Significant Hemoperitoneum in Blunt Trauma
Victims With Normal Vital Signs
and Clinical Examination
MICHAEL BLAIVAS, MD, RDMS,* PAUL SIERZENSKI, MD, RDMS,†
AND DANIEL THEODORO, MD
Clinical examination of the abdomen is generally reliable in stable
trauma patients with no distracting or head injury. Patients involved in
relatively minor trauma with normal examinations can be safely sent
home in most instances. We report 6 cases of blunt abdominal trauma
that had completely normal clinical examinations and vital signs but
were found to have significant hemoperitoneum on trauma ultrasound
examination. Four of the patients were examined for educational pur-
poses just before planned discharge from the emergency department.
These cases suggest that a screening ultrasound examination may have
a role in the evaluation of most blunt trauma patients. (Am J Emerg Med
2002;20:218-221. Copyright 2002, Elsevier Science (USA). All rights re-
served.)
Bedside ultrasonography in the evaluation of blunt
trauma patients is one of the most widely accepted ultra-
sound applications in emergency medicine. It is also one of
the earliest applications of ultrasound used widely by phy-
sicians who are nonradiologists. A number of studies have
documented the use of the focused abdominal sonography
for trauma (FAST) examination.1-8 The FAST examination
is most useful in blunt trauma patients with unstable vital
signs. The discovery of large amounts of fluid in the abdo-
men can lead to immediate operative intervention and save
lives as well as resources.7,8 Conversely, a patient with no
fluid in the abdomen would not benefit from emergency
laparotomy, and a search should be made of other causes of
abnormal vital signs such as pelvic fracture, pericardial
effusion, extremity injury, hemothorax, or spinal cord in-
jury.
Patients presenting in stable condition with a normal
sensorium, no distracting injuries, and a normal physical
examination have been thought safe to be sent home. This
does not apply to patients who have an altered mental state
or severe distracting injuries.9,10 Altered pain perception can
lead to significant missed injuries, which has been well
documented in the surgical literature.11,12 Further, pediatric
patients may be unreliable for abdominal examination, and
From the *Department of Emergency Medicine, North Shore Uni-
versity Hospital, Manhasset, NY, and the †Department of Emer-
gency Medicine, Christiana Care Health System, Newark, DE.
Manuscript received August 29, 2001, accepted October 7, 2001.
Address reprint requests to Michael Blaivas MD, RDMS, Depart-
ment of Emergency Medicine, North Shore University Hospital, 300
Community Drive, Manhasset, NY 11030. E-mail: blaivas@pyro.net.
Key Words: Emergency ultrasonography, ultrasound, emergency
medicine, hemoperitoneum, blunt trauma, unsuspected hemoperi-
toneum.
Copyright 2002, Elsevier Science (USA). All rights reserved.
0735-6757/02/2003-0015$35.00/0
doi:10.1053/ajem.2002.32637
218
a conservative approach with either admission and obser-
vation or computed tomography (CT) scan is indicated.13,14
Most emergency physicians would not expect patients
with a normal examination and vital signs to have abdom-
inal injury. However, this may not always be the case. We
report 6 cases of abdominal trauma with large amounts of
hemoperitoneum found incidentally on bedside emergency
ultrasound examination. In the following cases, a small
amount of intraperitoneal fluid is defined as a fluid stripe
less than 1 cm, a moderate amount of intraperitoneal fluid is
defined as 1 to 3 cm, and large peritoneal fluid amount is
defined as over 3 cm of fluid stripe in Morison’s pouch.15
CASE 1
J.H. is a 52-year-old woman with a history of tubal
ligation and tonsillectomy. The patient was the restrained
driver of a minivan involved a front-end collision. There
was no loss of consciousness (LOC), and the patient had
clear recall of the accident. Airbags had deployed, and she
was ambulatory at the scene. On arrival in the emergency
department (ED), the patient had no complaints. Vital signs
included a blood pressure of 153/89 mm Hg, heart rate of 76
beats per minute (bpm), respiratory rate of 14, temperature
of 98.1° F, and oxygen saturation of 98% on room air.
