INTRODUCTION

Background

Blunt abdominal trauma accounts for a substantial portion of trauma cases presenting to emergency departments, representing up to 10% of all trauma-related cases [1]. These injuries are associated with considerable morbidity and mortality, predominantly affecting younger men within the economically productive age group of 21 to 40 years [2]. Multiple factors, including demographics, injury mechanisms, quality of first responder interventions, and accessibility to healthcare infrastructure, contribute to significant variability in morbidity and mortality across regions [3]. Areas such as Bihar in Eastern India remain inadequately studied due to limited access to healthcare and disorganized referral systems [4]. This region has a predominantly young and male workforce, rendering trauma-related morbidity and mortality particularly impactful by imposing significant socioeconomic burdens on families.

Currently, no regional or national trauma management systems or trauma registries exist in this area. This study aims to characterize mechanisms of trauma, affected demographics, injury patterns, and outcomes specifically concerning abdominal injuries managed at a regional trauma center.

Objectives

This study was conducted to identify factors influencing morbidity and mortality in blunt abdominal trauma cases in the region and to evaluate the role of surgical intervention for blunt abdominal trauma where indicated.

METHODS

Ethics statement

This study was approved by the Institutional Ethical Committee of All India Institute of Medical Sciences, Patna, with a waiver of informed consent (No. AIIMS/Pat/IEC/1382). Informed consent was waived due to the retrospective nature of the study. The study was performed in accordance with the principles outlined in the Declaration of Helsinki.

Study design

A retrospective cross-sectional study was conducted utilizing data derived from the weekly surgical audit held in the department where the study took place. Patient data from an 18-month period (July 2022–December 2023) were collected and analyzed. The records of patients admitted to a level I trauma center in Eastern India with a diagnosis of blunt abdominal trauma were included. This center is the highest referral institution in the region for trauma management and is affiliated with an academic hospital comprising a total of 960 beds, including 90 dedicated beds within the trauma center. Over the specified 18-month period, the trauma center received 12,684 patients, of whom 1,904 were admitted. Data utilized for this study were derived from these admitted cases. Patients who had undergone any surgical intervention for abdominal trauma prior to referral to this institution were excluded, as their inclusion would not accurately reflect the morbidity and mortality rates specific to this single center.

Management protocols for blunt abdominal trauma at the trauma center

The management of all blunt abdominal trauma cases followed the American College of Surgeons Advanced Trauma Life Support (ATLS) protocols. Upon patient arrival in the trauma bay, initial triage was performed, and patients were categorized into red, yellow, or green zones based on age, injury mechanism, and vital signs. Each patient underwent a primary survey focusing on airway, breathing, circulation, disability, and exposure. The trauma team comprised a team leader certified in ATLS, resident doctors, and trauma nursing staff. Samples for blood crossmatching were drawn simultaneously during the insertion of wide-bore intravenous cannulas, and focused assessment with sonography for trauma (FAST) and arterial blood gas analyses were conducted during the primary survey itself. Patients demonstrating persistent hemodynamic shock who were FAST-positive and unresponsive to initial crystalloid resuscitation with 1 L of Ringer lactate had O-negative blood requested immediately without crossmatching. In such cases, the blood bank was alerted for potential activation of a massive transfusion protocol, and the patient was promptly transferred to the operating room. If a patient was stabilized during the primary survey, adjunct investigations, including chest and pelvic radiograms and a 12-lead electrocardiogram, were obtained using portable x-ray machines available at the center. A secondary survey was then carried out after completion of these adjunct studies. Further investigations, such as contrast-enhanced computed tomography (CECT) of the chest and abdomen, were performed only after confirmed stabilization, typically within 1 hour of patient presentation.

