Perioperative & Surgical Care

Trauma laparotomy: indications and approach

Clinical Overview and When to Suspect Need for Trauma Laparotomy

— Hemodynamic instability with positive FAST or peritoneal signs

— Penetrating abdominal wound with peritonitis, evisceration, or shock

— Gunshot wound traversing the peritoneal cavity (anterior abdomen)

— Free intraperitoneal air on imaging

— Diaphragmatic rupture

— Blood per NG tube, rectum, or GU tract in setting of penetrating injury

— Positive DPL (gross blood >10 mL, succus, bile, food)

— Blunt: high-speed MVC with lap belt sign, handlebar injury, fall from height

— Penetrating: any GSW below nipple line (T4) to gluteal fold, stab wounds violating anterior or posterior fascia

Definition: Exploratory laparotomy in trauma is a midline incision from xiphoid to pubis to identify and control intra-abdominal hemorrhage and hollow viscus injury after blunt or penetrating trauma.

Core principle: The decision to operate is driven by hemodynamics and physical exam, not by waiting for definitive imaging. A hypotensive trauma patient with a positive abdominal source goes to the OR — full stop.

Hard indications (proceed directly to OR after primary survey):

Soft/relative indications: Solid organ injury with ongoing transfusion requirement (>4 U PRBC in 6 h), failed nonoperative management, peritonitis evolving over serial exams.

Mechanisms that should heighten suspicion:

Step 3 management: In an unstable blunt trauma patient, the sequence is ABCs → FAST → if positive and unstable → OR. Do not send to CT first — CT is only for the hemodynamically stable patient.

Board pearl: "Unstable + positive FAST = laparotomy" is the single highest-yield trauma rule on Step 3. CT scanner is the "tunnel of death" for unstable patients.

CCS pearl: Early orders in the ED for a suspected hemoperitoneum patient: type & cross 6 units, activate massive transfusion protocol, two large-bore IVs, TXA within 3 hours, surgery consult STAT, NPO.

Presentation Patterns and Key History

— Restrained driver in high-speed MVC with seatbelt sign (linear ecchymosis across lower abdomen) → suspect small bowel, mesenteric, and Chance fracture (L1-L2)

— Cyclist with handlebar injury → duodenal hematoma, pancreatic transection over vertebral column

— Fall from height onto left flank → splenic laceration; right flank → hepatic injury

— Pedestrian struck → hollow viscus and solid organ combination injuries

— Stab wound: predictable trajectory, lower mortality, often amenable to local wound exploration

— GSW: unpredictable cavitation; assume multi-organ injury; small bowel (50%), colon (40%), liver (30%) most common

— Shotgun at close range: massive tissue destruction, mandatory laparotomy

— Time since injury (delayed presentation suggests contained injury or evolving peritonitis)

— Mechanism details: caliber of weapon, distance, type of object, vehicle speed, restraint use, airbag deployment

— Loss of consciousness (limits reliability of abdominal exam)

— Anticoagulant or antiplatelet use (DOACs, warfarin, clopidogrel — escalate trigger for imaging and reversal)

— Last meal (aspiration risk at intubation), tetanus status, allergies

Blunt abdominal trauma scenarios:

Penetrating patterns:

History elements that change management:

AMPLE history: Allergies, Medications, Past illnesses, Last meal, Events — the trauma mnemonic for rapid bedside history.

Key distinction: A reliable abdominal exam requires an awake, sober, non-distracted patient without spinal cord injury. Intoxication, head injury, intubation, and distracting injuries (long bone fracture) all mandate imaging or serial exams even if initial exam is benign.

Board pearl: Seatbelt sign + lumbar Chance fracture has up to a 50% association with small bowel perforation — get CT with PO/IV contrast and have a low threshold for laparotomy if free fluid without solid organ injury is seen.

Step 3 management: On anticoagulants? Reverse immediately — 4-factor PCC for warfarin/factor Xa inhibitors, idarucizumab for dabigatran, andexanet alfa for apixaban/rivaroxaban if available, plus vitamin K for warfarin.

Physical Exam Findings and Hemodynamic Assessment

— Class I (<15% loss, <750 mL): normal vitals

— Class II (15-30%): tachycardia, narrowed pulse pressure, anxiety

— Class III (30-40%): hypotension, tachycardia >120, confusion — transfuse blood

— Class IV (>40%): obtundation, profound hypotension — emergent OR

— Peritonitis: rebound, guarding, rigidity

— Evisceration of omentum or bowel

— Impaled object (do not remove in ED — remove in OR)

— Expanding abdominal wall hematoma

— Cullen sign (periumbilical) or Grey Turner sign (flank) — retroperitoneal bleeding

— Distention with hypotension — massive hemoperitoneum

— Rectal exam: blood = bowel injury; high-riding prostate = urethral injury (delay Foley)

— Perineal/scrotal hematoma: pelvic fracture

— Auscultate chest: absent breath sounds on left with bowel sounds = diaphragmatic rupture with herniation

— Responders: sustained improvement after 1-2 L crystalloid → likely stable, can proceed to CT

— Transient responders: improve then deteriorate → likely ongoing bleeding → OR or angio

— Non-responders: persistent hypotension despite resuscitation → immediate OR

Primary survey (ATLS): Airway, Breathing, Circulation, Disability, Exposure — abdomen is assessed under "C" because it is a major hemorrhage cavity along with chest, pelvis, retroperitoneum, and long bones ("blood on the floor and four more").

Hemodynamic classification of hemorrhagic shock:

Abdominal exam findings demanding laparotomy:

Adjunct exam pearls:

Hemodynamic responders define triage:

Key distinction: Hypotension in trauma is hemorrhagic until proven otherwise. Neurogenic shock (bradycardia + warm extremities) and tension pneumothorax must be excluded but do not delay laparotomy when intra-abdominal source is identified.

