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Abdominal Trauma

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Abdominal Trauma Kate Jessop RN, BSN Valley Hospital Medical Center Emergency Department Diagnosing Trauma Classic signs and symptoms Pain, guarding, rigid abdomen ... – PowerPoint PPT presentation

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Title: Abdominal Trauma


1
Abdominal Trauma
  • Kate Jessop RN, BSN
  • Valley Hospital Medical Center
  • Emergency Department

2
Objectives
  • List the major organs of the abdominal cavity and
    relate them to their anatomical location.
  • Correlate mechanism of injury with injuries to
    the abdominal organs.
  • List three classic signs of abdominal injury.
  • Identify the diagnostic modalities for abdominal
    injuries.

3
Review of Anatomical Structures
http//movies-sawyerneilcaldwell.blogspot.com/2011
/03/abdomen-organs-diagram.html
4
Hollow Organ Injuries
  • Esophagus, stomach, small bowel, colon (large
    bowel), urethra and bladder.
  • Blunt hollow viscous injuries occur in less than
    1 of trauma patients.
  • Small bowel most common hollow organ injured in
    trauma.
  • Ecchymosis present in lower abdomen should alert
    provider to possible intestinal injury.

http//jama.jamanetwork.com/data/journals/jama/233
10/s_jrc25002f1.png
5
Hollow Organ Injuries Mechanisms of Injury
  • Seat belts cause compression, which can result in
    rupture of small bowel or colon.
  • Deceleration injuries may lead to shearing,
    tearing or avulsion of the small bowel.
  • Majority of hollow organ injury is related to
    penetrating trauma.

6
Gastric Injuries
  • Signs and Symptoms
  • Peritoneal irritation
  • Patient guarding abdomen, pain with palpation,
    general sense of abdominal pain
  • Evisceration of stomach
  • Stomach and/or other abdominal organs outside of
    the peritoneal cavity, but still attached by
    muscle attachments or other organs.
  • Gross blood in gastric aspirate (after orogastric
    or nasogastric tube is in place)
  • This is a nonspecific sign!
  • Signs and symptoms of gastric injuries are
    related to chemical irritation of nearby tissues
    due to leaking of highly acidic gastric contents.

7
Gastric injuries
  • Gastric tear

http//www.ispub.com/journal/the-internet-journal-
of-gastroenterology/volume-7-number-2/isolated-gas
tric-tear-due-to-blunt-abdominal-trauma.html
8
Esophageal Injuries
  • Signs and symptoms
  • Pain in chest, shoulder and neck
  • Subcutaneous emphysema
  • Crackling sensation felt when palpating patients
    skin
  • Peritoneal irritation
  • Patient guarding abdomen, pain with palpation,
    general sense of abdominal pain
  • Gross blood in gastric aspirate (after orogastric
    or nasogastric tube is in place)
  • This is a nonspecific sign!

9
Large and Small Bowel Injuries
  • Signs and Symptoms
  • Peritoneal irritation
  • Abdominal muscle rigidity and/or pain
  • Spasm of abdominal muscle
  • Rebound tenderness
  • Evisceration of abdominal organs
  • Hypovolemic shock
  • Gross blood from rectum

10
Large and Small Bowel Injuries
  • Perforated intestines secondary to trauma

http//www.openabdomen.org/diseases/trauma.cfm
11
Large and Small Bowel Injuries
  • Rupture and partial evisceration of bowel

http//atlas-emergency-medicine.org.ua/ch.7.htm
12
Large and Small Bowel Injuries
  • Perforated small intestine leaking bowel contents

http//www.ispub.com/journal/the-internet-journal-
of-gynecology-and-obstetrics/volume-16-number-3/se
vere-intraabdominal-trauma-in-illegal-abortion-a-c
ase-report.html
13
Bladder and Urethral Injuries
  • More common in males due to longer urethra
  • Most commonly due to blunt force trauma
  • Associated with pelvic fractures
  • Signs and symptoms
  • Suprapubic pain
  • Urge to urinate but inability to
  • Hematuria
  • Urinanalysis will reveal microscopic blood in
    urine
  • Blood at the urethral meatus
  • Blood in scrotum