Study procedure

As the weekly departmental audit was initiated only after July 2022, comprehensive patient details were available solely from this point forward. Due to the absence of a regional trauma registry and inadequate record-keeping practices at various facilities in Bihar, the study was limited to a single-center evaluation. Variables were collected throughout each patient's hospital stay until discharge, as recorded in the departmental audit data. After applying inclusion and exclusion criteria, a total of 118 cases were identified for analysis. Variables for analysis were categorized into five groups according to the audit records: demographic (age, sex, mechanism of injury, and time from injury to hospital arrival), clinical (pulse, blood pressure, respiratory rate, Glasgow Coma Scale [GCS] score, and fluid responsiveness), radiological (chest x-ray, pelvic x-ray, FAST, and abdominal CT), surgical (interventions performed and operative findings), and outcome (hospital length of stay and mortality).

These variables were systematically tabulated and analyzed. Data entry and tabulation were conducted using Microsoft Excel (Microsoft Corp), and data analysis was performed with jamovi ver. 2.6.26 (jamovi project). Descriptive analyses were conducted for qualitative variables, and quantitative variables were expressed as means with standard deviations. Chi-square tests of association were used to identify statistically significant relationships.

RESULTS

Data from all trauma patients admitted over an 18-month period were collected, totaling 1,904 patients. Of these, 258 had sustained some form of abdominal trauma; specifically, 136 presented with penetrating abdominal injury, and 122 presented with blunt abdominal trauma. Four patients were identified as postoperative referrals and were thus excluded from analysis. Consequently, 118 patients were included in the study.

Descriptive data

The demographic data revealed a strong predominance of young male patients (102 patients, 86.4%). Furthermore, 87 patients (73.7%) were younger than 40 years of age. The mean patient age was 30.2±16.7 years (range, 4–75 years). Road traffic injuries were the predominant mechanism, accounting for 67 cases (56.8%), followed by 20 railway injuries, 18 falls from height, and 7 blunt physical assault injuries. Six cases did not fall within the aforementioned categories, comprising three hand pump injuries, two heavy object fall injuries, and one accidental machinery injury. Table 1 provides detailed demographic information, mechanisms of injury, and the interval from injury to hospital arrival (in hours).

The patients’ clinical presentations are summarized in Table 2. The mean pulse rate was 115±23.3 beats per minute (bpm; range, 60–163 bpm). Mean arterial pressure ranged from 30 to 120 mmHg, with an overall mean of 78.8±18.8 mmHg. Mean pulse pressure was 41.4±13.6 mmHg (range, 14–80 mmHg). All patients exhibited elevated respiratory rates (>12 cycles per minute [cpm]), with a maximum recorded respiratory rate of 50 cpm and a mean of 22.9±6.87 cpm. Most patients (84.7%) were conscious upon arrival and able to follow commands. Increased physiological exhaustion and poor fluid responsiveness were associated with worsening vital parameters and higher mortality rates.

All patients underwent FAST, chest x-rays, and pelvic x-rays as adjuncts to the primary survey. FAST was positive in 97 patients (77.1%) upon presentation. Chest x-rays and pelvic x-rays were not performed during the primary survey for 18 patients each due to their transient or nonresponder status. In these cases, radiographic imaging was deferred until stabilization in the intensive care unit (ICU). The most frequent pathology identified by chest x-ray was concomitant thoracic injuries, found in 32 of 100 patients (32.0%), followed by gas under the diaphragm in 16 of 100 patients (16.0%). Pelvic x-rays were normal in 84 of the 100 patients (84.0%) who underwent imaging, while pelvic or acetabular fractures were detected in 18 patients (18.0%).

CECT of the thorax and abdomen was conducted for 89 patients (70.3%) in the emergency department itself. Patients who did not undergo CECT included those with hemodynamic instability or clinical detection of hollow viscus perforation confirmed by pneumoperitoneum on chest x-ray. CECT findings included hemoperitoneum (67 patients), pneumoperitoneum (12 patients), liver injury (26 patients), spleen injury (23 patients), renal injury (11 patients), pancreatic injury (4 patients), urinary bladder injury (8 patients), diaphragmatic hernia (5 patients), and thoracic trauma (32 patients). Solid organ injuries were classified according to the Organ Injury Scale established by the American Association for the Surgery of Trauma. Of the 26 liver injuries identified on CECT, three were grade I, four grade II, eight grade III, nine grade IV, and two grade V injuries. The 23 spleen injuries comprised one grade I, three grade II, seven grade III, eight grade IV, and four grade V cases. Renal injuries included two grade II, four grade III, four grade IV, and one grade V cases. Pancreatic injuries involved one grade II and two grade III injuries, and one late-presenting pancreatic pseudocyst.

