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Acute Blunt Abdominal Trauma (Jan 2011)

Critical Issues in the Evaluation of Adult Patients Presenting to the Emergency Department with Acute Blunt Abdominal Trauma (January 2011)

Scope of Application

This guideline is intended for physicians working in hospital-based emergency departments.

Inclusion Criteria

This guideline is intended for nonpregnant adult patients presenting to the emergency department with acute, blunt abdominal trauma.

Exclusion Criteria

This guideline is not intended to address the care of pediatric patients or pregnant women.

Critical Questions

  • In a hemodynamically unstable patient with blunt abdominal trauma is bedside ultrasound the diagnostic modality of choice?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    In hemodynamically unstable patients (systolic blood pressure ≤90 mm Hg) with blunt abdominal trauma, bedside ultrasound, when available, should be the initial diagnostic modality performed to identify the need for emergent laparotomy.
    Level C Recommendations
    None specified.
    Level A Recommendations
    None specified.
    Level B Recommendations
    In hemodynamically unstable patients (systolic blood pressure ≤90 mm Hg) with blunt abdominal trauma, bedside ultrasound, when available, should be the initial diagnostic modality performed to identify the need for emergent laparotomy.
    Level C Recommendations
    None specified.
  • Does oral contrast improve the diagnostic performance of computed tomography (CT) in blunt abdominal trauma?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    Oral contrast is not required in the diagnostic imaging for evaluation of blunt abdominal trauma.* *All of the studies reviewed included the use of intravenous (IV) contrast.
    Level C Recommendations
    For patients with a negative CT scan result with IV contrast only, in whom there is high suspicion of bowel injury, further evaluation or close follow-up is indicated.
    Level A Recommendations
    None specified.
    Level B Recommendations
    Oral contrast is not required in the diagnostic imaging for evaluation of blunt abdominal trauma.* *All of the studies reviewed included the use of intravenous (IV) contrast.
    Level C Recommendations
    For patients with a negative CT scan result with IV contrast only, in whom there is high suspicion of bowel injury, further evaluation or close follow-up is indicated.
  • In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal computed tomography (CT) scan result?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after a negative result for abdominal CT with intravenous (IV) contrast (with or without oral contrast).

    Level C Recommendations

    Further observation, close follow-up, and/or imaging may be warranted in select patients based on clinical judgment.

    Level A Recommendations

    None specified.

    Level B Recommendations

    Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after a negative result for abdominal CT with intravenous (IV) contrast (with or without oral contrast).

    Level C Recommendations

    Further observation, close follow-up, and/or imaging may be warranted in select patients based on clinical judgment.

  • In patients with isolated blunt abdominal trauma, are there clinical predictors that allow the clinician to identify patients at low risk for adverse outcome who do not need an abdominal computed tomography (CT)?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Patients with isolated abdominal trauma, for whom occult abdominal injury is being considered, are at low risk for adverse outcome and may not need abdominal CT scanning if the following are absent: abdominal tenderness, hypotension, altered mental status (Glasgow Coma Scale score <14), costal margin tenderness, abnormal chest radiograph, hematocrit<30% and hematuria.* *Hematuria is defined variably in different studies, with the lowest threshold being greater than or equal to 25 RBCs/high-power field (HPF).

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Patients with isolated abdominal trauma, for whom occult abdominal injury is being considered, are at low risk for adverse outcome and may not need abdominal CT scanning if the following are absent: abdominal tenderness, hypotension, altered mental status (Glasgow Coma Scale score <14), costal margin tenderness, abnormal chest radiograph, hematocrit<30% and hematuria.* *Hematuria is defined variably in different studies, with the lowest threshold being greater than or equal to 25 RBCs/high-power field (HPF).

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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