Abdominal

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Abdominal
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Abdominal Organs
ADUKPIE
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Types of Abdominal Organs

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Abdominal Organs
LUQ
RUQ
Spleen Stomach Kidney Part of the
Liver Kidney Large Intestine Small Intestine Part
of the Pancreas
Liver Gall Bladder Kidney Part of the
Pancreas Large Intestine
Lt Ureter Large Intestine Small Intestine Femoral
Artery/Vein to Left Leg
Appendix Large Intestine Rt Ureter Small
Intestine Femoral Artery/Vein to Rt Leg
RLQ
LLQ
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Traumatic Injuries
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Abdominal Trauma

• May be difficult to evaluate in the prehospital
  setting due to
• Wide spectrum of potential injuries to multiple
  organs
• Physical findings that are sometimes lacking or
  exaggerated

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Abdominal Trauma

• Assessment may be compromised by
• Use of alcohol and/or recreational drugs
• Injury to brain, spinal cord
• Injury to ribs, spine, pelvis
• Exercise a high degree of suspicion based on
  mechanism of injury and kinematics

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Boundaries of the Abdomen

• Diaphragm
• Anterior abdominal wall
• Pelvic bones
• Vertebral column
• Muscles of the abdomen and flanks

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Surface Anatomy of Abdomen

• Quadrants
• Upper - right, left
• Lower - right, left
• Xiphoid
• Symphysis pubis
• Umbilicus

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Peritoneal Cavity

• Also called the true abdominal cavity
• Quadrants
• Upper - right, left
• Lower - right, left
• Contents-liver, spleen, stomach, small intestine,
  colon, gallbladder, female reproductive organs

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Pelvic Cavity

• Surrounded by the pelvic bones
• Lower part of retroperitoneal space
• Contents
• Rectum
• Bladder
• Urethra
• Iliac vessels
• In women, internal genitalia

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Retroperitoneal Space

• Potential space behind the true abdominal
  cavity
• Contents (ADUCKPIE)
• Abdominal aorta
• Duodenum
• Ureter
• Colon
• Kidneys
• Pancreas
• Inferior vena cava
• Esophagus

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Mechanisms of Abdominal Injury

• Blunt trauma
• Compression or crushing forces
• Shearing forces
• Deceleration forces
• Degree of injury is usually related to
• Quantity and duration of force applied
• Type of abdominal structure injured (fluid
  filled, gas filled, solid, hollow)

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Blunt Trauma

• Motor vehicle collisions
• Motorcycle collisions
• Pedestrian injuries
• Falls
• Assault
• Blast injuries

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Penetrating Trauma

• Energy imparted to the body
• Low velocity - knife, ice pick
• Medium velocity - gunshot wounds, shotgun wounds
• High velocity - high-power hunting rifles,
  military weapons
• Ballistics
• Trajectory
• Distance

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Solid Hollow Organs

• Solid Organs
• Liver
• Spleen
• Pancreas
• Kidneys
• Adrenals
• Ovaries (female)

• Hollow Organs
• Stomach
• Intestines
• Gallbladder
• Urinary bladder
• Uterus (female)

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Solid Organ Injury
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Liver

• Largest organ in the abdominal cavity
• Located in the right upper quadrant of abdomen
• Commonly injured from trauma to the
• Eighth through twelfth ribs on right side of body
• Upper central part of abdomen
• Damaged in 19 of blunt ABD trauma
• 37 of penetrating trauma

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Liver

• Suspect liver injury in any patient with
• Steering wheel injury
• Lap belt injury
• History of epigastric trauma
• After injury, blood and bile escape into
  peritoneal cavity
• Produces signs and symptoms of shock and
  peritoneal irritation, respectively

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Spleen

• Lies in upper left quadrant of abdomen
• Rich blood supply
• Slightly protected by organs surrounding it
  medially and anteriorly and by lower portion of
  rib cage
• Most commonly injured organ from blunt trauma
  (41)
• Associated intraabdominal injuries common
• 40 of patients do not show symptoms

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Spleen

• Suspect splenic injury in
• Motor vehicle crashes
• Falls or sport injuries in which there was an
  impact to lower left chest, flank, or upper left
  abdomen
• Kehrs sign
• Left upper quadrant pain with radiation to left
  shoulder
• Common complaint associated with splenic injury

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Kidneys

• Located high on posterior wall of abdominal
  cavity in retroperitoneal space
• Held in place by renal fascia
• Cushioned by a generous layer of adipose tissue
• Partially enclosed and protected by lower rib cage

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Kidneys

• Injuries may involve fracture and laceration
• Resulting in hemorrhage, urine extravasation, or
  both
• Contusions usually are self-limiting
• Heal with bed rest and forced fluids
• Fractures and lacerations may require surgical
  repair