Management and outcomes

Out of the 118 patients, there were 15 deaths, corresponding to an overall mortality rate of 12.7%. The cause of death in nine patients was hemorrhagic shock. Four patients died due to severe sepsis, and two succumbed to acute respiratory distress syndrome (ARDS). Among the nine patients who died of hemorrhagic shock, eight underwent damage control surgery via laparotomy or pelvic packing, and one patient experienced fatal reactionary hemorrhage following distal pancreatectomy. Injuries among those who died due to hemorrhagic shock included three liver injuries, five spleen injuries, one renal injury, three pancreatic injuries, two inferior vena cava (IVC) injuries, and five pelvic fractures. The four patients who died from severe sepsis had hollow viscus perforation and presented more than 24 hours after injury. One patient with a grade IV liver injury managed nonoperatively died of ARDS, exacerbated by concomitant thoracic and extremity injuries. Another patient who underwent surgical repair of a diaphragmatic hernia also died due to postoperative ARDS. Table 3 presents the distribution of cases according to the type of management administered and associated outcomes.

A total of 78 patients underwent some form of surgical intervention. The time interval from presentation to transfer into the operating room ranged widely, from a minimum of 10 minutes to a maximum of 7,200 minutes, with a median of 120 minutes (interquartile range, 615 minutes). Out of 118, 40 patients were successfully managed without surgical intervention. Most patients managed nonoperatively had an abdominal Abbreviated Injury Score (AIS) of either 3 or 4 (each 15 cases). Six patients initially planned for nonoperative management required emergency laparotomy due to continuously falling hematocrit or decreasing blood pressure. Forty-eight patients underwent emergency laparotomy via midline incision, with the earliest time to the operating room being 10 minutes, the longest 720 minutes, and a median of 60 minutes. Indications for emergency laparotomy included hemodynamically unstable hemoperitoneum unresponsive to initial resuscitation, peritonitis secondary to hollow viscus perforation, and one case of diaphragmatic hernia with respiratory distress. Among the nine cases requiring damage control surgery, splenectomy was performed in seven cases, nephrectomy in two, perihepatic packing or hepatorrhaphy in two, and repair or ligation of the IVC in three cases.

Eleven different types of injuries were identified radiologically and operatively among the 118 patients. These injuries included 35 mesenteric injuries, 12 omental injuries, 34 hollow viscus injuries, 30 liver injuries, 36 splenic injuries, 14 renal injuries, 6 pancreatic injuries, 5 diaphragmatic hernia, 3 IVC injuries, 19 pelvic fractures, and 11 urinary bladder injuries. Cases were further analyzed based on the types of injuries identified radiologically and/or operatively. Of the 78 patients who underwent surgical intervention, at least 44 had multiple injury findings. Tables 4 and 5 provide detailed distributions of detected injuries, management methods, mortality rates, and the most common causes of death.

The mean hospital length of stay was 10.6 days, with the shortest stay for discharged patients being 2 days and the longest being 31 days. ICU length of stay ranged from 1 to 17 days, with longer ICU stays more commonly associated with deaths due to factors other than hemodynamic shock. Injuries most frequently associated with prolonged hospital stays were pelvic fractures (mean, 12.3±8.65 days), pancreatic injuries (mean, 11.5±7.65 days), and hollow viscus perforations (mean, 11.3±5.26 days).

Upon categorizing the body into six regions according to the AIS system, it was found that 89 of the 118 patients (75.4%) had involvement of at least one region other than the abdomen, as depicted in Table 6. Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS) were subsequently calculated based on patient parameters (Table 7). Mortality rates correlated with worsening trauma scores, as illustrated.

