Abdominal and Pelvic Trauma

Abdominal and pelvic trauma means injury to solid organs (liver, spleen, kidney, pancreas), hollow organs (stomach, small bowel, colon, bladder), the mesentery, and the pelvic ring with the retroperitoneal space behind it. Blood loss is the first threat, and it can hide in the abdomen, retroperitoneum or pelvis. You will not always see it. Keep hemorrhage and peritoneal injury apart in your head, because they are two separate problems.

• Solid-organ injury: bleeding from the liver, spleen or kidney. CT grades how bad the injury is. A hemodynamically stable patient with an isolated blunt liver or spleen injury is often managed without an operation.
• Hollow-viscus injury: a hole in bowel or bladder, which can cause peritonitis. Early CT can come back negative, so repeat the exam over time.
• Pelvic ring injury: bleeding from fracture sites and pelvic veins, mostly into the retroperitoneal space. A pelvic binder shrinks pelvic volume and buys time. It does not stop the bleeding.
• Intra-abdominal hypertension: after damage-control resuscitation, belly pressure can climb and impair perfusion and organ function. See the open-abdomen note under ED & ICU Management.

Blunt Abdominal Trauma

• Seat belt sign (bruising across the lower abdomen or flank from a lap belt), abdominal pain, tenderness or guarding after a frontal crash, fall or rapid deceleration.
• Flank or back bruising, or pain that doesn't match the exam? That can mean retroperitoneal injury.

Penetrating Trauma

• Gunshot or stab wound to the torso, flank or pelvis. The entry wound doesn't tell you which organs were hit.
• After a penetrating wound, shock, peritonitis or evisceration means immediate surgical evaluation.

Pelvic Fracture

• Pelvic pain, leg-length change or rotation, or a pelvic fracture in a patient with shock. Bleeding from a pelvic fracture is often hidden.

Genitourinary Injury

• Blood at the urethral meatus, gross hematuria, scrotal or perineal bruising or swelling, or a high-riding prostate: think urethral injury.
• Do not pass a urinary catheter blindly when urethral injury is suspected; follow protocol.

Red Flags

• SBP below 90 mmHg, HR above 100, or shock index above 1.0
• Altered mentation, or cool, pale skin with delayed capillary refill
• Free fluid on FAST with hypotension
• Unstable pelvis, or pelvic fracture with shock

The focused exam is for the first minutes. A positive finding changes your next move. A negative one doesn't end the search.

• Hemothorax or tension pneumothorax: chest injury can cause shock too. Check breath sounds, then see Thoracic Trauma.
• Hemorrhagic shock from extremity or external bleeding: you may be able to see the source. See Hemorrhagic Shock.
• Non-traumatic causes of shock: after a fall or crash, a ruptured abdominal aortic aneurysm, sepsis or cardiogenic shock can look like trauma. See Shock States.
• Postpartum bleeding: abdominal pain and shock in a pregnant or recently delivered patient may be obstetric hemorrhage. See Postpartum Hemorrhage.

1. Scene safety and mechanism: note the crash, fall height, ejection or penetrating object, and the time of injury. That time sets your tranexamic acid window.
2. Control external bleeding: direct pressure, hemostatic dressing or tourniquet for limb bleeding, per the Hemorrhage Control page.
3. Pelvis: apply a pelvic binder for a suspected unstable pelvic fracture, per protocol. Center it over the greater trochanters, not the iliac crests, and do not rock or spring the pelvis. A binder buys time. It isn't definitive control, and it doesn't fit every pelvic injury. A fracture with an open wound needs protocol input.
4. Penetrating wounds: stabilize an impaled object in place with a dressing and padding, and do not remove it unless it blocks the airway or prevents CPR. For eviscerated bowel, cover it with a moist sterile saline dressing, do not push it back in, and keep the patient warm. Give nothing by mouth. Follow the trauma protocol and medical direction.
5. Oxygen and airway: give oxygen and assist ventilation if the patient cannot maintain oxygenation. Watch for decreased mental status from hypoperfusion.
6. Keep warm: cover the patient and limit exposure. Hypothermia makes clotting and perfusion worse.
7. Transport priority: abdominal or pelvic trauma with shock, an unstable pelvis, or a penetrating torso wound makes this a priority patient to move from scene to ambulance under field triage protocol.

