The abdominal examination in elderly patients is notoriously unreliable compared with younger patients, even in the absence of distracting pain, injuries, or altered sensorium. Even with an initially benign physical examination, emergency physicians must have a high index of suspicion for intraabdominal injuries in patients who have associated pelvic and lower rib cage fractures. For older patients, the adhesions associated with previous abdominal surgical procedures may increase the risk of performing diagnostic peritoneal lavage in the emergency department.1 Therefore, CT scanning with contrast material is a valuable diagnostic test. It is important to ensure adequate hydration and baseline assessment of renal function prior to the contrast load for the CT scan. Some patients may be volume depleted due to medications such as diuretics. This hypovolemia coupled with contrast administration may exacerbate any underlying renal pathology. 1 For unstable patients, and especially those with multiple scars on the abdominal wall from previous procedures, the trauma ultrasound examination is the ideal diagnostic study to detect free intraperitoneal fluid. In prospective studies by emergency physicians and trauma surgeons, ultrasonography has been demonstrated to be highly sensitive and specific for the identification of free intraperitoneal fluid. It also is rapid, portable, noninvasive, and easily repeatable. 13
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