Highlights from #AAST2014 - Distracting injuries and the abdominal exam.

It appears that distracting injuries aren't really all that distracting.

THE VALIDITY OF ABDOMINAL EXAMINATION IN BLUNT TRAUMA PATIENTS WITH DISTRACTING INJURIES

Jack Rostas MD, Benjamin Cason Jon Simmons MD, Mohammad Frotan MD, Sidney Brevard MD, Richard Gonzalez* MD, University of South Alabama

Invited Discussant: Andrew Kirkpatrick, MD, CD, MHSc. .! 

Introduction:Physicians who care for blunt trauma patients often disregard abdominal clinical examination in the presence of extra-abdominal distracting injuries. Furthermore, many trauma centers mandate a computed tomography (CT) scan of the abdomen in these patients. Ignoring the clinical examination in this patient population 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 GCS of 14 or 15 were entered into a prospective study at a Level 1 Trauma Center. Abdominal clinical examination was performed and documented prospectively on all patients entered. Abdominal clinical examination consisted of subjectively questioning the patient for the presence of abdominal pain and physical examination of the abdomen. Physical examination included a four-quadrant anterior abdominal palpation, flank palpation, lower thoracic palpation, pelvis examination, and palpation of and lumbar spine. Following documentation of the clinical examination, all patients underwent CT scan of the abdomen with IV contrast.

Results: Eight hundred and three patients were enrolled during the study period. Four hundred and fifty-one patients had distracting injuries, and 352 patients had no distracting injuries. Of the 352 patients without distracting injuries, one (0.3%) patient was found to have free intra-abdominal fluid that did not require surgical intervention. Of the 451 patients with distracting injuries, 232 patients had a positive abdominal examination, 62 (26.7%) of whom had an intra-abdominal injury diagnosed by CT scan. Of the 219 patients with negative abdominal examination and distracting injuries, 7 (3.2%) were diagnosed with an intra-abdominal injury. All of the seven missed injuries were solid organ injuries, none of which required surgical intervention or blood transfusion. The sensitivity and negative predictive value of abdominal clinical examination for patients with distracting injuries was 89.9% and 96.8%, 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 diminish the efficacy of clinical abdominal examination in the diagnosis of clinically significant abdominal injury. Clinical examination of the abdomen is valid in awake and alert blunt trauma patients, regardless of the presence of other injuries.