Evaluating the Abdomen after Trauma
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þ Stabs to Abdomen
 - consider exploring in ED
 - if doesn't penetrate peritoneum, close and send home
 - if penetrates, OR vs. CT or DPL
 - most likely to damage liver
 - bowel not frequently gotten as moves out of the way
 
þ GSW to abdomen
 - more likely to injure bowel

þ Seat Belt Sign
 - seat belt-induced bruise on abdomen
 - should always CT, even if benign abdominal exam, because high incidence
   of injury.
 - often associated with viscus rupture

þ Abdominal Exams in the Elderly:
 - it is common for blood to not provoke the expected peritoneal response
 - the abdominal evaluation of the elderly can be quite impressive in the face
   of major intra-abdominal processes.  I refer you to the study by Fenyo
   where only 21% of those over the age of 70 with a perforated ulcer had
   epigastric rigidity- yowser! (Fenyo,Am J Surg 1982;143:751, prospective
   study).

þ Cullen's and Turner's Signs
 - Turner's sign is an ecchymotic discoloration of the flank.
 - Cullen's sign is periumbilical ecchymosis.
 - Both of these signs are suggestive of
   retroperitoneal hemorrhage, but they are often not seen until several days
   after the injury. Ref: Rosen p472

þ Other abdominal signs:
 - Bruising of iliac crests: insignificant
 - Kerr's sign:  pain in either shoulder referred from diaphragm
  + 20-50% of those with splenic injury will have it
  + bring out by Trendelenburg position.
 - Carnett's sign:
  + tense rectus muscle, wall problems hurt more then
  + intraabdominal problems more when relaxed
  + unreliable, no good studies.

þ Bowel sounds
 - are useless

þ Misc. notes
 - Is physical exam useful in intoxicated patients with possible abdominal
   injury?  If GCS 15, yes.
   [Perez, 1991.]
 - Serial physical exams 94% sensitive for viscus injury
   [Ulman 1996]
 - When does someone with internal injuries develop abdominal tenderness?
  + viscus injury: about 2-4 hours later
  + bleeding:  6 hours later.
 - Abdominal Injury associations:
  + shock, belly pain or tenderness, lumbar or pelvic fractures
  + nontender belly, alert, with significant chest trauma (rib fractures or worse)
  + nontender belly, alert, gross hematuria (visible)
    (if none of these, should be OK to send home)
    [Grieshop, 1995]