This is the current release of the guideline.

Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly.

Acute blunt abdominal trauma

Evaluation

Emergency Medicine
Family Practice
Internal Medicine
Radiology

Physicians

• To present evidence-based recommendations regarding the accuracies of computed tomography (CT), diagnostic peritoneal lavage, and focused abdominal sonography for trauma (FAST) in identifying various intra-abdominal injuries
• To address the following critical questions:
  • What is the diagnostic performance of CT in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?
  • Does oral contrast improve the diagnostic performance of CT in blunt abdominal trauma?
  • What is the diagnostic performance of FAST in diagnosing hemoperitoneum in blunt abdominal trauma?
  • What is the diagnostic performance of diagnostic peritoneal lavage in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?

Nonpregnant adult patients presenting to the emergency department with blunt force injuries to the abdomen (e.g., falls, direct abdominal blows, motor vehicle collisions)

These guidelines are not intended for use in the following types of patients:

• children
• pregnant women
• victims of penetrating abdominal injuries

Diagnosis/Evaluation

1. Computed tomography (CT) with and without oral contrast
2. Focused abdominal sonography for trauma (FAST)
3. Diagnostic peritoneal lavage

Sensitivity, specificity, and prognostic value of diagnostic tests

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

A MEDLINE search for articles published between January 1966 and June 2002 was performed using the terms "abdominal injuries" and "abdominal trauma" in combination with the following: diagnosis, ultrasonography, peritoneal lavage, diagnostic peritoneal lavage, lavage, laboratory testing, and trauma panel. Other MEDLINE searches for articles published during the same time interval were performed using the following key words: tomography (x-ray computed); wounds (nonpenetrating); and injuries, in combination with the following key words: kidney, pelvis, ureter, and bladder. Searches were limited to English-language sources. Additional articles were reviewed from the bibliography of articles cited. Recent journals and standard texts were also examined for additional sources.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Literature Classification Schema^

Class 1

• Therapy*: Randomized, controlled trial or meta-analyses of randomized trials
• Diagnosis**: Prospective cohort using a criterion standard
• Prognosis***: Population prospective cohort

Class 2

• Therapy*: Nonrandomized trial
• Diagnosis**: Retrospective observational
• Prognosis***: Retrospective cohort; case control

Class 3

• Therapy*: Case series; case report; other (e.g., consensus, review)
• Diagnosis**: Case series; case report; other (e.g., consensus, review)
• Prognosis***: Case series, case report; other (e.g., consensus, review)

^ Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

* Objective is to measure therapeutic efficacy comparing >2 interventions

** Objective is to determine the sensitivity and specificity of diagnostic tests

*** Objective is to predict outcome including mortality and morbidity

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

All articles used in the formulation of this policy were classified by the subcommittee members into 3 classes on the basis of design of study, with design 1 representing strongest evidence and design 3 representing weakest evidence for therapeutic, diagnostic, and prognostic clinical reports, respectively. Reports were then graded on 6 dimensions thought to be most relevant to the development of a clinical guideline: blinded versus nonblinded outcome assessment, blinded or randomized allocation, direct or indirect outcome measures, biases (e.g., selection, detection, transfer), external validity (generalizability), and sufficient sample size. Articles received a final grade (I, II, III) on the basis of a predetermined formula taking into account design and grade of study. Articles with fatal flaws were given an "X" grade and not used in the creation of this policy.

Expert Consensus

This policy is a product of the American College of Emergency Physicians (ACEP) clinical policy development process, including expert review, and is based on the existing literature; where literature was not available, consensus of emergency physicians was used.

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence class I" or overwhelming evidence from "strength of evidence class II" studies that directly address all the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence class III" studies)

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence or, in the absence of any published literature, based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Expert review comments were received from emergency physicians, members of the American College of Emergency Physician's (ACEP's) Trauma Care and Injury Control Committee, leaders of ACEP's Section of Trauma and Injury Prevention, leaders of ACEP's Section of Emergency Ultrasound, and physicians from specialty societies, including individual members of the American College of Surgeons Committee on Trauma and the American Academy of Family Physicians. Their responses were used to further refine and enhance this policy.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (A-C) are repeated at the end of the Major Recommendations.

What is the diagnostic performance of computed tomography (CT) in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?

• Level A recommendations. None specified.
• Level B recommendations. When either liver or spleen injury is suspected, CT can reliably exclude injuries that require emergent operative intervention. CT alone cannot be used to exclude either bowel, diaphragm, or pancreas injury.

  Abdominal CT accurately identifies hemoperitoneum among patients with blunt abdominal trauma.

• Level C recommendations. None specified.

