Who Needs Evaluation

All patients undergo physical examination as part of the primary and secondary surveys. Physical examination is often inadequate to make the diagnosis of intraabdominal injury. On the other hand, application of expensive diagnostic testing or prolonged observation in every patient is clearly not possible. Conversely, a missed injury may result in long-term disability or death. Clearly, any patient with abdominal pain or other physical findings requires further evaluation. The mechanism of injury and other prehospital details also provide important information to guide the clinician.

The abdomen extends through the pelvis and rises to approximately the fourth intercostal space during deep exhalation. Patients with evidence of lower chest or pelvic injury require abdominal evaluation. In addition, patients involved in high-speed collisions or collisions where there has been substantial deformity to the vehicle probably should undergo abdominal evaluation regardless of physiologic status or physical findings. This is particularly true if the patient was unrestrained. Motor vehicle crashes with fatalities or those in which there were other substantial injuries also should make the clinician suspicious of abdominal injury even in seemingly asymptomatic patients.

Abdominal evaluation is mandated in all patients who sustain unprotected injury. Patients who are unable tolerate a missed injury or delayed diagnosis should undergo early abdominal evaluation even if the indications seem somewhat soft. The elderly or those with chronic cardiovascular or pulmonary disease should undergo prompt evaluation, since a delayed diagnosis certainly will increase their morbidity and mortality. Lastly, patients with distracting injuries such as long bone injuries should undergo abdominal evaluation because such patients clearly have sustained sufficient force to produce injury, and a concomitant abdominal injury is certainly possible.

There is debate as to whether all patients with a decreased sensorium require abdominal evaluation. Closed head injury or the presence of alcohol and other intoxicants limits a patient's ability to complain of pain or demonstrate physical findings such as subtle tenderness. In addition, small injuries may progress while patients are under observation. Ethanol may reduce the amount of blood loss necessary to produce shock. In general, we prefer to be aggressive and evaluate the abdomen in most patients with head injuries and decreased levels of consciousness.

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