Abdominal Trauma

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Abdominal Trauma

• Victor Politi, M.D., FACP, Medical Director,
  SVCMC School of Allied Health Professions

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The Abdomen

• Everything between diaphragm and pelvis
• Injury, illness very difficult to assess because
  of large variety of structures

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Introduction

• One of bodys largest cavities.
• Multiple vital organs.
• Large volumes of blood can be lost before signs
  and symptoms manifest.
• Must be alert for signs of transmitted injury
• Deformity, swelling, and ecchymosis
• Prevention
• Highway safety
• Seatbelt usage
• Proper application
• Airbags

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Abdominal Anatomy and Physiology

• Boundaries
• Superior Diaphragm
• Inferior Pelvis
• Posterior Vertebral column and posterior and
  inferior ribs
• Lateral Muscles of the flank
• Anterior Abdominal muscles

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Abdominal Anatomy and Physiology

• Three Specific Spaces
• Peritoneal Space
• Organs covered by abdominal (peritoneal) lining
• Retroperitoneal Space
• Organs posterior to the peritoneal lining
• Pelvic Space
• Organs contained within pelvis

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Organs by Abdominal Quadrant
Upper
Lower
Right
Left
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Hollow and Solid Abdominal Organs

• Solid
• Liver
• Spleen
• Pancreas
• Kidneys
• Ovaries

• Hollow
• Stomach
• Small intestine
• Large intestine
• Gall bladder
• Bladder
• Uterus

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Abdominal Anatomy and PhysiologyMajor Abdominal
Structures

• Digestive Tract
• AKA Alimentary canal
• Structures
• Stomach
• Small Intestine
• Large Intestine
• Rectum
• Accessory Organs
• Liver
• Gallbladder
• Pancreas

• Urinary System
• Kidneys
• Ureter
• Urinary Bladder
• Urethra
• Immune System
• Spleen
• Genitals
• Ovaries
• Fallopian tubes
• Uterus
• Vagina

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Abdominal Anatomy and PhysiologyDigestive Tract

• Function
• Churn material to be digested
• Excrete digestive juices
• Absorb nutrients and water
• Components
• Stomach
• Food mixed with HCl and enzymes to form chyme
• Small bowel
• Food moved through bowel by peristalsis
• Duodenum
• Jejunum
• Ileum
• Large bowel (Colon)
• Rectum
• Anus

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Abdominal Anatomy and PhysiologyAccessory Organs

• Liver
• Located in upper right quadrant
• 2.5 of total body weight
• Receives 25 of cardiac output and has greatest
  blood reserve
• Suspended by ligamentum teres
• Can lacerate liver in deceleration trauma
• Function
• Detoxifies blood
• Removes damaged or aged erythrocytes
• Stores glycogen and agents for metabolism
• Liver tissue will grow to normal size following
  partial removal.

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Abdominal Anatomy and PhysiologyAccessory Organs

• Gallbladder
• Small hollow organ located behind and beneath
  liver
• Receives bile
• Waste product from reprocessing of RBCs
• Used to digest fatty foods (emulsification)
• Pancreas
• Produces endocrine hormones and exocrine enzymes
• Glucagon
• Insulin
• Digestive enzymes that return the chyme pH to
  normal and break down proteins

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Abdominal Anatomy and PhysiologyAccessory Organs

• Spleen
• Part of immune system
• Located behind stomach and lateral to kidney in
  upper left quadrant
• Function
• Immunology
• Stores large volume of blood
• Most fragile abdominal organ
• Commonly injured in blunt trauma affecting the
  left flank

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Abdominal Anatomy and PhysiologyUrinary System

• Components
• Kidneys
• Collect waste products in blood stream
• Concentrate products into urine
• Reabsorb water and salt
• Regulate body osmotic balance
• Adrenal glands
• Superior and attached to kidneys
• Component of endocrine system
• Release epinephrine and norepinephrine
• Ureters
• Urinary bladder
• Can contain as much as 500 mL of urine
• Urethra

