Blunt Trauma Abdomen (BTA) 

Definition

Blunt abdominal trauma (BTA) refers to non-penetrating injury to abdominal organs due to external force, commonly from:

• Road traffic accidents (most common in India)
• Falls from height
• Assaults
• Crush injuries

 Mechanisms of Injury

1. Deceleration Injury

• Sudden stop → organs continue moving → shearing forces
• Common:
• Liver & spleen tears
• Mesenteric injury
• Aortic injury

2. Compression Injury

• External force compresses organs against spine
• Common:
• Pancreatic injury
• Hollow viscus perforation

3. Blast Injury

• Rare in civilian practice
• Causes combined barotrauma + blunt injury

 Anatomical Classification 

Solid Organ Injury

• Liver (most common overall)
• Spleen (most common requiring surgery)
• Kidney
• Pancreas

 Feature: Bleeding → hemoperitoneum

Hollow Viscus Injury

7

• Stomach, small bowel, colon
• Bladder

 Feature: Peritonitis, sepsis

 Retroperitoneal Injury

• Duodenum, pancreas, kidneys, aorta

 Feature: Occult → late diagnosis → high mortality

 Primary Survey 

Follow ABCDE approach:

A — Airway + C-spine protection

B — Breathing

C — Circulation (MOST IMPORTANT in BTA)

• Control hemorrhage
• 2 large-bore IV lines
• Massive transfusion protocol (1:1:1 ratio)

D — Disability (GCS)

E — Exposure (look for signs)

 Key Clinical Signs

 External Clues

• Seat belt sign → high risk of bowel injury
• Abdominal distension
• Ecchymosis (Grey Turner, Cullen’s → retroperitoneal bleed)

 Internal Clues

• Hypotension → hemorrhagic shock
• Guarding/rigidity → peritonitis
• Hematuria → renal injury

 Investigations 

1. FAST / E-FAST (FIRST LINE in unstable patient)

• Detects free fluid (blood)
• Views:
• Morrison pouch
• Splenorenal
• Pelvis
• Pericardium

 FAST positive + shock → Immediate laparotomy

 2. CECT Abdomen (GOLD STANDARD in stable patient)

• Identifies:
• Organ injury grading (AAST)
• Active bleeding (“contrast blush”)
• Retroperitoneal injury

 3. Labs

• Hb (trend more important than single value)
• Lactate → tissue perfusion
• ABG → metabolic acidosis
• Coagulation profile (trauma-induced coagulopathy)

4. DPL (Diagnostic Peritoneal Lavage)

• Rare now
• Used if FAST unavailable

• “Shock in trauma = bleeding until proven otherwise”
• FAST is not for diagnosis, but for decision-making
• CT scan is useless in unstable patient
• Splenic injury → try to preserve spleen
• Seat belt sign = suspect bowel injury

 Management Algorithm 

🔴 Hemodynamically UNSTABLE

 Definition:

• SBP < 90 mmHg OR ongoing shock

Approach:

• FAST:
• Positive → Immediate laparotomy
• Negative → look for other sources (chest, pelvis)

🟢 Hemodynamically STABLE- Do CECT

If Solid Organ Injury:

• Non-operative management (NOM) (standard of care)
• ICU monitoring
• Serial Hb
• Bed rest

 Indications for intervention:

• Active bleed → angioembolization
• Hemodynamic deterioration → surgery

If Hollow Viscus Injury:

• Surgery is mandatory
• Exploratory laparotomy

 Damage Control Surgery (DCS)

Indications:

• Hypothermia (<35°C)
• Acidosis (pH < 7.2)
• Coagulopathy

 “Lethal Triad”

Steps:

1. Control bleeding
2. Temporary closure
3. ICU resuscitation
4. Definitive surgery later

 Massive Transfusion Protocol (MTP)

• Ratio:
• PRBC : FFP : Platelets = 1 : 1 : 1
• Use:
• Tranexamic acid (within 3 hrs; CRASH-2 trial)

 Indications for Laparotomy 

• Hemodynamic instability + FAST positive
• Peritonitis
• Free air (perforation)
• Evisceration
• Ongoing bleeding despite resuscitation

Summary Table