CCS pearl: Order continuous BP, HR, SpO2, end-tidal CO2 if intubated; insert Foley (after rectal exam) to track urine output >0.5 mL/kg/h as resuscitation endpoint; place NG tube for gastric decompression pre-laparotomy.

Diagnostic Workup — Initial Labs, FAST, and Bedside Imaging

— Type and crossmatch (6 units PRBC minimum for hemodynamic instability)

— CBC: initial hemoglobin may be falsely normal in acute hemorrhage; trend it

— BMP, lactate, base deficit — markers of shock; lactate >4 or base deficit <−6 predicts need for massive transfusion

— Coagulation panel (PT/INR, aPTT, fibrinogen) and TEG/ROTEM if available

— ABG, βhCG in women of childbearing age, ethanol, UA (gross hematuria → GU injury workup)

— Troponin and ECG if blunt chest trauma

— Four views: perihepatic (Morison pouch), perisplenic, pelvic (pouch of Douglas/rectovesical), pericardial (subxiphoid)

— Detects free fluid as little as 200 mL; sensitive but not specific for blood

— Cannot reliably detect hollow viscus injury, retroperitoneal bleed, or diaphragmatic injury

— eFAST adds anterior thoracic views for pneumothorax and hemothorax

— Unstable + positive FAST → OR for laparotomy

— Unstable + negative FAST → look elsewhere (chest, pelvis, external, neurogenic); consider DPL or repeat FAST

— Stable + positive FAST → CT to characterize

— Stable + negative FAST → CT if mechanism warrants, otherwise serial exams

Labs to send on arrival:

FAST (Focused Assessment with Sonography for Trauma):

Decision tree from FAST:

DPL (diagnostic peritoneal lavage): Largely replaced by FAST and CT, but still useful when FAST equivocal in unstable patient. Positive if >10 mL gross blood, >100,000 RBC/μL, >500 WBC/μL, bile, bacteria, or food.

Chest and pelvic X-rays: Mandatory in blunt trauma — identify pneumothorax, hemothorax, free air under diaphragm, pelvic fracture (source of massive hemorrhage).

Board pearl: FAST is operator-dependent; obesity, subcutaneous air, and prior abdominal surgery reduce sensitivity. A negative FAST in an unstable patient does not rule out abdominal hemorrhage — consider DPL or empiric laparotomy.

Step 3 management: Activate massive transfusion protocol (1:1:1 PRBC:FFP:platelets) when >4 units anticipated in first hour or ABC score ≥2 (penetrating mechanism, SBP <90, HR >120, positive FAST).

Diagnostic Workup — CT and Confirmatory Studies

— Grades solid organ injury (AAST scale I-V for liver, spleen, kidney)

— Identifies active extravasation ("contrast blush") → angioembolization candidate

— Detects retroperitoneal hematoma, pancreatic injury, bowel wall thickening, mesenteric stranding

— Triple contrast (IV + PO + rectal) historically used for penetrating flank/back wounds; now IV alone often sufficient with modern multidetector CT

— Pneumoperitoneum (free air)

— Free fluid without solid organ injury → presumed hollow viscus injury

— Active contrast extravasation not amenable to angio

— Bowel wall discontinuity, mesenteric hematoma with active bleeding

— Diaphragmatic rupture

— Pancreatic ductal disruption (Grade III+)

— CT cystogram for suspected bladder rupture (pelvic fracture + gross hematuria)

— Retrograde urethrogram before Foley if blood at meatus or high-riding prostate

— CT angiography for vascular injury suspicion

— MRCP/ERCP for delayed pancreatic ductal evaluation

CT abdomen/pelvis with IV contrast is the gold standard for the hemodynamically stable trauma patient:

Findings that mandate or strongly favor laparotomy on CT:

Local wound exploration (LWE): For anterior abdominal stab wounds in stable patients — if anterior fascia is violated, proceed to CT or laparoscopy; if intact, discharge after observation.

Diagnostic laparoscopy: Increasingly used for stable penetrating injuries (especially left thoracoabdominal stab wounds) to evaluate diaphragm and peritoneal violation. Lower negative laparotomy rate.

Adjunct studies:

Key distinction: Free fluid without solid organ injury on CT in blunt trauma is a hollow viscus injury until proven otherwise — these patients need laparotomy or close serial exam with surgical consultation, not discharge.

Board pearl: Pancreatic and duodenal injuries are notoriously missed on initial CT. Persistent epigastric pain, elevated amylase/lipase 6-12 hours post-injury, or retroperitoneal air mandates repeat imaging or operative exploration.

Step 3 management: Splenic injury with contrast blush in a stable patient → IR for angioembolization, ICU admission, serial hemoglobin q6h, bed rest. Failure of nonop management (ongoing transfusion, hemodynamic deterioration) → laparotomy.

Risk Stratification and Operative Decision Logic

— 1. Is the patient hemodynamically stable? If no → OR or immediate intervention.

— 2. Is there peritonitis or hard sign of injury? If yes → OR.

— 3. Can the patient be reliably examined? If no → imaging and serial exams.

— Gunshot wound to abdomen: Mandatory laparotomy if peritoneal violation suspected (>80% have significant injury). Selective nonoperative management only for tangential wounds in stable patients at experienced centers.

— Stab wound: Selective management — laparotomy only for hemodynamic instability, peritonitis, evisceration, or clear peritoneal violation. Otherwise serial exams ± CT ± laparoscopy.