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Abdominal Anatomy and Physiology

• Genitalia
• Female sexual organs
• Represent an open passage to the interior of the
  abdominal cavity
• Components
• Ovaries
• Fallopian tubes
• Uterus
• Vagina
• Male sexual organs
• External to the abdomen
• Components
• Testes
• Penis

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Abdominal Anatomy and PhysiologyPregnant Uterus

• Uterus and contents grow rapidly after conception
  and until delivery
• 1st Trimester (012 weeks)
• Well protected
• 2nd Trimester (1224 weeks)
• Uterus displaces organs upward
• 3rd Trimester (24 weeks to term)
• Fills entire abdominal cavity
• Displaces diaphragm upward

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Abdominal Anatomy and PhysiologyPregnant Uterus

• Affects on Maternal Physiology
• Increases circulatory blood volume by 45
• Greater volume but fewer RBCs
• Results in relative anemia
• Cardiac output increases by 40
• Heart rate increases by 15 bpm
• Compresses the vena cava in 3rd trimester
• Reduces venous return
• Supine hypotensive syndrome

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Abdominal Anatomy and PhysiologyVasculature

• Key Vessels
• Abdominal aorta
• Blood supply to abdomen
• Left of spinal column
• Iliac arteries
• Bifurcation of aorta at the upper sacral level
• Inferior vena cava
• Adjacent to spinal column

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Abdominal Anatomy and PhysiologyVasculature

• Portal System
• Venous subsystem
• Collects venous blood, fluid, and nutrients
  absorbed by the bowel
• Transports to liver
• Detoxification, storage of excess nutrients
• Adds deficient nutrients

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Abdominal Anatomy and PhysiologyPeritoneum

• Serous membrane that surrounds the interior of
  most of the abdominal cavity
• Covers most of small bowel and some of the
  abdominal organs
• Small amount of fluid between peritoneal layers
• Mesentery
• Double fold of peritoneum
• Supports and suspends small bowel from posterior
  abdominal wall
• Omentum
• Additional fold
• Insulates and protects anterior surface of abdomen

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Retroperitoneal Structures

• Kidneys
• Duodenum
• Pancreas
• Urinary Bladder
• Posterior portions of ascending and
• descending colon
• Rectum
• Major vascular structures

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Pathophysiology of Abdominal InjuryMechanism of
Injury

• Penetrating Trauma
• Energy transmitted to surrounding tissue
• Projectile cavitation, pitch, and yaw
• Results in
• Uncontrolled hemorrhage
• Organ damage
• Spillage of hollow organ contents
• Irritation and inflammation of abdominal lining
• Liver most commonly affected organ
• Shotgun trauma
• Multiple projectiles

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Pathophysiology of Abdominal InjuryMechanism of
Injury

• Blunt Trauma
• Produces least visible signs of injury
• Causes
• Deceleration
• Contents damaged by change in velocity
• Compression
• Organs trapped between other structures
• Shear
• Part of an organ is able to move while another
  part is fixed
• Example ligamentum teres

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Pathophysiology of Abdominal InjuryMechanism of
Injury

• Blast Injuries
• Blunt and penetrating MOIs
• Irregular shaped shrapnel and debris
• Pressure wave
• Compresses and relaxes air-filled organs
• Contuses or ruptures organs
• Abdominal injury is secondary concern during
  blast injury.

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Pathophysiology of Abdominal Injury

• Injury to the Abdominal Wall
• Skin and muscles transmit blunt trauma to
  internal structures.
• Typically only show erythema.
• Visible swelling and ecchymosis occur over
  several hours.
• Penetrating trauma may appear minimal externally
  in comparison to internal trauma.
• Muscle may mask the size of the external wound.
• Evisceration may be present.

