Title: Abdominal Trauma
1Abdominal Trauma
- Kate Jessop RN, BSN
- Valley Hospital Medical Center
- Emergency Department
2Objectives
- 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.
3Review of Anatomical Structures
http//movies-sawyerneilcaldwell.blogspot.com/2011
/03/abdomen-organs-diagram.html
4Hollow 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
5Hollow 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.
6Gastric 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.
7Gastric injuries
http//www.ispub.com/journal/the-internet-journal-
of-gastroenterology/volume-7-number-2/isolated-gas
tric-tear-due-to-blunt-abdominal-trauma.html
8Esophageal 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!
9Large 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
10Large and Small Bowel Injuries
- Perforated intestines secondary to trauma
http//www.openabdomen.org/diseases/trauma.cfm
11Large and Small Bowel Injuries
- Rupture and partial evisceration of bowel
http//atlas-emergency-medicine.org.ua/ch.7.htm
12Large 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
13Bladder 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
14Bladder 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
15Solid 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
16Hepatic 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
17Hepatic Injuries
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18Hepatic Injuries
http//www.trauma.org/index.php/main/image/154/
19Hepatic Injuries
- Signs and symptoms
- Right upper quadrant pain
- Rigidity, spasm, or involuntary guarding
- Rebound tenderness
- Hypoactive or absent bowel sounds
- Signs of hypovolemic shock
20Splenic 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
21Splenic Injuries
http//www.trauma.org/index.php/main/image/156/
22Splenic 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
23Splenic Injuries
- Splenic hematoma with laceration
http//www.learningradiology.com/archives03/COW20
068-Splenic20laceration/spleniclaccorrect.htm
24Renal 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
25Renal 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
26Renal Injuries
http//clancyclark.blogspot.com/2012/06/grey-turne
r-s-sign.html
27Pelvic 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
28Abdominal 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
29Abdominal 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.
30Abdominal 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
31Abdominal 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
32Stabilizing Impaled Objects
http//www.medskills.eu/index.php/dropbox/en/Body/
level3/topic8/null/1434/
http//www.moondragon.org/health/disorders/specifi
cwoundtreatment.html
33Stabilizing 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/
34Diagnosing 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
35Diagnosing 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
36Diagnosing 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
37Diagnosing 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
38Bibliography
- TNCC trauma nursing core course (5th ed.).
(2000). Park Ridge, Ill. Emergency Nurses
Association.