Practice Essentials

Blunt abdominal trauma (see the image below) is a leading cause of morbidity and mortality among all age groups. Identification of serious intra-abdominal pathology is often challenging; many injuries may not manifest during the initial assessment and treatment period.

Blunt abdominal trauma. Right kidney injury with blood in perirenal space. Injury resulted from high-speed motor vehicle collision.

View Media Gallery

Signs and symptoms

The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate. The most reliable signs and symptoms in alert patients are as follows:

Pain
Tenderness
Gastrointestinal hemorrhage
Hypovolemia
Evidence of peritoneal irritation

However, large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings. Bradycardia may indicate the presence of free intraperitoneal blood.

On physical examination, the following injury patterns predict the potential for intra-abdominal trauma:

Lap belt marks: Correlate with small intestine rupture
Steering wheel–shaped contusions
Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign): Indicates retroperitoneal hemorrhage, but is usually delayed for several hours to days
Abdominal distention
Auscultation of bowel sounds in the thorax: May indicate a diaphragmatic injury
Abdominal bruit: May indicate underlying vascular disease or traumatic arteriovenous fistula
Local or generalized tenderness, guarding, rigidity, or rebound tenderness: Suggests peritoneal injury
Fullness and doughy consistency on palpation: May indicate intra-abdominal hemorrhage