Physical examination revealed the head, neck, lung, heart,
and extremities to be unremarkable. The abdominal exam-
ination showed a mildly obese nondistended abdomen with
no pain on palpation, guarding, or rebound. Bowel sounds
were normal in all 4 quadrants.
The ED attending as well as the trauma residents and
attending who were seeing a patient in an adjacent bay
evaluated the patient. She was felt to have no injuries and
was discharged home. Before actual discharge, an educa-
tional FAST examination was performed by the ED attend-
ing explicitly for teaching a trauma resident who had never
performed one. Unexpectedly, the patient’s abdomen was
noted to have a large quantity of fluid (Fig 1). The patient’s
discharge was canceled, and 2 large bore intravenous lines
were placed. Emergency CT was performed. The radiolo-
gists noted a significant splenic laceration and fluid in the
abdomen. The patient was taken to the operating room for
an exploratory laparotomy that resulted in a splenectomy.
She recovered uneventfully and left the hospital 3 days later.
CASE 2
N.S. is a 22-year-old man without significant past medi-
cal history who was a restrained driver in a rollover at
moderate speed. The patient stayed in the vehicle and had
BLAIVAS, SIERZENSKI, AND THEODORO ■ MISSED HEMOPERITONEUM ON FAST
FIGURE 1. A figure showing a large amount of fluid in Mori-
son’s pouch. L, liver; K, kidney; F, fluid.
no loss of consciousness. He exited from the vehicle under
his own power and was ambulatory at the scene. The patient
was boarded and collared at the scene by emergency med-
ical services. On arrival, the patient was alert and oriented
and had no complaints of pain. Vital signs were normal with
a heart rate of 74 bpm, respiratory rate of 14, blood pressure
of 119/65 mm Hg, temperature was 96.7° F, and oxygen
saturation was 99% on room air.
The patient’s head, eye, neck, heart, chest abdominal, and
extremity examinations were unremarkable. His spine was
clinically cleared, and he was taken off the board. Discharge
paperwork was prepared. Before discharge, an emergency
medicine resident and attending physician performed a
FAST examination for teaching purposes. The examination
showed a large fluid stripe in Morison’s pouch. Fluid was
also seen in the splenorenal recess and the pelvis. There was
no pericardial effusion detected. The patient remained clin-
ically stable and underwent abdominal CT scan, which
showed a large liver laceration. In the operating room, the
patient was found to have 1.5 L of blood in the abdomen.
The liver laceration was repaired, and the patient left the
hospital 5 days later without complication.
CASE 3
G.H. is a 19-year-old man with no significant past med-
ical history who was a restrained driver struck in the rear of
his car on the driver’s side. The car suffered moderate
damage. The patient had no LOC and complained of right
knee pain. He was quickly extricated from the car and
boarded and collared. On arrival in the ED, the patient had
a blood pressure of 125/78 mm Hg, heart rate of 84 bpm,
respiratory rate of 14, temperature of 96.9° F, and oxygen
saturation of 98% on room air. The head, neck, lung, and
extremity examinations were unremarkable with the excep-
tion of a 2-cm laceration on the right knee. The abdominal
examination revealed a soft, nontender abdomen with no
pain on palpation of all 4 quadrants. The patient was clin-
ically cleared and taken off the board. He sat in the bed
awaiting the arrival of his parents to transport him home.
While waiting, the patient volunteered to have a training
FAST examination performed on him. A moderate amount
of fluid was noted in Morison’s pouch, splenorenal recess,
219
and pelvis. An abdominal CT scan was ordered and revealed
a large splenic laceration and fluid throughout the abdomen.
The patient was taken to the operating room where his
spleen was removed. He was found to have almost 2 L of
blood in his abdomen. The patient suffered a wound dehis-
cence before discharge but recovered completely.
CASE 4
J.B. is a 44-year-old woman with a history of asthma who
was the passenger on a motorcycle that lost control and
tumbled at a moderate rate of speed. The patient was wear-
ing a helmet and leather riding gear. She reported no loss of
consciousness and ambulated at the scene. During transport
with emergency medical services, she noted right ankle pain
and complained of back discomfort from the board. On
arrival in the ED, the patient’s blood pressure was 115/65
mm Hg, heart rate was 78 bpm, respiratory rate was 16,
temperature was 96.0° F, and oxygen saturation was 99% on
room air. The head, neck, and lungs were unremarkable.