Doses vary by protocol; follow local protocols and medical direction.

• Vascular access (Paramedic/RN/CCT): two large-bore IV or IO lines when shock is present. See IV Insertion and IO Access.
• Tranexamic acid (Paramedic/RN/CCT): 1 g IV/IO over at least 10 min, then 1 g IV over 8 hr (the CRASH-2 regimen), for adults with suspected significant hemorrhage or hemorrhagic shock. Give early; do not wait for laboratory results. Do not start more than 3 hr after injury: in CRASH-2, treatment given after 3 hr increased death from bleeding (RR 1.44). Do not push the 1 g faster than 10 min (hypotension). Watch for thrombosis and seizures. Prehospital TXA is a protocol decision (see the 2025 NAEMSP, ACEP and ACS-COT joint position statement). See Tranexamic Acid.
• Analgesia (Paramedic/RN/CCT): in hypotension or shock (SBP below 90 mmHg), do not give morphine: histamine release and vasodilation can worsen hypotension. Use reduced, titrated fentanyl or sub-dissociative ketamine per protocol, with continuous BP, SpO2 and EtCO2 monitoring. Otherwise, morphine 0.1 mg/kg IV/IO slowly (adult max 10 mg initial dose), reassessed at peak effect and titrated in smaller increments. See Morphine. Fentanyl 1 mcg/kg IV/IO (adult max initial 100 mcg) is an alternative per protocol. See Fentanyl. Analgesia does not mask abdominal findings or delay diagnosis.
• Ketamine for analgesia (Paramedic/RN/CCT): sub-dissociative 0.1 to 0.3 mg/kg IV over 10 to 15 min, per protocol, as an opioid-sparing option. Monitor BP; resuscitate first and reduce the dose in profound shock (hypotension in catecholamine-depleted shock). See Ketamine.
• Massive transfusion (Paramedic/RN/CCT, where stocked): activate the program's massive-transfusion protocol. Red cells, plasma and platelets are given in the ratio the protocol sets. See Blood Products and Whole Blood.
• Crystalloid limit (Paramedic/RN/CCT): give only enough to keep a palpable radial pulse and intact mentation. Large volumes dilute clotting factors. See Normal Saline.
• Calcium (Paramedic/RN/CCT): give calcium per protocol when ionized calcium is low or during ongoing transfusion. Dose and route are protocol-dependent and are not given on this page. See Calcium Chloride.
• Permissive hypotension: target a restrained pressure (palpable radial pulse with intact mentation) per protocol, not normal pressure, except in traumatic brain injury. This page gives no numeric SBP target; use the protocol range. See Hemorrhagic Shock.
• Airway (Paramedic/RN/CCT): for a failing airway, see RSI.

• Imaging: CT of the abdomen and pelvis with IV contrast for a stable patient. A positive FAST with hypotension skips CT and goes to surgery or interventional radiology. A negative FAST in a stable patient still needs CT, because it doesn't rule out injury.
• Diagnostic peritoneal lavage: the German S3 polytrauma guideline update (2025, evidence searched to May 2021) dropped its recommendation for diagnostic peritoneal lavage in exceptional cases. That was a German consensus call, not a US standard. Local US trauma protocols may still use DPL or FAST for an unstable patient when FAST or CT isn't available. Follow local protocol.
• Solid-organ injury: nonoperative management is the approach for hemodynamically stable patients with isolated blunt liver or spleen injury, and selective angioembolization is an adjunct. Monitor hemoglobin and vital signs. When nonoperative management fails, the patient needs surgery or angioembolization.
• Penetrating trauma: diagnostic laparoscopy can be considered for a hemodynamically stable patient when the surgeon is unsure whether laparotomy is needed (German S3 2025 update). Whether to do it is a hospital surgical decision, not an EMS action.
• Pelvic fracture bleeding: a 2026 meta-analysis of 16 studies (6,591 participants) found no significant link between binder use and mortality in pooled adjusted analyses. Keep the binder as a temporizing step. Definitive control comes from the trauma team's pathway.
• Open abdomen: damage-control resuscitation can drive up intra-abdominal pressure or cause abdominal compartment syndrome. Leaving the abdomen open can relieve that pressure, per WSES guidance. For vasopressor support, see Shock States.
• Blood products and calcium: continue the massive-transfusion ratio and reassess after each product. Monitor ionized calcium and temperature during transfusion.
• Reversal: for warfarin-associated bleeding, 4-factor prothrombin complex concentrate with IV vitamin K per protocol. The PCC dose depends on pre-dose INR and body weight, per the product label. The label says to give vitamin K at the same time (vitamin K dose per protocol). See Prothrombin Complex Concentrate.