14
Bladder and Urethral Injuries
  • Traumatic tear
  • in the bladder

http//www.ispub.com/journal/the-internet-journal-
of-gynecology-and-obstetrics/volume-16-number-3/se
vere-intraabdominal-trauma
15
Solid Organ Injury
  • Liver, Spleen and Kidney
  • Highly vascular and prone to profuse bleeding
  • Injuries that result in shock, or continuing
    bleeding are indication for urgent surgery
  • Injuries with no hemodynamic abnormalities can be
    treated non-operatively

16
Hepatic Injuries
  • Hepatic injury should be stabilized
    hemodynamically and then sent straight to surgery
    if warranted
  • Severity of injury ranges controlled hematoma to
    profuse hemorrhage
  • Subcapsular hematomas
  • Parenchymal lacerations
  • Vascular injuries of hepatic veins
  • Hepatic avulsion

17
Hepatic Injuries
  • Subcapsular hematoma

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ection3247745_sensors-10-06017f3npos38prt3
18
Hepatic Injuries
  • Liver laceration

http//www.trauma.org/index.php/main/image/154/
19
Hepatic Injuries
  • Signs and symptoms
  • Right upper quadrant pain
  • Rigidity, spasm, or involuntary guarding
  • Rebound tenderness
  • Hypoactive or absent bowel sounds
  • Signs of hypovolemic shock

20
Splenic Injuries
  • Fractures of 10th to 12th ribs associated with
    splenic trauma.
  • Injuries vary in severity (from least to worst)
  • Laceration of capsule
  • Nonexpanding hematoma
  • Ruptured subcapsular hematomas
  • Parachymal laceration
  • Severely fractured spleen or vascular tear
  • Splenic ischemia and masive blood less

21
Splenic Injuries
  • Laceration of the spleen

http//www.trauma.org/index.php/main/image/156/
22
Splenic Injuries
  • Signs and symptoms
  • Left upper quadrant tenderness
  • Pain in left shoulder while lying flat (Kehrs
    sign)
  • Signs of hypovolemia or hemorrhage
  • Abdominal rigidity, spasm or guarding

23
Splenic Injuries
  • Splenic hematoma with laceration

http//www.learningradiology.com/archives03/COW20
068-Splenic20laceration/spleniclaccorrect.htm
24
Renal Injuries
  • Posterior rib or lumbar vertebrae fractures
    should raise concern for renal injury.
  • Signs and symptoms
  • Hematuria
  • Can be gross or microscopic
  • Approximately 95 of significant renal injuries
    have some degree of hematuria
  • Flank or abdominal tenderness upon palpation
  • Ecchymosis on flank
  • Grey Turners sign
  • Normally does not develop for 6-12 hours after
    injury

25
Renal Injuries
http//www.surgical-tutor.org.uk/default-home.htm?
core/trauma/renal_trauma.htmright
http//www.trauma.org/index.php/main/image/172/pri
nt/print
26
Renal Injuries
  • Grey Turners Sign

http//clancyclark.blogspot.com/2012/06/grey-turne
r-s-sign.html
27
Pelvic Trauma
  • Pelvic fractures can lacerate major vessels,
    causing fatal hemorrhaging into the pelvic cavity
  • Four liters of blood can be held in the pelvic
    cavityaverage human body contains 4-7 liters
  • Stabilize with a sheet or belt wrapped
    circumferentially around hips at level of greater
    trochanter

28
Abdominal Trauma-Assessment
  • Airway, Breathing, Circulation
  • Look (Inspection)
  • Swelling, bruising, lacerations or abrasions
  • Listen (Auscultate)
  • Bowel sounds are there any and where are they?
  • Feel (Palpate)
  • Subcutaneous emphysema soft, rigid or distended
    abdomen palpable masses stable pelvis flank
    tenderness anal sphincter-presence or absence of
    tone

29
Abdominal Trauma-Nursing Interventions
  • Establish two large bore intravenous catheters
  • Intravenous fluids as ordered
  • Start with 1-2 liters of isotonic crystalloid
    solution, continue as needed or ordered
  • Blood products as ordered
  • In active hemorrhage O negative blood is a
    universal donor
  • Antibiotics as ordered
  • Early administration helps combat infection
  • Pain medication and antibiotics as ordered
  • Reassess frequently for pain
  • Is there a intense increase in pain? Did the
    location of pain change? Reassess patients
    status, vital signs, physical assessmentmake
    sure your patient is not deteriorating.