— Unstable + positive FAST → OR

— Stable → CT → grade injury → nonoperative management for most solid organ injuries (especially spleen and liver) if no active extravasation requiring surgery

— Hypothermia <35°C

— Acidosis pH <7.2 or base deficit <−8

— Coagulopathy (INR >1.5, clinical oozing)

— Plus: massive transfusion >10 units, inability to close abdomen, need for vascular shunting

The "three-question" trauma triage:

Penetrating trauma algorithm:

Blunt trauma algorithm:

Damage control surgery indications (the "lethal triad" → abbreviated laparotomy):

Damage control sequence: Control hemorrhage → control contamination (staple bowel ends, no anastomoses) → temporary abdominal closure (Bogota bag or wound vac) → ICU rewarming, correction of coagulopathy → return to OR in 24-48 h for definitive repair.

Board pearl: Damage control is about physiology over anatomy — stop the bleeding and contamination, then leave. Definitive reconstruction kills cold, acidotic, coagulopathic patients.

Step 3 management: In a transient responder with positive FAST, do not delay for CT — the patient is bleeding faster than you can resuscitate. Move to OR while transfusing 1:1:1.

CCS pearl: Order arterial line, central venous access (femoral or subclavian — avoid IJ if cervical collar), Foley, NG, warming blanket, fluid warmer, and call OR before the patient leaves the trauma bay.

Pharmacotherapy — Resuscitation, Antibiotics, and Adjuncts

— Initial: 1 L warmed lactated Ringer's (avoid large-volume saline → hyperchloremic acidosis)

— Transition rapidly to blood products if no response or class III/IV shock

— Massive transfusion protocol: 1:1:1 ratio PRBC:FFP:platelets, mimicking whole blood

— Goal: permissive hypotension (SBP 80-90 mmHg) until hemorrhage control, except in TBI where MAP ≥80 is required

— 1 g IV over 10 min, then 1 g over 8 h

— Must be given within 3 hours of injury (CRASH-2 trial)

— Reduces mortality from hemorrhage; harmful if given late

— Citrate in transfused blood chelates calcium → hypocalcemia worsens coagulopathy and cardiac function

— Give 1 g calcium gluconate or chloride per 4 units PRBC; monitor ionized calcium

— Warfarin: 4-factor PCC (25-50 U/kg) + vitamin K 10 mg IV

— Dabigatran: idarucizumab 5 g IV

— Apixaban/rivaroxaban: andexanet alfa or 4-factor PCC

— Antiplatelets: platelet transfusion (controversial, limited benefit except neurosurgical bleeding)

— Pre-incision: cefoxitin or cefazolin + metronidazole for broad coverage of gut flora

— Penetrating abdominal trauma with hollow viscus injury: 24 h post-op antibiotics (longer not beneficial, increases resistance)

— No hollow viscus injury at exploration: single pre-op dose sufficient

Resuscitation fluids:

Tranexamic acid (TXA):

Calcium replacement:

Reversal of anticoagulants:

Prophylactic antibiotics:

Tetanus prophylaxis: Td or Tdap if >5 years since last dose; add TIG for high-risk wounds in incompletely vaccinated patients.

Analgesia and sedation: Fentanyl preferred (hemodynamic neutrality); avoid morphine (histamine, hypotension) in unstable patients. Ketamine is useful induction agent for hypotensive RSI.

VTE prophylaxis: Hold until hemorrhage controlled; restart LMWH within 24-48 h post-op if stable. Mechanical SCDs in interim.

Board pearl: TXA after 3 hours increases mortality — the window matters. Document time of injury, not time of arrival.

Step 3 management: For hemorrhagic shock, the resuscitation order is blood, not crystalloid after the first liter. Persistent crystalloid worsens coagulopathy, dilutes clotting factors, and increases ARDS risk.

Operative Approach — The Trauma Laparotomy Itself

— 1. Control hemorrhage first (pack, clamp, compress aorta at hiatus if needed)

— 2. Control contamination (staple/clamp bowel injuries)

— 3. Systematic survey: liver/diaphragm → spleen → stomach → small bowel from ligament of Treitz to ileocecal valve → colon → pelvis → retroperitoneum (Kocher maneuver for duodenum, mattox/cattell-braasch for vascular)

— Liver: Pringle maneuver (clamp portal triad ≤30 min), perihepatic packing, hepatic artery ligation, atriocaval shunt for retrohepatic IVC

— Spleen: splenectomy (most common in unstable) or splenorrhaphy if stable

— Pelvis: preperitoneal packing, REBOA (Zone III), external fixator

— Aorta/IVC: direct repair, shunt, or ligation depending on level

— Small bowel: primary repair if <50% circumference; resection with anastomosis for larger

— Colon: primary repair or resection with anastomosis in stable patients; diversion (colostomy) in damage control, gross contamination, or shock

— Duodenum: primary repair, pyloric exclusion, or trauma Whipple (rare)

Positioning and prep: Supine, arms out, prep chin to mid-thigh, nipples to table laterally — allows extension into chest or groin if needed.

Incision: Generous midline xiphoid-to-pubis incision — fast, bloodless, extensible. Avoid Pfannenstiel or transverse incisions in trauma.

Four-quadrant packing: Immediately on entry, pack all four quadrants with laparotomy pads to tamponade bleeding while anesthesia catches up with resuscitation.

Systematic exploration (the "trauma run"):

Hemorrhage control techniques:

Bowel injury management:

REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta): Adjunct for non-compressible torso hemorrhage; Zone I for abdominal bleeding, Zone III for pelvic. Bridge to definitive control, not a cure.

Temporary abdominal closure: Indicated for damage control, planned re-look, or abdominal compartment syndrome risk. Options: vacuum-assisted (ABThera), Bogota bag.

Board pearl: The order is always hemorrhage → contamination → reconstruction. Never attempt a complex anastomosis in a cold, coagulopathic patient.