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 essential to the evaluation of blunt abdominal trauma.
• Level C recommendations. None specified.

What is the diagnostic performance of focused abdominal sonography for trauma (FAST) in diagnosing hemoperitoneum in blunt abdominal trauma?

• Level A recommendations. None specified.
• Level B recommendations. FAST is useful as an initial screening examination to detect hemoperitoneum in blunt abdominal trauma patients.
• Level C recommendations. None specified.

What is the diagnostic performance of diagnostic peritoneal lavage in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?

• Level A recommendations. None specified.
• Level B recommendations. Diagnostic peritoneal lavage can be used to exclude hemoperitoneum in blunt abdominal trauma patients. Diagnostic peritoneal lavage does not define the extent of injury, has a 1 to 2% complication rate, and may lead to nontherapeutic laparotomies.
• Level C recommendations. On the basis of consensus and current practice patterns, the initial choices for the evaluation of blunt abdominal trauma are CT and FAST, depending on the patient's hemodynamic stability.

Definitions:

Literature Classification Schema^

Class 1

• Therapy*: Randomized, controlled trial or meta-analyses of randomized trials
• Diagnosis**: Prospective cohort using a criterion standard
• Prognosis***: Population prospective cohort

Class 2

• Therapy*: Nonrandomized trial
• Diagnosis**: Retrospective observational
• Prognosis***: Retrospective cohort; case control

Class 3

• Therapy*: Case series; case report; other (e.g., consensus, review)
• Diagnosis**: Case series; case report; other (e.g., consensus, review)
• Prognosis***: Case series, case report; other (e.g., consensus, review)

^ Some designs (e.g., surveys) will not fit this schema and should be assessed individually.

* Objective is to measure therapeutic efficacy comparing >2 interventions

** Objective is to determine the sensitivity and specificity of diagnostic tests

*** Objective is to predict outcome including mortality and morbidity

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence class I" or overwhelming evidence from "strength of evidence class II" studies that directly address all the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence class III" studies)

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence or, in the absence of any published literature, based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• This guideline may help physicians in the evaluation of adult patients presenting to the Emergency Department (ED) with acute blunt abdominal trauma.
• Refer to the original guideline document for evidence tables outlining sensitivities, specificities, and prognostic values of diagnostic tests discussed in this guideline.

• False-negative results. Computed tomography (CT), focused abdominal sonography for trauma (FAST), and diagnostic peritoneal lavage can produce false-negative results.
• False-positive results. The false-positive rate for diagnostic peritoneal lavage is between 13 and 54%.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. The American College of Emergency Physicians (ACEP) clearly recognizes the importance of the individual physician's judgment. Rather, this guideline defines for the physician those strategies for which medical literature exists to provide support for answers to the crucial questions addressed in this policy.

An implementation strategy was not provided.

Getting Better

Effectiveness
Timeliness

Not applicable: The guideline was not adapted from another source.

2004 Feb

American College of Emergency Physicians - Medical Specialty Society

American College of Emergency Physicians

American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee on Acute Blunt Abdominal Trauma

ACEP Clinical Policies Committee

Members of the Clinical Policies Subcommittee on Acute Blunt Abdominal Trauma: John M. Howell, MD (Chair); B. Tilman Jolly, MD; Thomas W. Lukens, MD, PhD; Roland Clayton Merchant, MD

Members of the Clinical Policies Committee: William C. Dalsey, MD (Chair, 2000-2002, Co-Chair 2002-2003); Andy S. Jagoda, MD (Co-Chair 2002-2003); Wyatt W. Decker, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; John M. Howell, MD; Alan H. Itzkowitz, MD (EMRA Representative 2000-2001); Shkelzen Hoxhaj, MD (EMRA Representative 2002-2003); J. Stephen Huff, MD; Edwin K. Kuffner, MD; Thomas W. Lukens, MD, PhD; Benjamin E. Marett, RN, MSN, CEN, CNA, COHN-S (ENA Representative 2001-2003); Thomas P. Martin, MD; Jessie Moore, RN, MSN, CEN (ENA Representative 2000-2001); Barbara A. Murphy, MD; Devorah Nazarian, MD; Scott M. Silvers, MD; Bonnie Simmons, DO; Edward P. Sloan, MD, MPH; Robert L. Wears, MD, MS; Stephen J. Wolf, MD (EMRA Representative 2001-2002); Robert E. Suter, DO, MHA (Board Liaison 2000-2001); Susan M. Nedza, MD, MBA (Board Liaison 2001-2003); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Not stated

This is the current release of the guideline.

Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly.

None available

None available

This NGC summary was completed by ECRI on April 21, 2004. The information was verified by the guideline developer on May 27, 2004.