Brasel KJ, Olson CJ, Stafford RE, Johnson TJ. Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma. J Trauma. 1998 May. 44(5):889-92. [QxMD MEDLINE Link].
Holmes JF, Offerman SR, Chang CH, Randel BE, Hahn DD, Frankovsky MJ, et al. Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries. Ann Emerg Med. 2004 Jan. 43(1):120-8. [QxMD MEDLINE Link].
Christiano JG, Tummers M, Kennedy A. Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma. J Pediatr Surg. 2009 Jun. 44(6):1242-8. [QxMD MEDLINE Link].
Shanmuganathan K. Multi-detector row CT imaging of blunt abdominal trauma. Semin Ultrasound CT MR. 2004 Apr. 25(2):180-204. [QxMD MEDLINE Link].
American College of Surgeons Committee on Trauma. Abdominal Trauma. In: ATLS Student Course Manual. 8th. American College of Surgeons; 2008.
Jansen JO, Yule SR, Loudon MA. Investigation of blunt abdominal trauma. BMJ. 2008 Apr 26. 336(7650):938-42. [QxMD MEDLINE Link]. [Full Text].
Cooper A, Barlow B, DiScala C, String D. Mortality and truncal injury: the pediatric perspective. J Pediatr Surg. 1994 Jan. 29(1):33-8. [QxMD MEDLINE Link].
Ong CL, Png DJ, Chan ST. Abdominal trauma--a review. Singapore Med J. 1994 Jun. 35(3):269-70. [QxMD MEDLINE Link].
Powell DC, Bivins BA, Bell RM. Diagnostic peritoneal lavage. Surg Gynecol Obstet. 1982 Aug. 155(2):257-64. [QxMD MEDLINE Link].
Hankin AD, Baren JM. Should the digital rectal examination be a part of the trauma secondary survey?. Ann Emerg Med. 2009 Feb. 53(2):208-12. [QxMD MEDLINE Link].
Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990 Jun. 30(6):666-9; discussion 669-70. [QxMD MEDLINE Link].
Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma. 1998 Jun. 44(6):1000-6; discussion 1006-7. [QxMD MEDLINE Link].
Kwok MY, Yen K, Atabaki S, et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med. 2015 Jan. 65 (1):63-71.e1. [QxMD MEDLINE Link].
Schnüriger B, Inaba K, Barmparas G, Eberle BM, Lustenberger T, Lam L, et al. Serial white blood cell counts in trauma: do they predict a hollow viscus injury?. J Trauma. 2010 Aug. 69(2):302-7. [QxMD MEDLINE Link].
Ritchie AH, Williscroft DM. Elevated liver enzymes as a predictor of liver injury in stable blunt abdominal trauma patients: case report and systematic review of the literature. Can J Rural Med. 2006 Fall. 11(4):283-7. [QxMD MEDLINE Link].
Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF Jr, Malangoni MA. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 1997 Jul. 63(7):598-604. [QxMD MEDLINE Link].
Knudson MM, McAninch JW, Gomez R, Lee P, Stubbs HA. Hematuria as a predictor of abdominal injury after blunt trauma. Am J Surg. 1992 Nov. 164(5):482-5; discussion 485-6. [QxMD MEDLINE Link].
Tso P, Rodriguez A, Cooper C, Militello P, Mirvis S, Badellino MM, et al. Sonography in blunt abdominal trauma: a preliminary progress report. J Trauma. 1992 Jul. 33(1):39-43; discussion 43-4. [QxMD MEDLINE Link].
Kawaguchi S, Toyonaga J, Ikeda K. Five point method: An ultrasonographic quantification formula of intra-abdominal fluid collection. Jpn J Acute Med. 1987;7:993-7.
Tiling T, Boulion B, Schmid A, et al. Ultrasound in blunt abdominothoracic trauma. In: Border JR, ed. Blunt Multiple Trauma: Comprehensive Pathophysiology and Care. New York: Marcel Dekker; 1990:415-33.
Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. 2004 Nov. 22(7):601-4. [QxMD MEDLINE Link].
Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. 1997 Jun. 42(6):1086-90. [QxMD MEDLINE Link].
Kornezos I, Chatziioannou A, Kokkonouzis I, Nebotakis P, Moschouris H, Yiarmenitis S, et al. Findings and limitations of focused ultrasound as a possible screening test in stable adult patients with blunt abdominal trauma: a Greek study. Eur Radiol. 2010 Jan. 20(1):234-8. [QxMD MEDLINE Link].
Kendall JL, Faragher J, Hewitt GJ, Burcham G, Haukoos JS. Emergency Department Ultrasound Is not a Sensitive Detector of Solid Organ Injury. West J Emerg Med. 2009 Feb. 10(1):1-5. [QxMD MEDLINE Link]. [Full Text].
Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995 Sep. 39(3):492-8; discussion 498-500. [QxMD MEDLINE Link].
Chiu WC, Cushing BM, Rodriguez A, Ho SM, Mirvis SE, Shanmuganathan K, et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma. 1997 Apr. 42(4):617-23; discussion 623-5. [QxMD MEDLINE Link].
Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev. 2018 Dec 12. 12:CD012669. [QxMD MEDLINE Link].
Thiessen MEW, Riscinti M. Application of Focused Assessment with Sonography for Trauma in the Intensive Care Unit. Clin Chest Med. 2022 Sep. 43 (3):385-92. [QxMD MEDLINE Link].
Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017 Jun 13. 317 (22):2290-2296. [QxMD MEDLINE Link].
Kornblith AE, Addo N, Plasencia M, et al. Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children. JAMA Netw Open. 2022 Mar 1. 5 (3):e222922. [QxMD MEDLINE Link]. [Full Text].
Firnberg M, Addo N, Lin-Martore M, Shaahinfar A, Kornblith A. Evaluation of Focused Assessment With Sonography for Trauma Completeness of Children in the Clinical Setting. J Ultrasound Med. 2024 May. 43 (5):873-9. [QxMD MEDLINE Link].
Matsumoto S, Sekine K, Yamazaki M, Sasao K, Funabiki T, Shimizu M, et al. Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deterioration in patients with blunt torso trauma. J Trauma. 2010 Dec. 69(6):1398-402. [QxMD MEDLINE Link].
Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug. 62 (2):107-16.e2. [QxMD MEDLINE Link].
