Inspect the genitals and perineum for soft tissue injuries, bleeding and haematoma.Flank bruising and swelling may raise suspicion for a retroperitoneal injury. However, this symptom usually takes several hours to develop. Cullen's sign - ie periumbilical ecchymosis - may indicate retroperitoneal haemorrhage.Bradycardia may indicate the presence of free intraperitoneal blood in a patient with blunt abdominal injuries.Note abdominal distention and any discolouration. Observe the respiratory pattern, since abdominal breathing may indicate spinal cord injury.The seat belt sign is particularly associated with an increased risk of gastrointestinal and pancreatic injuries in children. People injured in motor vehicle collisions may present with a 'seat belt sign' (bruising along the site of the lap portion of the seat belt), which is associated with a high rate of injury to the abdominal organs.Note patterns of abrasion and/or bruising. Examine the abdomen to determine the presence of external signs of injury.This will ensure that occult abdominal injuries are picked up quickly. Victims of blunt trauma who have a benign abdomen upon initial presentation, should have frequent serial examinations, in conjunction with the appropriate diagnostic studies, such as abdominal CT scan and bedside ultrasonography. For life-threatening injuries requiring emergency surgery, comprehensive secondary survey should be delayed until the patient has been stabilised.After appropriate primary survey and initiation of resuscitation, focus attention on secondary survey of the abdomen. However, a high index of suspicion must be maintained to avoid missing occult injuries. They are usually more predictable with regard to injured organs. Stab wound injuries can be inflicted by many objects other than knives, including knitting needles, garden forks, wire, fence railing, pipes and pencils.Shotgun injuries, especially at close range, are frequently associated with massive tissue damage and should be regarded as high-energy transfer injuries. The velocity of military firearms and hunting rifles is much higher than that of civilian handguns and therefore has a much higher energy transfer. The path of the missile is unpredictable and secondary missiles - eg, bone fragments or fragments of the bullet - can inflict other injuries. A gunshot wound is associated with high-energy transfer and the extent of intra-abdominal injuries is difficult to predict.This implies that either a gunshot wound (or other high-velocity missile/fragment), shrapnel or a stab wound has entered the abdominal cavity.
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