Extremity examination showed a shallow 1.5-cm laceration
of the right lateral maleolus without deformity or bony
tenderness. The abdominal examination showed a soft, non-
tender abdomen with no pain on palpation of all 4 quad-
rants.
The patient was clinically cleared and taken off the board.
No further testing was believed to be needed. The patient
agreed to a request by the trauma attending for a FAST
examination that revealed a large amount of fluid in the
pelvis and Morison’s pouch. An abdominal CT scan was
ordered and showed a splenic laceration and large amount
of fluid in the abdomen. The patient was taken to the
operating room where her spleen was repaired with mesh.
She was discharged 7 days later with a postoperative pneu-
monia treated with oral antibiotics.
CASE 5
K.P. is a 36-year-old woman with no significant past
medical history who slipped on ice and fell down approxi-
mately 5 stairs onto her left side. The patient had no loss of
consciousness and complained of left thigh pain. She ar-
rived to the ED by private automobile. On physical exam-
ination, her blood pressure was 120/60 mmHg, heart rate
was 77 bpm, respiratory rate was 14, oxygen saturation was
100% on room air, and she was afebrile. Eye and head
examination showed an abrasion to the left forehead. The
neck, lung, and heart examinations were normal. Abdomi-
nal examination showed an abrasion on the left flank, with-
out pain on palpation or crepitus. Extremity examination
revealed a left thigh abrasion with no deformity and minor
discomfort on palpation.
The patient was clinically cleared and dispositioned for
discharge. A bedside ultrasound examination was per-
formed for teaching purposed with the patient’s permission
that revealed fluid in the splenorenal recess and pelvis. A
urine human chorionic gonadotropin (HCG) was negative.
An abdominal CT scan was ordered and showed a large
amount of fluid in the abdomen and a splenic laceration. The
patient was admitted and treated conservatively at her in-
sistence. She required 1 transfusion during her hospital
course and was followed with repeat abdominal CT scan.
She was discharged 5 days later without complication.
220 AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 20, Number 3 ■ May 2002
CASE 6
J.N. is an 18-year-old man who fell onto a metal rail
striking his right upper quadrant and his right hand while
skateboarding. The patient had no LOC and was able to
ambulate. On arrival to the ED, he complained of right wrist
pain. Physical examination showed a blood pressure of
130/74 mm Hg, heart rate of 86 bpm, respiratory rate of 16,
and oxygen saturation of 99% on room air. Eye and neck
examinations were normal. Head examination showed a
minor abrasion over the right eyebrow. Heart and lung
examinations were negative. Abdominal and chest exami-
nations showed a midaxilary abrasion over ribs 8 and 9. No
fractures or crepitus was noted. All 4 quadrants of the
abdomen were completely normal with bowel sounds
present. Extremity examination showed equal pulses in all 4
extremities and no deformities. There was mild wrist ten-
derness in the right snuffbox.
The patient was cleared clinically and removed from
board and collar. A radiograph of the right wrist revealed no
fracture. As part of ongoing training, the patient received a
FAST examination, which revealed a fluid stripe in Mori-
son’s pouch. No fluid was noted elsewhere. An abdominal
and pelvic CT scan was ordered, which confirmed the
presence of a moderate amount of fluid in the abdomen but
no organ injury was detected. The patient was admitted for
conservative treatment. Shortly after arrival in the trauma
ward, the patient’s systolic blood pressure dropped below
90 mm Hg, and he was taken to the operating suite. A
mesenteric tear was noted and repaired. No further injury
was noted on laparotomy. The patient was discharged with-
out further complications 5 days later.
DISCUSSION
Ultrasound in the evaluation of trauma patients dates
back almost 20 years.1-4 Over the last 5 years, the FAST
examination has become part of the advance trauma life
support protocol and has been endorsed by several organi-
zations.5-7 The FAST examination has largely replaced the
diagnostic peritoneal lavage in trauma centers that use this
technology and often results in a more rapid and efficient
evaluation of the trauma patient.