CCS pearl: Post-op orders: ICU admission, ventilator, continued resuscitation to lactate clearance, q1h Hgb until stable, monitor bladder pressure q4h for abdominal compartment syndrome (>20 mmHg with organ dysfunction = decompression).

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher mortality at every injury severity score — physiologic reserve is limited

— Normal vital signs are misleading: HR 90 may represent tachycardia in a beta-blocked elder; SBP 110 may be relative hypotension in a chronic hypertensive

— Lower threshold for trauma activation, imaging, and ICU admission

— Triage trigger: age >65 with any mechanism warrants trauma team activation per ACS guidelines

— Anticoagulation use is near-universal — assume DOAC or warfarin until proven otherwise; reverse early

— Frailty and sarcopenia delay weaning, increase pneumonia and delirium

— Rib fractures: each additional rib fracture in elderly increases mortality ~19%; aggressive analgesia (epidural, multimodal) prevents pneumonia

— Falls from standing can cause significant intra-abdominal injury — do not dismiss low-energy mechanisms

— Avoid iodinated contrast if possible; if CT essential, accept risk and treat AKI after (life > kidney in trauma)

— Adjust antibiotic dosing post-op (cefoxitin, vancomycin)

— Avoid NSAIDs for analgesia

— Monitor for rhabdomyolysis (crush injury) → CK >5000, aggressive IV fluids, alkalinize urine

— Baseline coagulopathy and thrombocytopenia worsen trauma outcomes

— Ascites complicates abdominal exam and FAST interpretation (pre-existing free fluid)

— Higher risk of hepatic injury bleeding due to portal hypertension and varices

— Albumin and synthetic function affect drug binding and wound healing

— Fentanyl preferred over morphine in both renal and hepatic disease

— Avoid acetaminophen >2 g/day in cirrhotics

— LMWH requires renal dosing (enoxaparin 30 mg daily if CrCl <30); consider UFH instead

Geriatric trauma considerations:

Common geriatric pitfalls:

Renal impairment:

Hepatic impairment:

Pharmacologic adjustments:

Board pearl: A normotensive elderly trauma patient on a beta-blocker may already be in shock. Use lactate, base deficit, and urine output as truer markers of perfusion than vital signs alone.

Step 3 management: Elderly trauma patient on warfarin with positive head CT or expanding abdominal hematoma → reverse INR with 4-factor PCC + vitamin K immediately, do not wait for FFP infusion.

Special Populations — Pregnancy and Pediatrics

— Leading cause of non-obstetric maternal death; MVC and intimate partner violence are top mechanisms (screen routinely)

— Resuscitate the mother to save the fetus — the best fetal therapy is maternal resuscitation

— Left lateral decubitus tilt (15°) after 20 weeks to relieve IVC compression

— Physiologic changes: HR baseline +15-20, BP −10/−15, plasma volume +50% → blood loss masked until 30-35% volume lost

— FAST is first-line — no radiation

— CT if indicated — do not withhold; fetal dose from a single CT abdomen ~25 mGy, well below teratogenic threshold (100 mGy)

— Shield when possible but never delay diagnosis for radiation concerns

— Placental abruption: vaginal bleeding, uterine tenderness, contractions, fetal distress; monitor with continuous CTG for ≥4 h (24 h if any abnormality) after blunt abdominal trauma >20 weeks

— Uterine rupture: rare, catastrophic; requires emergent laparotomy

— Rh-negative mothers: administer RhoGAM within 72 h of any abdominal trauma

— Perimortem cesarean section: within 4-5 min of maternal arrest if fetus ≥23-24 weeks

— Anatomy: thin abdominal wall, less protective fat, proportionally larger solid organs → higher rate of solid organ injury from blunt trauma

— Larger head, smaller airway, faster decompensation but better physiologic reserve until sudden collapse

— Nonoperative management is the default for hemodynamically stable solid organ injuries (spleen, liver, kidney) — success rates >90%

— Vital sign normals are age-dependent; use Broselow tape for dosing

— Handlebar injuries → pancreatic and duodenal injuries; high index of suspicion

— Mandatory reporting if abuse suspected (inconsistent history, delayed presentation, patterned bruising, retinal hemorrhages, multiple healing fractures)

Pregnant trauma patient:

Imaging in pregnancy:

Specific pregnancy injuries:

Pediatric trauma:

Non-accidental trauma:

Board pearl: Kleihauer-Betke test in Rh-negative pregnant trauma patients quantifies fetomaternal hemorrhage and determines if additional RhoGAM is needed beyond standard 300 μg dose.

Step 3 management: Pregnant trauma >20 weeks: notify OB immediately, continuous fetal monitoring ≥4 h, RhoGAM if Rh−, left lateral tilt, do not delay imaging.

Complications and Adverse Outcomes

— Massive transfusion sequelae: hypothermia, hyperkalemia, hypocalcemia, dilutional coagulopathy, TRALI, TACO

— Missed injuries: most commonly duodenum, pancreas, diaphragm, mesenteric, ureter — second-look laparotomy at 24-48 h reduces missed injury mortality

— Abdominal compartment syndrome (ACS): Bladder pressure >20 mmHg with new organ dysfunction (oliguria, elevated peak airway pressures, hypotension) → decompressive laparotomy. Risk highest after massive resuscitation, damage control, or tight closure.

