Blunt trauma is physical trauma to a body part, either by impact, injury or physical attack. The latter is often referred to as blunt force trauma, though it can also result from high-velocity impact. Blunt trauma is the initial trauma, from which develops more specific types such as contusions, abrasions, lacerations, and/or bone fractures. Blunt trauma is contrasted with penetrating trauma, in which an object such as a projectile or knife enters the body, though either can prove fatal. Classification.

Blunt abdominal trauma

Abdominal CT showing left renal artery injury

Blunt abdominal trauma (BAT) represents 75% of all blunt trauma and is the most common example of this injury. The majority occurs in motor vehicle accidents, in which rapid deceleration may propel the driver into the steering wheel, dashboard, or seatbelt causing contusions in less serious cases, or rupture of internal organs from briefly increased intraluminal pressure in the more serious, depending on the force applied. Initially, there may be few indications that serious internal abdominal injury has occurred, making assessment more challenging and requiring a high degree of clinical suspicion.

There are two basic physical mechanisms at play with the potential of injury to intra-abdominal organs: compression and deceleration. The former occurs from a direct blow, such as a punch, or compression against a non-yielding object such as a seat belt or steering column.

This force may deform a hollow organ, increasing its intraluminal or internal pressure and possibly lead to rupture. Deceleration, on the other hand, causes stretching and shearing at the points where mobile contents in the abdomen, like bowel, are anchored. This can cause tearing of the mesentery of the bowel and injury to the blood vessels that travel within the mesentery. Classic examples of these mechanisms are a hepatic tear along the ligamentum teres and injuries to the renal arteries.

When blunt abdominal trauma is complicated by 'internal injury,' the liver and spleen (see blunt splenic trauma) are most frequently involved, followed by the small intestine.

In rare cases, this injury has been attributed to medical techniques such as the Heimlich Maneuver, attempts at CPR and manual thrusts to clear an airway. Although these are rare examples, it has been suggested that they are caused by applying excessive pressure when performing these life-saving techniques. Finally, the occurrence of splenic rupture with mild blunt abdominal trauma in those recovering from infectious mononucleosis or ‘mono’ is well reported.

Diagnosis

In most settings, the initial evaluation and stabilization of traumatic injury follows the same general principles of identifying and treating immediately life-threatening injuries. In the US, the American College of Surgeons publishes the Advanced Trauma Life Support guidelines, which provide a step-by-step approach to the initial assessment, stabilization, diagnostic reasoning, and treatment of traumatic injuries that codifies this general principle. The assessment typically begins by ensuring that the subject's airway is open and competent, that breathing is unlabored, and that circulation—i.e. pulses that can be felt—is present. This is sometimes described as the "A, B, C's"—Airway, Breathing, and Circulation—and is the first step in any resuscitation or triage. Then, the history of the accident or injury is amplified with any medical, dietary (timing of last oral intake) and past history, from whatever sources such as family, friends, previous treating physicians that might be available. This method is sometimes given the mnemonic "SAMPLE". The amount of time spent on diagnosis should be minimized and expedited by a combination of clinical assessment and appropriate use of technology, such as diagnostic peritoneal lavage (DPL), or bedside ultrasound examination (FAST) before proceeding to laparotomy if required. If time and the patient's stability permits, CT examination may be carried out if available. Its advantages include superior definition of the injury, leading to grading of the injury and sometimes the confidence to avoid or postpone surgery. Its disadvantages include the time taken to acquire images, although this gets shorter with each generation of scanners, and the removal of the patient from the immediate view of the emergency or surgical staff. Many providers use the aid of a algorithm such as the ATLS guidelines to determine which images to obtain following the initial assessment. These algorithms take into account the mechanism of injury, physical examination, and patient's vital signs to determine whether patients should have imaging or proceed directly to surgery.

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John George
Journal of Trauma and Orthopedic Nursing
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