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Pathophysiology of Abdominal Injury

• Injury to the Abdominal Wall
• Trauma to thorax, buttocks, flanks, and back may
  penetrate abdomen.
• Lower chest may injure spleen, liver, stomach, or
  gallbladder.
• Diaphragmatic tears
• Herniation of abdominal contents into thorax.

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Pathophysiology of Abdominal Injury

• Injury to the Hollow Organs
• May rupture with compression from blunt forces
• May tear due to penetrating trauma
• Spillage of contents into
• Retroperitoneal space
• Peritoneal space
• Pelvic space

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Pathophysiology of Abdominal Injury

• Injury to the Hollow Organs
• Intestines have a large amount of bacteria
• Leakage can result in sepsis
• Manifestations of Blood Loss
• Hematochezia blood in stool
• Hematemesis blood in emesis
• Hematuria blood in the urine

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Pathophysiology of Abdominal Injury

• Injury to the Solid Organs
• Dense and less strongly held together
• Prone to contusion
• Bleeding
• Fracture (rupture)
• Unrestricted hemorrhage if organ capsule is
  ruptured

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Pathophysiology of Abdominal Injury

• Injury to solid organs
• Specific Organs
• Spleen pain referred to left shoulder
• Pancreas pain radiates to back
• Kidneys pain radiates from flank to groin and
  hematuria
• Liver pain referred to the right shoulder

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Pathophysiology of Abdominal Injury

• Injury to the Vascular Structures
• Abdominal aorta and vena cava
• Prone to direct blunt or penetrating trauma
• May be injured in deceleration injuries
• Blood accumulates beneath diaphragm.
• Irritation of muscular structures
• Produces referred pain in the shoulder region
• Greater volume of blood can be lost
• Presence of blood in abdomen stimulates vagus
  nerve resulting in slowing of heart rate
• Blood can isolate in any of the abdominal spaces.

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Pathophysiology of Abdominal Injury

• Injury to the Mesentery and Bowel
• Provides bowel with circulation, innervation, and
  attachment
• Disrupts blood vessels supplying the bowel
• Leads to ischemia, necrosis, or rupture
• Blood loss minimal
• Peritoneal layers contain hemorrhage
• Tear of mesentery may rupture bowel
• Penetrating trauma to the lateral abdomen likely
  to injure large bowel

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Pathophysiology of Abdominal Injury

• Injury to the Peritoneum
• Delicate and sensitive lining of anterior abdomen
• Peritonitis
• Inflammation of the peritoneum due to
• Bacterial irritation
• Due to torn bowel or open wound
• Chemical irritation
• Caustic nature of digestive enzymes
• Urine initiates inflammatory response

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Pathophysiology of Abdominal Injury

• Injury to the Peritoneum
• Blood does not induce peritonitis
• Progression
• Slight tenderness at location of injury
• Rebound tenderness
• Guarding
• Rigid, board-like feel

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Pathophysiology of Abdominal Injury

• Injury to the Pelvis
• Serious skeletal injury
• Life-threatening hemorrhage
• Potential injury to pelvic organs
• Ureters
• Bladder
• Urethra
• Female Genitalia
• Prostate
• Rectum
• Anus

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Pathophysiology of Abdominal Injury

• Injury During Pregnancy
• Trauma is the number one killer of pregnant
  females.
• Penetrating abdominal trauma accounts for 36 of
  maternal mortality.
• GSW account for 4070 of penetrating trauma.
• Blunt trauma due to improperly worn seatbelts.
• Auto collisions are leading cause of mortality.
• Changing dimensions of uterus
• Protects abdominal organs.
• Endangers uterus and fetus.