— Recurrent hemorrhage: tachycardia, falling Hgb, increasing pressor requirement → return to OR or angio

— Anastomotic leak: fever, ileus, peritonitis post-op day 3-7 → CT with contrast, return to OR

— Intra-abdominal abscess: post-op day 5-10, fever, leukocytosis, tender mass → CT-guided drainage

— ARDS from massive transfusion, aspiration, fat emboli — lung-protective ventilation (6 mL/kg IBW, PEEP titration, plateau <30)

— Pneumonia: VAP prevention bundles, early extubation when feasible

— Surgical site infection: 20-40% in colon injury; lower with primary closure of contaminated skin avoidance

— Sepsis from missed hollow viscus injury or anastomotic leak

— VTE: trauma patients are hypercoagulable; restart LMWH within 24-48 h if bleeding controlled

— Heparin-induced thrombocytopenia in prolonged ICU stays

— Incisional hernia (10-20%, higher with damage control and open abdomen)

— Adhesive small bowel obstruction

— Post-traumatic stress disorder — screen and refer

— Post-splenectomy: lifelong risk of overwhelming post-splenectomy infection (OPSI) from encapsulated organisms

Intraoperative complications:

Early postoperative complications:

Pulmonary:

Infectious:

Hematologic:

Late complications:

Board pearl: Post-splenectomy vaccinations before discharge (or at 14 days post-op for optimal response): pneumococcal (PCV20 or PCV15+PPSV23), meningococcal (MenACWY + MenB), and Hib. Annual influenza vaccine.

Step 3 management: A trauma laparotomy patient with rising peak airway pressures, oliguria, and tense abdomen on POD 1 = abdominal compartment syndrome — measure bladder pressure, prepare for emergent bedside decompression.

When to Escalate Care — ICU, Consults, and Transfer

— All damage control patients (open abdomen, ongoing resuscitation)

— Massive transfusion (>10 units PRBC in 24 h)

— Mechanical ventilation requirement

— Vasopressor dependence

— Coagulopathy, hypothermia, or persistent acidosis

— Multiple injuries requiring serial reassessment

— Trauma/acute care surgery: primary team

— Vascular surgery: major vascular injury, REBOA placement

— Orthopedics: pelvic ring injuries, open fractures

— Neurosurgery: concomitant TBI or spinal injury

— Interventional radiology: solid organ contrast blush, pelvic angioembolization

— Urology: GU injury, bladder/urethral repair

— OB: pregnant patient >20 weeks

— Cardiothoracic: thoracoabdominal injury, diaphragmatic rupture with major chest involvement

— Penetrating injuries beyond local capability

— Need for pediatric trauma expertise

— Burn center criteria (per ABA)

— Limb-threatening vascular injury without vascular surgery available

— Concomitant major TBI without neurosurgery

— Stabilize first: secure airway, control external hemorrhage, start blood products, place chest tubes if needed

— Do not delay transfer for non-essential imaging at sending facility

— Send all imaging, labs, and procedure notes electronically or with patient

— Direct physician-to-physician handoff to receiving trauma surgeon

ICU admission criteria post-trauma laparotomy:

Specialist consults to consider:

Transfer to higher-level trauma center (ACS Level I or II):

Inter-facility transfer principles:

Step 3 management: Use the EMTALA-compliant transfer process — stabilize within capability, document medical necessity, obtain accepting physician, copy of records with patient, appropriate level of transport (ALS with critical care RN for unstable trauma).

Board pearl: A community ED stabilizing a GSW abdomen should not waste time on CT before transfer if the patient is unstable — the receiving Level I center will repeat imaging or proceed directly to OR. "Stabilize and ship" beats "scan and stall."

CCS pearl: When transferring, orders should include: type O-negative blood × 2 units in transit, TXA if within window, IV antibiotics started, tetanus updated, Foley placed, NG tube to suction, family notified.

Key Differentials — Same-Category Causes (Abdominal Trauma Mimics and Source Localization)

— Splenic injury: Most commonly injured solid organ in blunt trauma. LUQ pain, left shoulder pain (Kehr sign from diaphragmatic irritation), positive FAST in LUQ. AAST grades I-V.

— Hepatic injury: Most commonly injured organ in penetrating trauma; second in blunt. RUQ pain, often associated with right rib fractures. Bleeding can be massive (hepatic veins, retrohepatic IVC).

— Renal injury: Flank pain, hematuria. Most managed nonoperatively; surgery for shattered kidney or ureteropelvic disruption.

— Pancreatic injury: Epigastric pain, elevated lipase 6-12 h post-injury. Grade III+ (ductal disruption) needs distal pancreatectomy or drainage.

— Small bowel perforation: Seatbelt sign, free air on imaging, peritonitis. Often delayed presentation 12-24 h.

— Colonic injury: More common in penetrating; primary repair vs. diversion based on shock, contamination, and damage control status.

— Duodenal injury: Retroperitoneal location → subtle presentation; "double bubble" sign, retroperitoneal air on CT.

— Gastric injury: Most penetrating; blood in NG tube; primary repair usually possible.

— Aortic injury (rare in blunt abdomen, more common thoracic)

— IVC injury — retrohepatic injuries among the most lethal

— Mesenteric vessel injury — bowel ischemia if missed

— Zone I (central): explore in blunt or penetrating — vascular injury

— Zone II (lateral/flank): explore if penetrating or expanding; observe if stable blunt

— Zone III (pelvic): do not open in blunt — pelvic packing, angioembolization; explore if penetrating

When evaluating intra-abdominal hemorrhage or peritonitis after trauma, consider these intra-abdominal sources:

Solid organ injuries:

Hollow viscus injuries:

Vascular injuries:

Mesenteric and omental injuries: Mesenteric hematoma with active extravasation requires exploration; isolated stable hematomas may be observed.

Diaphragmatic rupture: Left more common (right protected by liver). Bowel sounds in chest, NG tube curling into thorax on CXR. Mandatory surgical repair.

Retroperitoneal hematoma zones:

Key distinction: Free fluid without solid organ injury on CT = hollow viscus injury until proven otherwise. This is one of the most tested concepts in trauma imaging.

Board pearl: Kehr sign (left shoulder pain from diaphragmatic irritation by splenic blood) is classic — it indicates intraperitoneal blood, not necessarily splenic origin specifically.