• Destination: a trauma center with general surgery and interventional radiology, and an obstetric team for pregnancy at 20 weeks or more.
• Continue in transit: pulse oximetry, capnography and continuous ECG. Reassess blood pressure, mental status and abdominal exam at the protocol interval.
• Air transport: as you climb, gas in closed spaces expands (Boyle's law). See Flight Transport Physiology. Confirm the hemorrhage plan before departure.
• Watch for: falling blood pressure, rising pain or distension, recurrent bleeding, and hypothermia.
• Handoff: mechanism and time of injury, FAST result, tranexamic acid time and dose, opioid doses and times, blood products given, and Rh status if pregnant.

• Pediatrics: kids compensate well, then crash suddenly. In the 2024 prospective validation of the PECARN intra-abdominal injury rule (7,542 children with blunt abdominal trauma), it found all 145 children with an injury needing acute intervention. In a 2025 external validation of 2,188 children, it caught 60 of 62 injuries needing intervention (sensitivity 96.8%) but missed some other intra-abdominal injuries, most often liver laceration. Adding trauma-bay labs and a chest x-ray improved identification. Pooled point-of-care ultrasound sensitivity runs lower in children (0.63 vs 0.78 in adults or mixed populations, thoracoabdominal injury). Dose by weight, and read vital signs against age-specific thresholds: see Weight-Based Dosing, Vital Signs and Pediatric Shock. Standardized pediatric tranexamic acid dosing has not been established, so use the program's weight-based protocol. IV or IO morphine bolus dosing in children is off-label. See Morphine.
• Pregnancy: resuscitate the mother first. Good maternal resuscitation is the best early treatment for the fetus (2025 EAST guideline). Assess the fetus at the end of the primary survey, once the mother has had a rapid evaluation. The 2025 EAST guideline conditionally recommends a formal observation period of at least 4 to 6 hours for a viable pregnancy. Radiation exposure is no reason to hold imaging when it is medically indicated. In traumatic arrest with a pregnancy of 20 weeks or more, the 2025 EAST guideline conditionally recommends resuscitative hysterotomy as soon as possible (ED/OB). Rh-negative patients get Rh D immune globulin within 72 hours of injury, with the dose set by the Kleihauer-Betke test. See Rho(D) Immune Globulin. Involve obstetrics early.
• Older Adults: anticoagulant and antiplatelet use raises the bleeding risk, and beta-blockers or limited reserve can blunt tachycardia. See Hemorrhagic Shock.
• Renal Impairment: the kidneys clear tranexamic acid, so reduce doses per the label and protocol.
• Patients on Anticoagulants: reversal depends on the agent. Warfarin gets 4-factor prothrombin complex concentrate with IV vitamin K per protocol, dosed by pre-dose INR and weight. Other agents follow the reversal protocol.

• Error: you read a negative FAST as proof of no bleeding. Pooled abdominal sensitivity is 68%, so a negative exam in a stable patient still needs CT.
• Error: you send a hypotensive patient with a positive FAST to CT first. With hypotension and a positive exam, that patient belongs in surgery or interventional radiology.
• Error: you call a pelvic binder definitive hemorrhage control. Pooled observational data show no mortality link, but those studies may be confounded by injury severity. Judge the binder by bleeding control and transfusion needs.
• Error: you admit every patient with a seat belt sign by reflex after a negative, high-quality CT. A 2022 cohort found hollow-viscus injury was very rare in that setting. Follow local policy.
• Error: you discharge a patient with a seat belt sign who has pain, guarding or free fluid on CT.
• Error: you run the PECARN rule on a child without trauma-bay labs or a chest x-ray. The 2025 external validation missed some other intra-abdominal injuries, most often liver laceration. Most of those misses had an abnormal trauma-bay lab or chest x-ray finding.
• Error: you skip Rh status in a pregnant trauma patient. Rh-negative patients need a Kleihauer-Betke test and, if indicated, Rh D immune globulin.