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Pathophysiology of Abdominal Injury

• Injury During Pregnancy
• Maternal Changes
• Increasing size and weight of uterus
• Compresses inferior vena cava
• Reduces venous return to heart
• Increasing maternal blood volume
• Protects mother from hypovolemia
• 3035 of blood loss necessary before signs of
  shock
• Uterus is thick and muscular
• Distributes forces of trauma uniformly to fetus
• Reduces chances for injury

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Pathophysiology of Abdominal Injury

• Injury During Pregnancy
• Risk of uterine and fetal injury increases with
  the length of gestation.
• Greatest risk during 3rd trimester
• Penetrating trauma may cause fetal and maternal
  blood mixing.
• Blunt trauma complications
• Uterine rupture
• Abruptio placentae
• Premature rupture of amniotic sac

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Pathophysiology of Abdominal Injury

• Injury to Pediatric Patients
• Children have poorly developed abdominal
  musculature and smaller diameter
• Rib cage more cartilaginous
• Transmits injury to organs beneath easier
• Increased incidence of injury to
• Liver
• Kidney
• Spleen

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Pathophysiology of Abdominal Injury

• Injury to Pediatric Patients
• Shock
• Compensate well for blood loss
• May not show signs and symptoms until 50 of
  blood is lost

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Assessment of the Abdominal Injury Patient

• Scene Size-up
• Must evaluate MOI to assess seriousness of injury
• Identify strength and direction of forces
• Velocity of impact
• Focus observations and palpation on that site
• Develop a mental list of possible organs involved
• If auto crash
• Determine if seatbelts used properly
• Interior signs of impact
• Steering wheel and dashboard deformity

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Assessment of the Abdominal Injury Patient

• Scene Size-up
• Auto Crash Injury Patterns
• Frontal impact
• Compress abdomen
• Liver, spleen, and rupture of hollow organs
• Right impact
• Liver, ascending colon, and pelvis
• Left impact
• Spleen, descending colon and pelvis
• Children and pedestrians
• Abdominal injuries common

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Assessment of the Abdominal Injury Patient

• Scene size-up
• Gunshot Wounds
• Type and caliber of weapon
• Check whether assailant still on scene

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Assessment of the Abdominal Injury Patient

• Initial Assessment
• LOC
• Drug or alcohol use
• Evaluate ABCs and immediate threats

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Assessment of the Abdominal Injury Patient

• Rapid Trauma Assessment
• Rapid and Full Trauma Assessment.
• Closely examine regions with a high index of
  suspicion.
• Expose and Examine for DCAP-BTLS.
• If suspected pelvic injury, DO NOT test pelvis.
• Palpate entire abdomen.
• Evaluate for entrance and exit wounds.

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Assessment of the Abdominal Injury Patient

• OPQRST Assessment
• Characteristics of pain
• Tenderness versus rebound tenderness
• SAMPLE History
• Vital Assessment

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Assessment of the Abdominal Injury Patient

• Considerations with Pregnant Patients
• Be observant for
• Signs of shock
• PRETREAT signs may not develop until 30 of
  blood volume lost
• Body begins shunting blood from GI/GU to primary
  organs
• Supine hypotensive syndrome
• Premature contractions
• Vaginal hemorrhage
• Uterine rupture versus abruptio placentae
• Uterus development
• Abnormal asymmetry

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Assessment of the Abdominal Injury Patient

• Ongoing Assessment
• Trend vital signs
• Every 5 minutes for critical patients
• Evaluate for
• Progressive peritonitis
• Progressive hemorrhage
• BP and capillary refill
• Pulse rate and pulse oximetry
• Mental status
• Skin condition
• Ineffective aggressive fluid resuscitation

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Assessment of the Abdominal Injury Patient

• Ongoing Assessment
• Trend vital signs
• Every 5 minutes for critical patients
• Evaluate for
• Progressive peritonitis
• Progressive hemorrhage
• BP and capillary refill
• Pulse rate and pulse oximetry
• Mental status
• Skin condition
• Ineffective aggressive fluid resuscitation

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Management of the Abdominal Injury Patient