Key Differentials — Other-Category Causes (Non-Abdominal Sources of Shock)

— Tension pneumothorax: tracheal deviation, absent breath sounds, JVD → needle decompression (5th ICS, anterior axillary line per updated ATLS), then chest tube

— Cardiac tamponade: muffled heart sounds, JVD, hypotension (Beck triad); positive pericardial FAST → pericardiotomy or pericardiocentesis

— Neurogenic shock: spinal cord injury above T6 → hypotension with bradycardia and warm extremities; treat with fluids, then vasopressors (norepinephrine)

— Cardiogenic shock: blunt cardiac injury, MI precipitating the trauma → ECG, troponin, echo

— Air embolism, fat embolism: rare but consider with appropriate mechanism

When the trauma patient is hypotensive, intra-abdominal hemorrhage is one of five major sources — work through the differential systematically using "blood on the floor and four more":

1. External hemorrhage ("on the floor"): Scalp lacerations, open extremity wounds, junctional hemorrhage. Apply direct pressure, tourniquets, hemostatic gauze.

2. Chest: Hemothorax (each pleural cavity holds 3-4 L), tension pneumothorax (obstructive, not hemorrhagic, but mimics), cardiac tamponade (Beck triad). eFAST and CXR identify quickly. Chest tube for hemothorax; pericardiocentesis or thoracotomy for tamponade.

3. Abdomen: As discussed — FAST, CT, or operative exploration.

4. Pelvis: Pelvic ring fractures can sequester >2 L of blood. Pelvic binder, angioembolization, preperitoneal packing. Pelvic fracture + hypotension is a major killer.

5. Long bones (especially femur): Each femur fracture can lose 1-2 L; bilateral femur fractures with hypotension are common. Splint, traction, fix early.

Non-hemorrhagic causes of post-trauma hypotension:

Anaphylaxis from contrast or medications: can occur during resuscitation; epinephrine if suspected.

Adrenal insufficiency: rare acute trauma cause, but consider in patients on chronic steroids — give stress-dose hydrocortisone 100 mg IV.

Key distinction: Neurogenic shock (warm, dry, bradycardic) is the only shock state in trauma where the patient is hypotensive but not tachycardic. Hemorrhage with cervical cord injury can coexist — never assume neurogenic shock until hemorrhage excluded.

Board pearl: A trauma patient with persistent hypotension despite a negative FAST, normal CXR, and stable pelvis is hiding bleeding — repeat FAST, look at the long bones, consider retroperitoneal source, and get CT once stable enough.

Post-Discharge Plan, Secondary Prevention, and Long-Term Care

— Analgesia: multimodal (acetaminophen scheduled, NSAIDs if no renal/bleeding concern, short-course opioids with clear taper and PDMP check)

— VTE prophylaxis: continue LMWH 2-4 weeks if mobility limited or high-risk injury

— Bowel regimen: stool softeners and laxatives to prevent opioid-induced constipation

— Antibiotics: typically not continued post-discharge unless intra-abdominal abscess or infection identified

— Antiulcer prophylaxis: PPI during hospitalization, taper at discharge unless other indication

— Vaccinations (if not given in hospital): pneumococcal (PCV20 or PCV15+PPSV23), meningococcal ACWY and B, Hib; annual influenza; COVID-19 boosters

— Standby antibiotics: amoxicillin-clavulanate or levofloxacin to take at first sign of fever pending evaluation

— Medic-alert bracelet identifying asplenic status

— Patient education: OPSI risk for life; seek care for any fever; malaria prophylaxis if traveling

— Stoma nurse education before discharge

— Reversal typically planned at 3-6 months once nutritional and physiologic status optimized

— Midline incision: monitor for SSI, dehiscence; abdominal binder for comfort

— Open abdomen patients: complex wound care, eventual ventral hernia repair

— No heavy lifting (>10 lb) for 6 weeks

— No driving while on opioids

— Gradual return to work depending on occupation

— Seatbelt use, helmet use, safe storage of firearms

— Substance use screening (SBIRT — Screening, Brief Intervention, Referral to Treatment) — alcohol involved in ~50% of trauma; brief intervention reduces recurrence

— Intimate partner violence screening, especially if mechanism suspicious

— Fall risk assessment in elderly: home safety, vision, medication review

— Screen for PTSD, depression, anxiety at follow-up

— Refer to trauma recovery programs

Discharge medications after trauma laparotomy:

Post-splenectomy long-term plan:

Post-colostomy/ileostomy care:

Wound care:

Activity restrictions:

Injury prevention counseling (secondary prevention):

Mental health:

Step 3 management: Every trauma admission is an opportunity for SBIRT — alcohol-positive patients should receive brief intervention before discharge; this is evidence-based, billable, and reduces re-injury.

Board pearl: Post-splenectomy vaccinations should ideally be given 14 days post-op for optimal immune response, but if the patient may be lost to follow-up, vaccinate before discharge — partial protection beats none.