30
Abdominal Trauma-Nursing Interventions
  • Gastric tube
  • Decompresses the stomach and prevents aspiration
  • Prevents bradycardia secondary to vagal
    stimulation
  • Minimizes gastric leakage into abdominal cavity
  • May assist in identifying possible organ injury
    (test aspirate for occult blood)
  • Urinary catheter
  • Minimizes urine leakage into the surrounding
    tissues
  • Contraindications
  • Gross blood at urethral meatus indicates possible
    urethral trauma
  • Suprapubic catheterization should be considered
    at this point

31
Abdominal Trauma-Nursing Interventions
  • Cover wounds with sterile dressing
  • Both surgical and non-surgical wounds
  • Evisceration of abdominal contents requires a
    sterile dressing soaked in an isotonic
    crystalloid solution (such as 0.9 sodium
    chloride)
  • Do not push abdominal contents back into the
    torso
  • Stabilize impaled objects
  • Do NOT remove, stabilize instead
  • Use gauze, tape, any supplies availableif it
    works, use it!
  • Be careful not to move object during
    stabilization, remember movement of object means
    damage of underlying tissue
  • Stabilization should be at least a two person job
  • One person to hold object in place, another to
    stabilize object with materials

32
Stabilizing Impaled Objects
http//www.medskills.eu/index.php/dropbox/en/Body/
level3/topic8/null/1434/
http//www.moondragon.org/health/disorders/specifi
cwoundtreatment.html
33
Stabilizing Impaled Objects
http//members.tripod.com/cynthia_gray/emsphotos/i
njuries.html
http//www.medskills.eu/index.php/wiki/en/body/med
ical20fundamentals/critical20trauma20patients/a
bdominal20trauma/
34
Diagnosing Trauma
  • Classic signs and symptoms
  • Pain, guarding, rigid abdomen
  • Chemical peritonities pancreatic injury
  • Kehrs sign pain that radiates to shoulder
    during inspiration indicates splenic injury
  • Physical exam and interventions
  • Vital signs
  • Inspection
  • Auscultation
  • Percussion
  • Palpation
  • Gastric tube (orogastric or nasogastric)
  • Urinary Catheter

35
Diagnosing Trauma
  • Diagnostic exams continued
  • Diagnostic Peritoneal lavage
  • Presence of bile, feces or food fibers indicate
    bowel leakage
  • False negatives are a possibility
  • Decompress bladder and stomach via catheter and
    gastric tube to prevent accidental puncture
  • If initial aspiration of peritoneal fluid
    includes 10cc or more of blood equals an
    automatic positiveassume abdominal trauma
    present
  • Inexpensive, highly useful for intra-abdominal
    hemorrhage or with a hemodynamically unstable
    patient
  • Can be used to replace computerized tomography or
    focused assessment sonography for trauma

36
Diagnosing Trauma
  • Diagnostic exams continued
  • Focused Assessment Sonography for Trauma
  • Rapid, accurate, inexpensive, noninvasive and can
    be repeated multiple times
  • Can detect as little as 100 cc of fluid
  • Evaluates four areas for free fluid hepatorenal
    fossa, splenoreal fossa, pericardial sac, and
    pelvis
  • Radiographic study
  • Used when computerized tomography is unavailable
  • Useful to diagnose diaphragmatic rupture, free
    air indicating disruption of the gastrointestinal
    tract, and foreign bodies
  • Computerized tomography
  • Noninvasive and highly accurate but expensive
  • Patient needs to be hemodynamically stable

37
Diagnosing Trauma
  • Laboratory Tests
  • Hematocrit and Hemoglobin levels
  • Is a blood transfusion needed? Have levels
    changed from patients initial baseline values?
  • Serum lactate
  • Lactic acid is produced during sepsis (systemic
    infection).
  • Coagulation studies
  • Is the patient prone to hemorrhage due to
    coagulation abnormalities?
  • Is the patient on blood thinners?
  • Analysis of urine, stool or gastric contents for
    blood
  • Possible injury of related organ

38
Bibliography
  • TNCC trauma nursing core course (5th ed.).
    (2000). Park Ridge, Ill. Emergency Nurses
    Association.
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