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Hollow Organ Injury
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Stomach

• Not commonly injured after blunt trauma because
  of its protected location in abdomen
• Penetrating trauma may cause gastric transection
  or laceration
• Patients exhibit signs of peritonitis rapidly
  from leakage of gastric contents
• Diagnosis confirmed during surgery unless
  nasogastric drainage returns blood

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Colon and Small Intestine

• Injury is usually the result of penetrating
  trauma
• Large and small intestine may also be injured by
  compression forces
• High-speed motor vehicle crashes
• Deceleration injuries associated with wearing
  personal restraints
• Bacterial contamination common problem with these
  injuries

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Retroperitoneal Organ Injury

• May occur because of blunt or penetrating trauma
  to the
• Anterior abdomen
• Posterior abdomen (particularly the flank area)
  or
• Thoracic spine

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Ureters

• Hollow organs
• Rarely injured in blunt trauma because of their
  flexible structure
• Injury usually occurs from penetrating abdominal
  or flank wounds (stab wounds, firearm injuries)

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Pancreas

• Solid organ that lies in the peritoneal space
• Blunt injury usually occurs from a crushing
  injury of the pancreas between the spine and a
  steering wheel, handlebar, or blunt weapon
• Most pancreatic injuries are due to penetrating
  trauma

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Duodenum

• Lies across the lumbar spine
• Seldom injured due to its location in the
  retroperitoneal area, near pancreas
• May be crushed or lacerated when great force of
  blunt trauma or penetrating injury occurs
• Usually associated with concurrent pancreatic
  trauma

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Pelvic Organ Injury

• Usually results from motor vehicle crashes that
  produce pelvic fractures
• Less frequent causes
• Penetrating trauma
• Straddle-type injuries from falls
• Pedestrian accidents
• Some sexual acts

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Urinary Bladder

• Hollow organ
• May be ruptured by blunt or penetrating trauma or
  pelvic fracture
• Rupture more likely if bladder is distended at
  time of injury
• Suspect bladder injury in inebriated patients
  subjected to lower abdominal trauma

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Vascular Structure Injury

• Intraabdominal arterial and venous injuries may
  be life-threatening
• Injury usually occurs from penetrating trauma
• May also occur from compression or deceleration
  forces applied to abdomen
• Usually presents as hypovolemia
• Occasionally associated with a palpable abdominal
  mass

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Vascular Structure Injury

• Major vessels most frequently injured
• Aorta
• Inferior vena cava
• Renal, mesenteric, and iliac arteries and veins

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Pelvic Fractures

• Disruption of the pelvis may occur from
• Motorcycle crashes
• Pedestrian-vehicle collisions
• Direct crushing injury to the pelvis
• Falls from heights greater than 12 feet
• Blunt or penetrating injury may result in
• Fracture
• Severe hemorrhage
• Associated injury to urinary bladder and urethra

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Pelvic injury

• Most common injured organs are the urinary
  bladder and urethra
• Mortality rate 6.4 19
• Structural damage to the pelvis
• Room to empty large quantity of blood (shock)
• Inability to urinate
• Gross hematuria suspect bladder
• Blood at the meatus, suspect urethral damage

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Pelvic Fractures

• Suspicion of pelvic injury should be based on
• Mechanism of injury
• Presence of tenderness on palpation of iliac
  crests
• Force may be direct or indirect
• Assessment findings
• Management

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Evisceration

• Protrusion of an internal organ through a wound
  or surgical incision, especially in the abdominal
  wall
• Common finding with stab wounds
• May be seen to a lesser degree with gunshot
  wounds
• Do not replace organs back into abdomen
• Protect organs from further damage
• Cover with sterile saline moistened dressing
• Transport

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Focused History and Physical

• Head injury and/ or intoxicants (drugs/alcohol)
  mask signs and symptoms
• Hemoperitoneum (solid organ/vascular injuries)
• Adult abdomen will accommodate 1.5 liters with no
  abdominal distention
• Often present even with normal abdominal exam
• Unexplained shock
• Shock out of proportion to known injuries

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Peritonitis S/S

• Pain (subjective symptom from patient)
• Tenderness (objective sign with
  percussion/palpation)
• Guarding/rigidity
• Distention (late finding)
• Abrasions
• Ecchymosis
• Visible wounds
• Mechanism of injury
• Unexplained shock

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Critical Findings

• Rapid assessment and transport
• Detailed assessment
• On-going assessment

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Noncritical Findings

• Focused history and physical examination
• Other interventions and transport considerations

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Comprehensive Assessment

• Vital signs
• Inspection
• Auscultation
• Percussion
• Palpation

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Comprehensive Assessment

• Absence of signs and symptoms does not rule out
  abdominal injuries
• Not necessary to determine definitively if
  abdominal injuries are present
• Remember to examine the back
• Differential diagnosis
• Continued management

