In a hemodynamically unstable patient with blunt abdominal trauma, is bedside ultrasound the diagnostic modality of choice?

• Level A recommendations: None specified.
• Level B recommendations: In hemodynamically unstable patients (systolic blood pressure less than or equal to 90 mm Hg) with blunt abdominal trauma, bedside ultrasound, when available, should be the initial diagnostic modality performed to identify the need for emergent laparotomy.
• Level C recommendations: None specified.

Comments: In a hemodynamically unstable patient with blunt abdominal trauma, identification of free fluid in the abdomen directly affects management. Abdominal free fluid is an indication for emergent laparotomy. Bedside ultrasound performed by a credentialed operator has been shown to have high sensitivity and specificity for identifying abdominal free fluid and has no known side effects. However, it is not useful for identification of a source of bleeding or for the evaluation of hollow viscera.

Does oral contrast improve the diagnostic performance of CT in blunt abdominal trauma?

• Level A recommendations: None specified.
• Level B recommendations: Oral contrast is not required in the diagnostic imaging for evaluation of blunt abdominal trauma (all of the studies reviewed included the use of IV contrast).
• Level C recommendations: For patients with a negative CT result with IV contrast only, in whom there is high suspicion of bowel injury, further evaluation or close follow-up is indicated.

Comments: CT scan with IV contrast has mostly replaced diagnostic peritoneal lavage as the criterion standard for identification of intra-abdominal injuries in stable blunt abdominal trauma patients. Despite some local practices to use oral contrast for patients with blunt abdominal trauma, data supporting its use are limited. In addition, the use of oral contrast may necessitate delayed imaging to allow it to transit the bowel.

In a clinically stable patient with isolated blunt abdominal trauma, is it safe to discharge the patient after a negative abdominal CT scan result?

• Level A recommendations: None specified.
• Level B recommendations: Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after a negative result for abdominal CT with IV contrast.
• Level C recommendations: Further observation, close follow-up, and/or imaging may be warranted in select patients based on clinical judgment.

Comments: With increasing ED wait times and hospital crowding, the question of ED observation time has become increasingly pertinent. The risk of delayed presentation of intra-abdominal injury with normal CT scans with IV contrast has been shown to be small. With further advances in CT scanning technology, including the widespread use of 64-slice scanners, the sensitivity of CT for identification of intra-abdominal injury is expected to increase.