Follow-Up, Monitoring, and Rehabilitation

— Trauma/surgery clinic: 2 weeks for wound check and pathology review

— 6 weeks: activity restriction lift, hernia assessment, return-to-work clearance

— 3 months: imaging follow-up for solid organ injuries (CT for splenic pseudoaneurysm screening if high-grade injury managed nonoperatively)

— 6 months: ostomy reversal planning if applicable

— Splenic injury managed nonoperatively: repeat imaging at 1-2 weeks for pseudoaneurysm; gradual return to contact sports at 6-8 weeks for high-grade injuries

— Hepatic injury: LFTs; rare bile leak presents as fever and abdominal pain — HIDA scan or ERCP

— Pancreatic injury: lipase trend, monitor for pseudocyst (presents weeks later with mass, pain, early satiety)

— Renal injury: UA, BP monitoring (post-traumatic hypertension), follow-up imaging at 3 months

— Bowel anastomosis: monitor for stricture, anastomotic complications

— Physical therapy for deconditioning, especially after prolonged ICU stay

— Occupational therapy for ADLs

— Nutrition consultation: catabolic state after major trauma; protein 1.5-2 g/kg/day, micronutrients, possibly enteral supplementation

— Pulmonary rehab if prolonged ventilation or rib fractures

— PTSD screening at 1 month and 3 months (PCL-5 instrument)

— Depression and anxiety screening (PHQ-9, GAD-7)

— Substance use follow-up if SBIRT initiated

— Social work referral for housing, finances, return to work

— Resume routine cancer screening, vaccinations, chronic disease management

— Coordinate with PCP — trauma admission is often a missed prevention opportunity

— Glasgow Outcome Scale, FIM scores, return to work, quality of life measures

— Significant percentage of major trauma survivors do not return to baseline function — set realistic expectations

Outpatient follow-up cadence:

Specific monitoring needs:

Rehabilitation:

Psychosocial:

Health maintenance restart:

Functional recovery metrics:

Key distinction: Nonoperative management of solid organ injury is not the same as no follow-up. Splenic pseudoaneurysm can rupture days to weeks later — repeat imaging is essential for high-grade injuries.

Step 3 management: At the 2-week post-op visit, address: wound, pain control taper, VTE prophylaxis completion, vaccinations if asplenic, mental health screening, return-to-activity plan, and PCP handoff for chronic disease resumption.

Ethical, Legal, and Patient Safety Considerations

— Implied consent applies to unconscious or incapacitated trauma patients requiring emergent life-saving surgery — no formal consent required, document the emergency rationale

— For awake, competent patients, obtain consent even when urgent; if surrogate available, use them; document decision-making capacity

— Jehovah's Witnesses: respect blood refusal in competent adults even at risk of death; document discussion; explore bloodless options (cell saver, factor concentrates, iron, EPO); minor children of JW parents may receive court-ordered transfusion if life-threatening

— Gunshot and stab wounds: report to law enforcement in nearly all U.S. states

— Child abuse, elder abuse, intimate partner violence: mandatory reporting varies by state but child and elder abuse are universally reportable

— Document objective findings; you do not need to be certain of abuse to report — reasonable suspicion suffices

— Failure to report is a legal and ethical violation

— Clothing collected and bagged (paper, not plastic — preserves DNA)

— Bullets removed from tissue handled with care, no metal-on-metal contact, given to law enforcement with chain of custody

— Photograph injuries with consent or per institutional policy

— In catastrophic injuries (e.g., devastating TBI with non-survivable abdominal injury), early goals-of-care discussions with family; involve palliative care

— Organ donation: notify organ procurement organization for any imminent death; do not discuss donation with family — that is OPO role

— Handoffs are the highest-risk patient safety moment in trauma; use structured tools (I-PASS, SBAR)

— Tertiary survey within 24 h to catch missed injuries (10-20% of multi-trauma patients have missed injuries on initial survey)

— Medication reconciliation at admission, transfer, and discharge — anticoagulants, beta-blockers, immunosuppressants must be addressed

Informed consent in trauma:

Mandatory reporting:

Evidence preservation:

End-of-life and futility:

Transition-of-care safety:

Step 3 patient safety pearl: The tertiary survey — a head-to-toe re-examination within 24 hours of admission — is a mandatory patient safety practice to catch occult injuries missed during the chaotic primary and secondary surveys. Always documented; tested on Step 3.

Board pearl: A trauma patient who refuses surgery while clearly intoxicated, hypoxic, or in shock does not have capacity — proceed with emergent surgery under implied consent and document carefully.

Health systems pearl: Level I trauma centers have lower mortality than lower-level centers for severe trauma — appropriate triage and transfer is a system-level patient safety intervention.

High-Yield Associations and Rapid-Fire Clinical Facts

— Peritonitis

— Evisceration

— Gunshot wound traversing peritoneum

— Free air on imaging

— Anemia/hemodynamic instability + positive FAST

— Shock with abdominal source

— Transrectal/transurethral blood

— Blunt: spleen (1st), liver (2nd), kidney (3rd)

— Penetrating stab: liver, small bowel, diaphragm

— Penetrating GSW: small bowel, colon, liver

— Kehr sign: left shoulder pain = splenic injury/diaphragmatic blood

— Cullen sign: periumbilical bruising = retroperitoneal/intraperitoneal bleeding

— Grey Turner sign: flank bruising = retroperitoneal hemorrhage

— Seatbelt sign: linear abdominal ecchymosis = small bowel/mesenteric injury, Chance fracture

— Balance sign: dullness in LUQ from splenic hematoma

Trauma laparotomy hard indications mnemonic — "PEG-FAST":

Most commonly injured organs:

Signs and their associations:

Lethal triad of trauma: hypothermia, acidosis, coagulopathy — drives damage control surgery decision.

Massive transfusion ratio: 1:1:1 (PRBC:FFP:platelets); add cryoprecipitate if fibrinogen <150.

TXA window: within 3 hours of injury; 1 g over 10 min, then 1 g over 8 h.

FAST views: RUQ (Morison), LUQ (perisplenic), pelvis (Douglas/rectovesical), pericardial (subxiphoid).

Pringle maneuver: clamps portal triad (portal vein, hepatic artery, common bile duct) at foramen of Winslow — used for liver bleeding, max 30 min warm ischemia.

Cattell-Braasch maneuver: mobilizes right colon and small bowel mesentery for IVC and right retroperitoneum exposure.

Mattox maneuver: left medial visceral rotation for aortic exposure.

Kocher maneuver: mobilizes duodenum for retroperitoneal duodenal and pancreatic head exposure.