Analysis

Logistic regression analysis using univariate methods identified several significant factors associated with mortality, including age, pulse pressure, pulse rate, respiratory rate, mean arterial pressure, GCS, ISS, and RTS. Following multivariate analysis adjustments, two predictors remained significant: age (adjusted odds ratio [aOR], 1.05; P=0.014), suggesting that each 1-year increase in age corresponded to a 5% increase in mortality risk, and RTS (aOR, 0.30; P=0.023), indicating that each 1-unit increase in RTS was associated with a 70% decrease in mortality risk (Table 8). A receiver operating characteristic curve was plotted to determine the sensitivity and specificity of this adjusted model for mortality prediction (Fig. 1). The discriminatory threshold positioned toward the right side demonstrated that the adjusted model effectively distinguished between outcomes. The area under the curve of 0.871 signified a strong discriminative ability, with a sensitivity of 53.3%, specificity of 97.1%, and overall accuracy of 91.5%. This result indicates high predictive efficacy for mortality risk in patients with blunt abdominal trauma.

Chi-square analysis was conducted to examine associations between clinical presentation and outcomes. Of the 30 patients who presented with shock, 11 died and 19 survived. Among 88 normotensive patients, 84 survived. The chi-square test yielded a P-value of less than 0.001, confirming a strong association between the presence of shock at presentation in abdominal trauma patients and mortality. Analyses were also performed for hospital length of stay and management type. Patients undergoing operative management demonstrated significantly longer hospital stays (P=0.030) and higher mortality rates (P=0.012). Variations in mortality were noted according to associated injuries (P=0.840), type of fluid responsiveness (P=0.302), and presence of hemoperitoneum (P=0.571); however, these differences were not statistically significant. Similarly, no statistically significant correlations were identified between outcomes and the time interval from injury to hospital arrival or the duration between hospital presentation and entry into the operating room.

DISCUSSION

The use of assessment tools as recommended by ATLS protocols, along with adjunct methods such as FAST, improves sensitivity and specificity in detecting blunt abdominal trauma [5]. Patient factors such as age, mechanism of injury, and clinical presentation influence outcomes differently; however, management protocols remain consistent. Most patients are young adults between 21 and 40 years, with a clear male predominance. Nevertheless, older patients (aged above 60 years) exhibit prolonged hospital stays and increased mortality rates. Gender differences regarding outcomes have been found statistically insignificant [1].

Road traffic accidents constitute the most common mechanism of blunt abdominal trauma. Our study documented road traffic injuries as the cause in 56.8% of cases. Wiik Larsen et al. [1], Yogish et al. [6], and Choi et al. [7] reported similar findings, with road traffic injuries typically comprising the majority of blunt abdominal trauma cases. The second most common mechanism in our study was railway injuries, whereas many other studies have identified falls from height as the second most common cause. Studies conducted in India indicate a higher prevalence of railway injuries, with abdominopelvic trauma documented in approximately 28% of fatal railway injury cases [8].

The management and outcomes of blunt abdominal trauma are also influenced by the interval from injury to hospital presentation. Poor healthcare and transportation infrastructure in India, coupled with inadequate public knowledge, leads to delayed patient arrival and poorer outcomes [4]. In our study, only 5.1% of patients arrived within the "golden hour," while 50% arrived between 1 and 24 hours, and the remainder presented after 24 hours. Since our institution is a regional tertiary care facility and level I trauma center, many cases were referrals after primary management elsewhere. Significant disparities exist in access to healthcare services and basic transportation, including ambulances, particularly in lower socioeconomic regions in Northern and Eastern India. The state of Bihar, where this study was conducted, exhibits particularly poor access to healthcare across various demographic determinants such as age, sex, income, caste, and religion [9]. Improved ambulance personnel training and increased healthcare expenditure have been suggested as potential solutions to transportation-related healthcare challenges [10].

The ATLS protocol categorizes patients based on the blood pressure response to an initial isotonic crystalloid fluid bolus of 1 L in adults or 20 mL/kg in children. The three response categories are as follows [11]: (1) responders (or rapid responders), whose vital signs normalize quickly, typically requiring limited resuscitation and fewer blood products, and who have a lower likelihood of requiring surgery; (2) transient responders, who have moderate blood loss or slower ongoing bleeding and whose vital signs deteriorate after initial improvement, generally requiring blood products and surgical intervention; and (3) nonresponders, who have substantial blood loss, typically necessitating immediate surgical intervention and potentially massive transfusion.