It is generally accepted in emergency medicine practice
that not all patients sustaining blunt trauma need diagnostic
imaging provided they have no complaints of pain, are
clinically stable, and no distracting injury nor change in
mental status exist. A normally mentating patient with nor-
mal vital signs and no head injury, distracting injury, or
abdominal pain could be sent home without a diagnostic
peritoneal lavage (DPL), abdominal CT scan, or other im-
aging modalities. However, there are patient subgroups in
which significant missed injury is a possibility. These have
traditionally included patients who have altered levels of
consciousness for whatever reason and spinal cord injury
patients who may lack the sensation necessary to detect
abdominal pain.11,12
The literature on missed injuries in patients with normal
levels of consciousness generally describes delayed splenic
rupture, occasionally caused by conservative treatment fail-
ure.16,17 However, careful review of the articles shows that
the patients discussed had abdominal pain on physical ex-
amination, and an argument could be made that they re-
quired further diagnostic studies such as an abdominal CT
scan. Another group of trauma patients in whom abdominal
injury can be missed with ease is the pediatric population.
Gordon13 reported on 40 cases of missed injuries in pediat-
ric trauma patients, the majority of which were orthopedic
injuries. Missed abdominal injuries included 3 patients with
ruptured spleens, 3 with liver rupture, and 1 with ruptured
bowel. However, some of the patients in the study were
under 5 years of age and typically present a diagnostic
challenge.
Cases of spontaneous splenic rupture such as with mono-
nucleosis have been reported and, as described in 1 emer-
gency medicine report, can be concomitant with minimal to
no abdominal pain.16 However, we could find no instances
in the English literature in which cases of significant hemo-
peritoneum were found in blunt trauma patients that were
clinically normal and ready to be discharged home. In part,
this could be because of the lack of easily available diag-
nostic tools at the bedside such as the ultrasound machine.
Previously, these patients would have simply been sent
home without the diagnosis being obtained on the initial
visit. Some of them may have even done well and required
no return visits, whereas others could have succumbed after
discharge. With the spread of ultrasound technology
throughout emergency medicine, it is likely that such cases
will be encountered more frequently.
Other investigators have expressed misgivings regarding
the reliability of physical examination. Bennett and Jehle18
noted, “Even alert patients with isolated abdominal trauma
resulting in intraperitoneal hemorrhage may be deceptively
asymptomatic.” However, the investigators cited no litera-
ture to support this position. Scalea et al19 raised the concern
that young patients may be able to lose up to 60% of total
circulating blood volume and remain relatively asymptom-
atic. However, this position was derived from research on
healthy young dogs in an experimental setting, and the
relationship to human abdominal trauma patients is not
clear. Furthermore, there is still no literature documenting
significant hemoperitoneum in patients without abdominal
pain who have a normal level of consciousness as in our
case series. Nor is it clear what percentage of patients with
hemoperitoneum is relatively asymptomatic when evaluated
soon after their traumatic injury.
Although it is tempting to think that these patients had
signs of abdominal injury missed on examination, the cases
are from level 1 trauma centers that are accustomed to
evaluating blunt trauma patients. Furthermore, several of
the patients presented were evaluated by trauma surgeons as
well as emergency physicians, and they felt that the patients
did not require imaging studies of the abdomen or DPL. The
ultrasound examinations performed were done so for edu-
cational purposes on patients that were essentially acting as
voluntary normal controls. The detection of intraabdominal
blood was a surprise in each case, and in 2 of them the
discharge paperwork had to be voided. Although it is dif-
ficult to recommend scanning all blunt trauma patient based
on only 6 cases, it may be prudent to use the FAST exam-
ination more liberally when the bedside technology is avail-
able. Such cases are less likely to be missed especially when
BLAIVAS, SIERZENSKI, AND THEODORO ■ MISSED HEMOPERITONEUM ON FAST
coupled with repeat ultrasound examinations, which have a
proven use as suggested in both emergency medicine and
trauma literature.20,21
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