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Snapshot
  • A 50-year-old man is brought to the emergency room after a motor vehicle accident. He is hemodynamically stable at that time; his blood pressure is 110/70 mmHg and pulse is 90/min. After the team ensures that his airway and breathing are secured, they note ecchymoses in the shape of a steering wheel and ecchymosis of the flanks. They obtain a focused assessment with sonography for trauma (FAST) and discover the presence of blood in the abdominal cavity. As they proceed with the examination, his blood pressure drops to 90/60 mmHg and is no longer responsive to fluid resuscitation. He is prepped emergently for a diagnostic laparotomy.
Introduction
  • Overview
    • hemoperitoneum describes the presence of blood within the peritoneal cavity, often secondary to trauma
      • treatment is typically an urgent laparotomy  
  • Epidemiology
    • etiology
      • penetrating trauma
      • blunt abdominal trauma
        • splenic or hepatic injury
      • abdominal aortic aneurysm rupture
      • perforated gastric ulcer
      • disseminated intravascular coagulation
      • complications of abdominal surgery
  • Pathogenesis
    • mechanism
      • abdominal cavity has the potential to hold > 5 L of blood, which can accumulate quickly, resulting in rapid blood loss causing hemorrhagic shock
      • large volume of blood can accumulate before patients present with any significant symptoms
  • Prognosis
    • depends on etiology of hemoperitoneum and rapid diagnosis/treatment
Presentation
  • Symptoms
    • common symptoms
      • lightheadedness
      • abdominal pain
  • Physical exam
    • inspection
      • hemorrhagic shock
        • hypotension
        • tachycardia
    • motion
      • tenderness to palpation
      • rebound tenderness
      • rigid abdomen
      • tenderness with percussion
Imaging
  • Focused assessment with sonography for trauma (FAST)
    • indication
      • rapid diagnosis of hemoperitoneum
      • may not determine source of hemorrhage
    • findings
      • blood in peritoneal cavity
  • Computed tomography
    • indications
      • detection of solid organ injury
      • can determine source of hemorrhage
      • hemodynamically stable patients
    • findings
      • solid organ injury
Studies
  • Serum labs    
    • complete blood count
      • assess for need for transfusion
    • blood type and cross
  • Invasive studies
    • diagnostic peritoneal lavage (abdominal paracentesis)
      • indication
        • can rapidly determine presence of intraperitoneal blood
        • hemodynamically unstable patient in whom FAST exam may not be useful (i.e., obstructed views)
Differential
  • Ectopic pregnancy
    • key distinguishing factors
      • hemoperitoneum may not be seen on imaging
      • transvaginal ultrasound may reveal ectopic pregnancy
      • elevated beta-HCG
Treatment
  • Medical
    • blood transfusion
      • indications
        • hemorrhagic shock
    • supportive care
      • indications
        • all patients
  • Surgical
    • laparotomy
      • indications
        • signs of peritonitis
        • hemorrhagic shock
        • clinical decompensation
Complications
  • Death
 

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