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INTRODUCTION

Trauma, in its myriad patterns of injury, presents a constant battle not only within the patient but within the systems management of trauma care. Rightfully, the first priority is patient care—identifying those that need immediate invasive intervention, those that require further diagnostic information, and those that can be observed. The focus of this chapter will be abdominal trauma both from a tertiary center’s perspective and within a resource-limited environment. One must stress the importance of adhering to the Advance Trauma Life Support (ATLS) and American College of Surgeons Committee on Trauma (ACS-COT) guidelines and principles.1

In all scenarios, the therapy provided will rise to the capability of the health system. In a system with abundant resources and staff, most if not all, standards at each level of care can be met easily. However, in crisis situations the allocation of staff is a priority as is the usage of supplies needed by them.2 With a tiered response, a single credentialed specialist can guide those that are capable but unfamiliar with the nature of the inciting pathology/pandemic.2 Supporting them are physician extenders and other providers who can care for the acutely injured or critically ill.

EPIDEMIOLOGY

Currently in the United States, motor vehicle collision (occupants and pedestrians struck by vehicles) is one of the most common mechanisms of injury in blunt abdominal trauma, comprising 80% of blunt injuries. Roughly 13% of these patients will have intraperitoneal injury. Large solid organs are the most commonly injured (spleen and liver); however, all the structures should be considered for injury when examining patients.3,4 Penetrating abdominal trauma is on a decreasing trend across the country but is a significant source of mortality. Trauma is the leading cause of death in those younger than 45 and is still a significant cause of mortality in age groups above 45.5

TRIAGE AND MANAGEMENT

Penetrating injuries cause trauma via direct and indirect disruption of the traversed tissue. Blunt injury tends to be pressure against the retroperitoneal structures or shearing forces which then lead to vascular disruption and hollow viscus injury.6 Simultaneous blunt and penetrating mechanisms can be combined during one event. The triage of this patient population is often related to the severity of the mechanism of injury and the presenting physiology/pathology of the victim. It is important to note that in order to effectively triage, no one single severity index, evaluation or factor can be recommended with Grade I evidence.7 However, multiple studies focus on using a combined approach which can increase effective triage rates.8,9 An experienced clinician’s examination plus physiologic parameters can be used to effectively triage patients. The aim should be over-triaging when resources are plentiful and available. However, the tenets of ATLS—recognizing those that will succumb to their injuries no matter the timeliness of intervention from those that will benefit ...

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