• General Management
• Position patient
• Position of comfort unless spinal injury
• Flex knees or left lateral recumbent
• General shock care
• PASG application
• Specific injury care
• Impaled objects or eviscerations

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Management of the Abdominal Injury Patient

• Fluid Resuscitation
• Large-bore IV with isotonic solution
• Consider 2 bolus if pulse does not slow
• Large-bore IV lock for use if patients BP drops
  below 80 mmHg
• Fluid challenge 250 mL or 20 mL/kg
• Limit to 3 L
• Titrate to SBP of 80 mmHg

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Management of the Abdominal Injury Patient PASG

• Contraindications
• Concurrent penetrating chest trauma
• Abdomen inflation contraindicated in pregnancy
• Inflate legs only

• Indications
• Evisceration
• If SBP lt60 mmHg
• Intra-abdominal bleeding
• Shock
• Incremental inflation titrated to BP and Pulse

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Management of the Abdominal Injury Patient

• Management of the Pregnant Patient
• Positioning
• Left lateral recumbent.
• If on backboard tilt backboard.
• Facilitates venous return
• Oxygenation
• High-flow O2.
• Consider PPV by BVM if hypoxia ensues.
• Maintain high index of suspicion for
  intra-abdominal bleeding.
• Consider IV and PASG.

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To review - Abdominal Trauma Patients

• ABC in all patients
• Airway Obstruction
• Pneumothorax, Hemothorax
• Adequate IV Access Short, Large-bore
• Hemodynamic stability
• ? Presence of abdominal injury
• Intraperitoneal
• Retroperitoneal
• Diagnostic interventions
• Therapeutic interventions

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ED Ultrasound

• Not an echocardiogram
• Learning curve and operator-dependent
• Four quadrant evaluation for fluid
• In common use
• Useful in conjunction with CT and to
• triage unstable patient

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CT Scan

• Hemodynamically stable patients
• Visualizes retroperitoneum
• Duodenum, pancreas, kidneys
• Cystogram
• Poor sensitivity for bowel injury
• Seat belt injury associated with bowel injury
• L-2 to L-4 fracture
• Peri-umbilical abdominal contusion

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Injuries Often Associated with Abdominal Trauma

• Scapular Fracture Aorta/GV
• First/Second Rib Aorta/GV
• Lumbar Spine (L2) Pancreas, Duodenum
• Femur/Humerus Neurovascular
• Knee Dislocation Popliteal Artery
• Fall Calcaneus, T/L Spine
• Rib Fractures Pulmonary

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Blunt Hepatic Trauma

• Many liver injuries stop bleeding spontaneously
• Non-therapeutic laparotomies frequent
• CT grade does not predict need for surgery
• Mortality less in non-operative group
• Few failures with non-operative approach

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Hepatic Injury

• Associated injuries affect mortality
• Hemorrhage Packing with re-look laparotomy in
  24-48 hours
• Wide drainage with closure
• Bile Leak
• Interval closure may be required
• Vigilance for Abdominal Compartment Syndrome

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Blunt Abdominal Trauma

• Blunt abdominal trauma is a leading cause of
  morbidity and mortality among all age groups.
• Identification of serious intra-abdominal
  pathology is often challenging.

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Blunt Abdominal Trauma

• Many injuries may not manifest during the initial
  assessment and treatment period.

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Blunt Abdominal Trauma

• Mechanisms of injury often result in other
  associated injuries that may divert attention
  from potentially life-threatening intra-abdominal
  pathology.

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Missed Injuries

• Missed or delayed diagnoses of injuries occur in
  about 10 of trauma patients
• Life before limb may preclude complete exam in
  ER
• Altered mental status predisposes to overlooked
  injuries
• Failure to examine, order appropriate tests,
  interpret tests, follow-up

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Just Remember !!!!

• ABC in every patient
• ABC with every location change
• Trauma series of radiographs in all patients
• Consider ED ultrasound early
• Travel to Radiology only with stable patient
• Consider associated injuries