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The validity of abdominal examination in blunt trauma patients with distracting injuries

Rostas, Jack MD; Cason, Benton MD; Simmons, Jon MD; Frotan, Mohammed A. MD; Brevard, Sidney B. MD; Gonzalez, Richard P. MD

Journal of Trauma and Acute Care Surgery: June 2015 - Volume 78 - Issue 6 - p 1095–1101
doi: 10.1097/TA.0000000000000650
AAST 2014 Plenary Papers
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BACKGROUND Many trauma care providers often disregard the abdominal clinical examination in the presence of extra-abdominal distracting injuries and mandate abdominal computed tomographic scan in these patients. Ignoring the clinical examination may incur undue expense and radiation exposure. The purpose of this study was to assess the efficacy of abdominal clinical examination in patients with distracting injuries.

METHODS During a 1-year period, all awake and alert blunt trauma patients with Glasgow Coma Scale (GCS) score of 14 or 15 were entered into a prospective study. Abdominal clinical examination was performed and documented prospectively on all patients. Abdominal clinical examination included four-quadrant anterior abdominal palpation, flank palpation, lower thoracic palpation, pelvis examination, and palpation of the thoracolumbar spine. Following examination documentation, all patients underwent computed tomographic scan of the abdomen and pelvis with intravenous contrast.

RESULTS A total of 803 patients were enrolled: 451 patients had distracting injuries, and 352 patients did not. Of the 352 patients without distracting injuries, 19 (5.4%) had intra-abdominal injuries, of whom 2 (10.5%) had negative clinical examination result. Of the 451 patients with distracting injuries, 48 (10.6%) were diagnosed with intra-abdominal injury, of whom 5 (10.4%) had negative clinical examination result. All five missed injuries in patients with distracting injuries were solid organ injuries, none of which required surgical intervention or blood transfusion. The sensitivity and negative predictive value of abdominal examination for patients with distracting injuries were 90.0% and 97.0%, respectively. The sensitivity and negative predictive value of abdominal examination for surgically significant and transfusion-requiring injuries were both 100%.

CONCLUSION Distracting injuries do not seem to diminish the efficacy of clinical abdominal examination for the diagnosis of clinically significant abdominal injury. These data suggest that clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries.

LEVEL OF EVIDENCE Diagnostic study, level III.

From the Division of Trauma and Surgical Critical Care (J.R., B.C., J.S., J.S., S.B.B.), Department of Surgery, University of South Alabama, Mobile, Alabama; Department of Surgery (M.A.F.), Texas Health Presbyterian, Dallas, Texas; and Division of Trauma, Surgical Critical Care, Burns (R.P.G.), Department of Surgery, Loyola University Medical Center, Maywood, Illinois.

Submitted: October 7, 2014, Revised: March 2, 2015, Accepted: March 9, 2015.

This study was presented at the 73rd Annual Meeting of the American Association for the Surgery of Trauma, September 9–13, 2014, in Philadelphia, Pennsylvania.

Address for reprints: Richard P. Gonzalez, MD, United States; email: rgonzalez@health.southalabama.edu.

© 2015 Lippincott Williams & Wilkins, Inc.