REBOA zones: Zone I (above celiac) for abdominal, Zone III (infrarenal) for pelvic; Zone II not used.

Pediatric NOM success: >90% for splenic and hepatic injuries in stable children.

Post-splenectomy vaccines: pneumococcal, meningococcal (ACWY + B), Hib; ideally 14 days post-op.

Abdominal compartment syndrome threshold: bladder pressure >20 mmHg + new organ dysfunction.

Board pearl: A negative FAST does not rule out abdominal hemorrhage — it has ~80% sensitivity; clinical suspicion trumps a negative scan.

Step 3 management: Memorize: unstable + positive FAST = OR; stable + any concerning mechanism = CT; peritonitis at any time = OR.

Board Question Stem Patterns

"A 35-year-old man involved in a high-speed MVC arrives with BP 80/50, HR 130, GCS 14. Two large-bore IVs and 1 L LR given without response. FAST shows fluid in Morison pouch and pelvis. Next step?"

— Answer: Exploratory laparotomy. Not CT, not more fluid — unstable + positive FAST = OR.

"Stable patient with seatbelt sign and Chance fracture; CT shows free fluid without solid organ injury. Next step?"

— Answer: Exploratory laparotomy. Free fluid without solid organ injury = hollow viscus injury until proven otherwise.

"GSW to the right flank, BP 110/70, HR 100, mild peritonitis on exam. Next step?"

— Answer: Exploratory laparotomy. GSW with peritoneal violation = mandatory laparotomy regardless of stability.

"Stable patient with anterior abdominal stab wound, soft abdomen, no peritonitis. Next step?"

— Answer: Local wound exploration — if anterior fascia intact, discharge after observation; if violated, proceed to CT or laparoscopy and serial exams.

"After 8 units PRBC, patient has pH 7.1, temp 34°C, INR 1.8, ongoing oozing. Next step in OR?"

— Answer: Damage control laparotomy — pack, control contamination, temporary closure, ICU for resuscitation, return in 24-48 h.

"24-week pregnant woman in MVC, Rh-negative, stable, no obvious injury. Management?"

— Answer: CT if indicated, RhoGAM within 72 h, continuous fetal monitoring ≥4 h, left lateral tilt.

"POD 1 after damage control, peak airway pressures rising, urine output dropping, abdomen tense. Diagnosis and management?"

— Answer: Abdominal compartment syndrome — measure bladder pressure, decompressive laparotomy if >20 mmHg with organ dysfunction.

"82-year-old on warfarin (INR 3.5), low fall, abdominal tenderness, hypotensive. Next step?"

— Answer: 4-factor PCC + vitamin K immediately, type and cross, FAST, surgery consult.

— "Send unstable patient to CT" — never the right answer

— "Continue crystalloid resuscitation" beyond 1-2 L without blood — wrong in hemorrhagic shock

— "Observe peritonitis" — never; peritonitis = OR

— "Withhold CT in pregnancy" — wrong; do not delay diagnosis

Classic stem #1 — Unstable blunt trauma:

Classic stem #2 — Stable blunt trauma with seatbelt sign:

Classic stem #3 — Penetrating abdominal GSW:

Classic stem #4 — Stab wound, asymptomatic:

Classic stem #5 — Damage control:

Classic stem #6 — Pregnant trauma:

Classic stem #7 — Post-op deterioration:

Classic stem #8 — Anticoagulated elder:

Common distractors to avoid:

Board pearl: When in doubt on Step 3 trauma questions, ask: "Is this patient stable?" If no, the answer is intervention (OR, chest tube, blood). If yes, the answer is diagnostic (CT, observation, serial exams).

Step 3 management: Recognize the stem keywords — "transient responder," "positive FAST," "peritonitis," "evisceration," "free air" — all point to OR.

One-Line Recap

— Unstable + positive FAST = OR. Stable = CT. This single rule answers most Step 3 trauma triage questions.

— Hard indications for laparotomy: peritonitis, evisceration, hemodynamic instability with intra-abdominal source, free air, GSW traversing peritoneum, transrectal/transurethral blood with penetrating mechanism, impaled object, diaphragmatic rupture.

— Damage control trumps definitive repair in the lethal triad (hypothermia, acidosis, coagulopathy) — stop bleeding, stop contamination, temporary closure, resuscitate in ICU, return in 24-48 h.

— Resuscitation strategy: 1:1:1 massive transfusion, TXA within 3 hours, permissive hypotension (except in TBI), calcium replacement, early reversal of anticoagulants, prophylactic antibiotics covering gut flora.

— Tertiary survey within 24 h to catch missed injuries

— Mandatory reporting for GSW, stab wounds, abuse

— Post-splenectomy vaccinations and lifelong OPSI awareness

— RhoGAM in Rh-negative pregnant trauma patients

— SBIRT for alcohol-related trauma before discharge

— Abdominal compartment syndrome surveillance post-op (bladder pressure)

Bottom line: Trauma laparotomy is indicated whenever the abdomen is the source of hemodynamic instability, peritonitis, or hard signs of injury — and the decision is driven by physiology and exam, not by waiting for definitive imaging.

High-yield recap bullets:

Don't-miss safety items:

Step 3 closer: Trauma care is a system — the right patient, the right place, the right time, the right operation. Recognize who needs the OR now, who needs the scanner, and who needs transfer; resuscitate with blood not crystalloid; reverse anticoagulants early; never forget the tertiary survey; and use every trauma admission as a secondary prevention opportunity through SBIRT, IPV screening, vaccination, and PCP handoff.

Board pearl: If a Step 3 stem describes an unstable trauma patient with any abdominal finding, the answer is almost always exploratory laparotomy — pick the OR, not the CT scanner, and you will get the majority of trauma questions right.