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Step 1: Does This Patient Need Surgery NOW?

  • Obvious penetrating injury to abdomen
  • Peritonitis
  • Hypotensive

Step 2: FAST Scan

  • Performed with bedside ultrasound machine
  • Blood/intra-peritoneal fluid is hypoechoic (black) in appearance
  • Four views required
    • Right upper quadrant
      • Probe marker points towards patient’s head
      • “Morrisons Pouch”
        • Potential space between liver and right kidney
    • Left upper quadrant
      • Probe marker towards patient’s head
      • Most difficult view to obtain
      • Potential space around spleen and between spleen and left kidney
    • Suprapubic
      • Probe marker towards patient’s head
      • Looking for thin rim of fluid between bladder wall and bowel wall
    • Subxiphoid
      • Hold probe flat and aim through liver towards heart
      • Looking for fluid around heart and evidence of cardiac tamponade

Step 3: Consider the Mechanism

  • Low risk
    • Low speed MVAs
    • Falling down only a few steps
  • High risk
    • Falling off ladder/roof
    • High velocity MVA/impact

Step 4: Perform Careful Abdominal Exam

  • Pain
  • Bruising/Seatbelt sign
  • Distension
  • Peritonitis
    • Rigidity
    • Rebound
    • Guarding

Step 5: Obtain Imaging if High Risk Mechanism or Abnormal Exam

  • CT Abdomen/Pelvis with IV contrast
  • If normal CT scan but you still have clinical concern- ADMIT
    • Serial abdominal exams
    • CT notorious for missing small bowel and diaphragmatic injuries

Additional Reading