Radiological investigations form another critical aspect of the primary survey in abdominal trauma management. In FAST-positive, nonresponsive patients, emergency laparotomy is indicated immediately, bypassing additional radiological adjuncts such as chest and pelvic x-rays. In our study, 77.1% of patients were FAST-positive upon presentation, while the remaining 22.9% included cases of minor, contained injuries, extraperitoneal injuries, or diaphragmatic hernias. In these situations, CECT of the thorax and abdomen proved more sensitive.

CECT of the thorax and abdomen demonstrates high sensitivity and specificity for abdominal trauma detection. It can detect hemoperitoneum volumes as low as 100 mL, whereas FAST requires at least 150 mL. Additionally, CECT can identify concealed or contained hemorrhage, ongoing bleeding, and specific organ injuries even without significant blood loss [12]. Hemoperitoneum was the most frequent finding in our study, consistent with literature reports. Naeem et al. [13] have indicated the liver as the most commonly injured organ, followed by injuries to the spleen, kidneys, urinary bladder, and pancreas.

In our study, 89 out of 118 patients (75.4%) presented with polytrauma, which is higher compared to the 51.4% incidence reported by Wiik Larsen et al. [1]. Skin and soft tissue involvement was the most common additional injury observed, closely followed by thoracic injuries. Other common injuries included those to extremities, facial regions, and the head. The high prevalence of polytrauma in our study can be explained by its setting in a tertiary referral center. In our study, 46 patients (38.9%) were initially planned for nonoperative management, of which 6 required subsequent emergency laparotomy via midline incision due to nonoperative management failure. Fodor et al. [14] reported a nonoperative management rate of 82.6% with a 96.7% success rate over a 17-year retrospective review. However, Yogish et al. [6] documented a notably lower rate of nonoperative management (28.3%). Nonoperative or minimally invasive management strategies are generally associated with improved outcomes [14], but these require robust healthcare resources, skilled interventional radiology teams, and formalized trauma systems capable of rapid patient referral. In our setting, patients with severe injuries or ongoing bleeding were often planned for surgical intervention post-resuscitation if hemodynamically feasible. This strategy was adopted due to the poor transportation and peripheral healthcare infrastructure in our region, leading to lower patient compliance and poorer outcomes in cases of abdominal complications [4].

The most common indication for laparotomy in our study was hollow viscus perforation, followed by hemodynamic shock. There was a notably high incidence of hollow viscus perforations, particularly involving the epigastric region. Hollow viscus injury generally occurs due to energy transmission into the viscera, generating a compression shock wave. Another contributing factor is the "bucket-handle" type of mesenteric injury, causing segmental devascularization, subsequent bowel gangrene, and perforation, which typically presents in a delayed manner. The sudden deceleration forces, tissue strength, and anatomical fixation at the ligament of Treitz or the ileocecal junction also play significant roles in causing perforation [15]. Most literature reports indicate a lower rate of hollow viscus injury, typically ranging from approximately 1% to 15% [6,15,16]. In contrast, our study identified hollow viscus perforation in 35 of 118 patients (29.6%), demonstrating a higher incidence. The high prevalence of road traffic injuries involving two-wheeler vehicles and increased referrals of patients requiring operative intervention likely contributed to the elevated rate observed in this study.

Yogish et al. [6] demonstrated higher rates of spleen injury necessitating surgical intervention (53.4%), while liver injury repairs were documented in 23.0% of cases. Conversely, Wiik Larsen et al. [1] reported the liver as the most commonly injured solid organ, accounting for 56.2% of cases. In our study, liver injuries were the most frequently detected solid organ injury on radiological assessment; however, spleen injuries were more common during surgical interventions. Additionally, our study demonstrated a relatively higher incidence of complex injuries, including IVC injuries, pancreatic injuries, and diaphragmatic hernias, as seriously injured or moribund patients were often referred to our trauma center. Outcomes following blunt abdominal trauma usually include extended hospital stays and mortality rates ranging from 10% to 20%. Factors such as extremes of age, associated injuries, and injury severity typically influence mortality rates [1]. Our findings corroborated these observations through logistic regression analysis, which identified age, pulse pressure, pulse rate, respiratory rate, mean arterial pressure, oxygen saturation, GCS, ISS, and RTS as significant factors affecting mortality.

