Because sometimes, the most dangerous injuries are the ones you can’t see.
The Calm Before the Collapse
Blunt abdominal trauma rarely announces itself.
There’s no arterial spray, no frantic rush to clamp a vessel. Just a quiet abdomen, a cooperative patient, and a false sense of control that fools even seasoned clinicians.
Then, without warning, the heart rate climbs, the pressure drops, and the colour drains from both the patient and the room.
Blunt trauma doesn’t shout, it deceives.
The Pathophysiology: The Energy You Don’t See
It’s all about energy transfer. What the body absorbs silently often does more damage than what’s torn apart.
Mechanisms include:
- Deceleration injuries: shearing at fixed points such as the ligamentum teres, splenic hilum, and mesenteric root. The organs may look fine; it’s the vessels and mesentery that tear.
- Compression injuries: the abdominal wall crushed against the spine, bursting solid organs and bowel.
- Blast overpressure: hollow viscera fail first, rupturing under internal stress.
- Crush injury: prolonged compression leads to tissue ischaemia, reperfusion injury, and metabolic collapse.
The result is a cocktail of haemorrhage, inflammation, and contamination, the triple threat of blunt trauma.
The High-Risk Mechanisms
- High-speed road traffic collisions
- Falls from height
- Pedestrian impact
- Handlebar or steering wheel impacts
- Crush or blast injuries
Mechanism always trumps the monitor. A normal set of observations can lull you into false security, until they don’t.
The Assessment: Where Instinct Meets Discipline
The Look
You know before you touch.
A pale, anxious, sweating patient with shallow breathing and a quiet abdomen is telling you everything you need to know, if you’re listening.
Never trust a trauma patient who “looks fine”.
Primary Survey (CABCDE)
- Catastrophic haemorrhage: look for overt and covert exsanguination
- Airway & Breathing: Always think of diaphragmatic injury, especially left-sided, it’s the great mimic.
- Circulation: Check central and peripheral pulses. The peripheries lie first.
- Disability: Confusion = shock until proven otherwise.
- Exposure: Fully undress, look for bruising, distension, or seatbelt marks.
The primary survey is not a checklist; it’s a conversation with physiology.
Secondary Survey
Palpate gently.
Guarding, distension, or localised tenderness should worry you.
Classic warning signs:
- Seatbelt sign → think hollow viscus or mesenteric tear.
- Left lower rib fractures → spleen until proven otherwise.
- Right lower rib fractures → liver or kidney.
- Epigastric tenderness → pancreas or duodenum.
- Flank bruising → retroperitoneal bleed.
The Hidden Killers: Missed Bowel Injuries in Deceleration
Deceleration injuries are subtle, and lethal when missed. The bowel tears at fixed points where it’s tethered to the posterior abdominal wall.
The five danger zones:
- Duodenojejunal flexure (Ligament of Treitz):
Shears at the junction between fixed and mobile bowel. Posterior rupture often retroperitoneal and easily missed. - Terminal ileum and ileocaecal junction:
Anchored by the ileocaecal fold, common site for blowout and mesenteric tear. - Mid-jejunum at the root of the mesentery:
Sudden deceleration causes avulsion of small mesenteric vessels, leading to ischaemia rather than immediate perforation. - Sigmoid colon at the rectosigmoid junction:
Another fixed–mobile interface, tears may be small, leading to delayed peritonitis. - Duodenum (second and third parts):
Especially from handlebar or steering wheel compression; retroperitoneal, so signs are late and misleading.
If you’re not looking for them, you will miss them. And when you do, they’ll come back, in the form of peritonitis, sepsis, and regret.
Investigations: Seeing What the Eye Can’t
FAST (Focused Assessment with Sonography for Trauma)
Quick, reliable, and repeatable.
Detects free fluid, not the source. A positive FAST in an unstable patient = theatre.
Negative FAST doesn’t mean safe; it just means the bleeding hasn’t reached the window yet.
CT Abdomen (Contrast-enhanced)
The gold standard for stable or borderline patients.
It reveals:
- Solid organ injury and grading
- Active extravasation
- Mesenteric injury
- Pneumoperitoneum without obvious organ damage → suspect bowel or mesentery
Never delay surgery for imaging when the physiology is collapsing.
Laboratory Clues
- Haemoglobin: Liar in the acute phase.
- Lactate / base deficit: The real indicators of tissue perfusion.
- Amylase / lipase: Elevated in pancreatic or duodenal trauma.
- Cross-match early: Blood saves lives; numbers don’t.
Management: Judgement Over Bravery
Unstable Patients
No delay. No debate. Straight to laparotomy.
Steps:
- Midline incision, xiphoid to pubis.
- Pack all quadrants rapidly, right, left, pelvis.
- Identify and control major bleeding.
- Liver: pack, Pringle manoeuvre, re-pack if needed.
- Spleen: splenectomy if uncontrolled.
- Mesentery: clamp, staple, move on.
- Control contamination from bowel perforations.
- If the patient is acidotic, cold, and coagulopathic → damage control surgery.
- Temporary closure, never force fascia together over oedematous bowel.
You’re saving physiology, not chasing perfection.
Stable or Borderline Patients
CT, observe, decide.
Non-operative management is suitable for:
- Haemodynamically stable
- No peritonitis
- No hollow viscus injury
- Access to interventional radiology
Monitor closely. Serial exams, repeat imaging.
Failure is not a moral defeat, it’s the nature of blunt trauma.
Hollow Viscus and Mesenteric Injuries
They’re subtle, progressive, and deadly when missed.
CT hints, free air, mesenteric streaking, unexplained fluid.
Operate early if you suspect one.
You’ll never regret an unnecessary laparotomy as much as you’ll regret a missed bowel injury.
The Second Wave: Complications
- Abdominal compartment syndrome
- Delayed bowel perforation
- Pancreatic leak or abscess
- Hepatic necrosis or bile leak
- Sepsis and multi-organ failure
The first few hours are about survival.
The next few days are about not undoing it.
Damage Control and Resuscitation
If the patient is circling the drain, stop operating.
Pack, drain, get out.
Correct physiology first:
- Warmth
- Whole blood or balanced transfusion
- Plasma and platelets early
- Calcium every 4–6 units
Return for definitive repair when pH, base deficit, and lactate recover.
The first operation stops dying. The second one starts healing.
The Philosophy of Blunt Trauma
Blunt trauma teaches humility.
It hides, waits, and punishes arrogance.
You can’t see it all. You can only suspect, respect, and stay one step ahead.
Those who keep looking after everyone else has stopped; they save the lives that statistics forget.
And From the Patient’s Side…
They’ll never know the tension in that operating theatre, or the quiet panic of a missed jejunal tear.
They won’t remember the hours of observation, or the scans, or the drip rates.
They’ll just know that somehow, they lived.
Because someone refused to be fooled by a calm abdomen.
Because you listened to the silence, and heard the truth beneath it.