Mahajan P, Kuppermann N, Tunik M, Yen K, Atabaki SM, Lee LK, et al. Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma. Acad Emerg Med. 2015 Sep. 22 (9):1034-41. [QxMD MEDLINE Link].
Benjamin E, Cho J, Recinos G, et al. Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients. J Trauma Acute Care Surg. 2018 Jan. 84 (1):128-32. [QxMD MEDLINE Link].
Benjamin ER, Siboni S, Haltmeier T, Lofthus A, Inaba K, Demetriades D. Negative Finding From Computed Tomography of the Abdomen After Blunt Trauma. JAMA Surg. 2015 Dec 1. 150 (12):1194-5. [QxMD MEDLINE Link].
Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA. A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg. 1993 May. 217(5):557-64; discussion 564-5. [QxMD MEDLINE Link]. [Full Text].
Ivatury RR, Simon RJ, Weksler B, Bayard V, Stahl WM. Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma. 1992 Jul. 33(1):101-8; discussion 109. [QxMD MEDLINE Link].
Ortega AE, Tang E, Froes ET, Asensio JA, Katkhouda N, Demetriades D. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc. 1996 Jan. 10(1):19-22. [QxMD MEDLINE Link].
Neuhof H, Cohen I. ABDOMINAL PUNCTURE IN THE DIAGNOSIS OF ACUTE INTRAPERITONEAL DISEASE. Ann Surg. 1926 Apr. 83(4):454-62. [QxMD MEDLINE Link]. [Full Text].
ROOT HD, HAUSER CW, MCKINLEY CR, LAFAVE JW, MENDIOLA RP Jr. DIAGNOSTIC PERITONEAL LAVAGE. Surgery. 1965 May. 57:633-7. [QxMD MEDLINE Link].
Liu M, Lee CH, P'eng FK. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma. 1993 Aug. 35(2):267-70. [QxMD MEDLINE Link].
Cryer HG, Larmon B. Patient care phase: prehospital and resuscitation care. In: Greenfield LJ, Mulholland MW, Oldham KT, Zelenock GB, Lillemoe KD, eds. Surgery: Scientific Principles and Practice. Philadelphia: Lippincott-Raven;. 1997:280-4.
Pryor JP, Pryor RJ, Stafford PW. Initial phase of trauma management and fluid resuscitation. Trauma Reports. 2002;3(3):1-12.
Nirula R, Maier R, Moore E, Sperry J, Gentilello L. Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer's effect on mortality. J Trauma. 2010 Sep. 69(3):595-9; discussion 599-601. [QxMD MEDLINE Link].
Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2007 Oct 17. CD000567. [QxMD MEDLINE Link].
Bunn F, Trivedi D, Ashraf S. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev. 2008 Jan 23. CD001319. [QxMD MEDLINE Link].
Hauser CJ, Boffard K, Dutton R, Bernard GR, Croce MA, Holcomb JB, et al. Results of the CONTROL trial: efficacy and safety of recombinant activated Factor VII in the management of refractory traumatic hemorrhage. J Trauma. 2010 Sep. 69(3):489-500. [QxMD MEDLINE Link].
Requarth JA, D'agostino RB Jr, Miller PR. Nonoperative Management of Adult Blunt Splenic Injury With and Without Splenic Artery Embolotherapy: A Meta-Analysis. J Trauma. 2011 Oct. 71(4):898-903. [QxMD MEDLINE Link].
Mora MC, Wong KE, Friderici J, et al. Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank. J Am Coll Surg. 2016 Jun. 222 (6):977-82. [QxMD MEDLINE Link].
Crookes BA, Shackford SR, Gratton J, Khaleel M, Ratliff J, Osler T. "Never be wrong": the morbidity of negative and delayed laparotomies after blunt trauma. J Trauma. 2010 Dec. 69(6):1386-91; discussion 1391-2. [QxMD MEDLINE Link].
Mayglothling JA, Haan JM, Scalea TM. Blunt splenic injuries in the adolescent trauma population: the role of angiography and embolization. J Emerg Med. 2011 Jul. 41(1):21-8. [QxMD MEDLINE Link].
Pommerening MJ, DuBose JJ, Zielinski MD, Phelan HA, Scalea TM, Inaba K, et al. Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy. Surgery. 2014 Aug. 156 (2):431-8. [QxMD MEDLINE Link].
[Guideline] Smyth L, Bendinelli C, Lee N, et al. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg. 2022 Mar 4. 17 (1):13. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Blunt abdominal trauma. Normal Morison pouch (ie, no free fluid).
Blunt abdominal trauma. Free fluid in Morison pouch.
Blunt abdominal trauma. Normal splenorenal recess.
Blunt abdominal trauma. Free fluid in splenorenal recess.
Blunt abdominal trauma with splenic injury and hemoperitoneum.
Blunt abdominal trauma with liver laceration.
Blunt abdominal trauma. Right kidney injury with blood in perirenal space. Injury resulted from high-speed motor vehicle collision.
Ultrasound image of right flank. Clear hypoechoic stripe exists between right kidney and liver in Morison pouch.
Ultrasound image of left flank in same patient, with thin hypoechoic stripe above spleen and wider hypoechoic stripe in splenorenal recess.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

of 10

#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Samuel M Keim, MD, MS Professor and Chair, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jeffrey P Salomone, MD, FACS, NREMT-P Associate Professor of Surgery, Emory University School of Medicine; Deputy Chief of Surgery, Grady Memorial Hospital

Jeffrey P Salomone, MD, FACS, NREMT-P is a member of the following medical societies: American College of Surgeons, American Medical Association, Medical Association of Georgia, National Association of EMS Physicians, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John Udeani, MD, FAAEM Assistant Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine

John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Sidney R Steinberg, MD, FACS, to the development and writing of a source article.

TOP PICKS FOR YOU

Blunt Abdominal Trauma

Practice Essentials

Signs and symptoms

References

Tables

Contributor Information and Disclosures

What would you like to print?