Comparisons among trauma severity scores indicate that TRISS is a more effective predictor of patient outcomes than ISS. Anatomical scores like ISS, however, have proven to be better predictors of prolonged hospital stays and ICU admissions [17]. In our study, patients predicted by TRISS to have a lower probability of survival indeed exhibited higher mortality rates. Nonetheless, some fatalities occurred even among patients with high predicted survival probabilities, underscoring the necessity of improving trauma systems within both our center and the broader region. Furthermore, trauma scores lack sensitivity in detecting delayed complications such as ARDS and severe sepsis. The management of these complications requires aggressive critical care and stringent hospital protocols to prevent infection. Consequently, minimizing hospital length of stay and infection risk remains essential in the effective management of blunt abdominal trauma.

Limitations

The study was a single-center observational analysis with a limited duration. Due to its retrospective design, controlling for potential biases such as comorbidities or interventions performed prior to admission was not feasible. Additionally, resource constraints prevented detailed postdischarge follow-up.

Conclusions

There is a high prevalence of blunt abdominal trauma among young male patients, likely due to increased exposure to risk factors. FAST and CECT play crucial roles in trauma detection and patient management. While demographic factors such as age significantly affect patient outcomes, clinical presentation parameters—including pulse rate, blood pressure, respiratory rate, and level of consciousness—are equally crucial determinants of prognosis. Trauma scoring systems such as ISS, RTS, and TRISS are valuable in predicting mortality risk. Nonoperative management and minimally invasive interventions remain essential in improving survival outcomes but depend heavily upon the patient’s clinical presentation, resource availability, and healthcare staffing. Emergency interventions, particularly in the presence of hemodynamic shock, are associated with high mortality rates. Hollow viscus perforation represents another critical injury in abdominal trauma, with delayed detection potentially leading to severe sepsis. In the absence of shock or peritonitis, nonoperative management remains the cornerstone of abdominal trauma care, significantly reducing mortality and hospital stays. Effective multidisciplinary coordination, involving blood bank services, critical care, and interventional radiology, can enhance patient outcomes. Our study underscores the need to establish a comprehensive trauma system and referral protocol in the region, alongside regional and national trauma registries, to better document trauma burdens. Moreover, improving local center protocols and expanding healthcare infrastructure and staffing are essential, given the significant mortality rates associated with hemodynamic shock.

ARTICLE INFORMATION

Author contributions

Conceptualization: AK; Data curation: RS, HK, AHS, AVK, MA; Formal analysis: RS, Methodology: AK, RS, HK; Project administration: AK; Supervision: AK; Writing–original draft: RS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Acknowledgments

The authors are profoundly grateful to Dr. Anil Kumar (Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Patna [AIIMS Patna], Patna, India) for his mentorship and guidance. His invaluable recommendations, emotional sustenance, and meticulous oversight have greatly enriched this study. The authors also express their sincere gratitude to Drs. Rekha Kumari and Sanjay Kumar (Division of Anaesthesia, Department of Trauma Surgery and Critical Care, AIIMS Patna), who have been invaluable parts of the team without whom the research would have been impossible; and to the residents of AIIMS Patna, Drs. Deepak Kumar, Abhishek Kumar, Shashikant, Jeeshan, Mayank, Anupam, Shaman, Karthik, Ankit, Shivangi, Aadil, Sayani, and Bhavya, for helping them in every way and allowing them to more effectively collect data.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Receiver operating characteristic curve showing a discriminatory threshold to the right side and an area under the curve of 0.871, suggesting strong discriminative ability.

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Figure & Data

References

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