunct to the physical examination when evaluating hemodynamically stable patients with blunt trauma with equivocal findings.9 10 14 16–19 A high-grade sensitivity (97%– 98%) and specificity (97%–99%) for diagnosing IAI in patients with BAT has been noted and there have been several studies that advocate for the utilization of CT as a screening tool in patients with blunt trauma.16 18 20–22 One study reported that liberal whole body CT imaging in patients with blunt multisystem trauma without obvious signs of injury changed the course of management in nearly 19% of patients (eg, discharged home, sent directly to the operating room).21 However, others argue that the diagnostic yield of these additional CT findings may not significantly change overall patient management, resulting only in unnecessary patient radiation exposure, inefficient resource management, excessive patient and hospital expense, and increased time of initial evaluation.21 23–28 The utility of the history and physical examination during the initial assessment for IAI in patients with BAT is controversial. We seek to assess the feasibility of using self-reported abdominal pain Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma Michael M Neeki,1,2 Dylan Hendy,1 Fanglong Dong,3 Jake Toy,3 Kevin Jones,1 Keasha Kuhnen,1 Ho Wang Yuen,1,2 Pamela Lux,1,2 Arnold Sin,1,2 Eugene Kwong,1 David Wong4,5 to cite: Neeki MM, Hendy D, Dong F, et al. Trauma Surg Acute Care Open 2017;2:1–7. 1Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA 2Department of Emergency Medicine, California University of Science and Medicine, Colton, California, USA 3College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California, USA 4Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA 5Department of Surgery, California University of Science and Medicine, Colton, California, USA correspondence to Dr Michael M Neeki, Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CA 92324, USA; michaelneeki@ gmail. com Received 7 May 2017 Revised 27 August 2017 Accepted 5 September 2017 Original article group.bmj.com on October 10, 2017 Published by http://tsaco.bmj.com/ Downloaded from