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Management/Treatment Plan

• Surgical intervention only effective therapy
• Rapid evaluation
• Initiation of shock resuscitation
• Rapid packaging and transport to nearest
  appropriate facility
• Facility must have immediate surgical capability
• Rapid transport
• Defeated if hospital cannot provide immediate
  surgical intervention
• Crystalloid fluid replacement en route to hospital

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Indications for Rapid Transport

• Critical findings
• Surgical intervention required to control
  hemorrhage and/ or contamination
• High index of suspicion for abdominal injury
• Unexplained shock
• Physical signs of abdominal injury

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Indications for Rapid Transport

• Hemorrhage continues until controlled in OR
• Survival determined by length of time from injury
  to definitive surgical control of hemorrhage
• Any delay in the field negatively impacts this
  time period

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ABD and Renal Disease
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Hiatal Hernia

• Herniation of the stomach through the
  diaphragmatic opening
• S/S
• Chest pain (especially when lying down)
• Difficulty swallowing
• Reflux
• Burping
• Possible hemorrhage
• May see signs of shock if severe

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Hiatal Hernia

• Treatment
• ABCs
• Position of comfort
• O2
• Rule out ischemia
• Treat for shock if applicable
• Transport

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Inguinal Hernia

• Herniation of intestine into inguinal canal
• S/S
• Pain and/or discomfort
• Mass may increase with strenuous activity
• N/V
• Treatment
• ABCs
• O2
• Position of comfort

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Umbilical Hernia

• Herniation of intestines or fluids into the
  umbilicus
• S/S
• May increase with crying, strains or is upright
• Usually no pain associated with tightening
• Treatment
• ABCs
• Pt comfort
• O2 if necessary

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Bowel Obstruction

• Blockage of the intestines due to tumor, feces,
  adhesions or hernias
• S/S
• N/V
• Distention
• Pain (Crampy and intermittent)
• Diarrhea (early)/Constipation (Late)
• Fever (late)
• Absent bowel sounds (late)
• BAD Breath
• Signs of shock

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Bowel Obstruction

• Treatment
• ABCs
• O2
• Position of comfort
• IV
• ALS ? (May need gravol or pain relief)

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Diverticulitis

• Inflammation of the diverticula
• S/S
• Maybe asymptomatic
• Abdominal pain (usually LLQ)
• Febrile
• N/V
• Cramps
• Chills
• Constipation/diarrhea
• Bright red blood
• Signs of shock

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Diverticulitis

• Treatment
• ABCs
• Position of comfort
• Treat for shock
• IV ?
• ALS ? (Pain, N/V)

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Intussusception

• Telescoping of intestine onto itself (commonly at
  the small/large intestine juncture), usually in
  infants
• S/S
• Sudden onset of ABD pain
• N/V (with feces)
• Distention
• Febrile
• Possible bleeding

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Intussusception

• Treatment
• ABCs
• O2
• Position of comfort
• ALS ?

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Adhesions

• Scar tissue forming between two surfaces of the
  body, usually in the intestines, as a result of
  surgery or traumatic insult
• S/S
• If severe
• N/V
• Pain
• Fever
• Change in bowel habits

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Reflux

• Weakness of esophageal sphincter allowing gastric
  contents to enter esophagus
• S/S
• Heartburn
• Burning sensation
• Burping
• N/V
• etc

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IBS

• Spastic colon
• S/S
• Stress
• Change in bowel habits
• ABD pain or cramping
• Excessive gas
• Decrease in appetite

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Acute Appendicitis

• Inflammation of the appendix
• S/S
• Sever pain (periumbilical moving to LRQ)
• Febrile
• Loss of appetite
• Rebound tenderness
• If ruptured
• Signs of shock

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Colitis

• Inflammation of the large intestine
• S/S
• Diarrhea
• Loss of appetite
• Rectal bleeding
• Signs of shock if severe

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Chrones Disease

• Chronic inflammatory disease causing ulcerations
  in the small intestines (but may affect large and
  other regions of the tract)
• S/S
• Diarrhea
• ABD pain
• N/V
• Anorexia
• Dependant on area and amount of damage

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Acute Peritonitis

• Acute inflammation of the peritoneum
• S/S
• ABD pain
• Tenderness
• Guarding
• Is severe signs of shock

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Anorexia Bulemia

• Eating disorders usually connect to the
  psychology of the patient
• S/S
• Obsession with weight loss
• May be purging, using laxatives, diuretics
• Dehydration
• Signs of shock (metabolic and hypovolemia)

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Acute Pancreatitis

• Inflammation of the pancreas due to stones,
  necrosis, infections
• S/S
• Severe epigastric pain
• N/V
• If severe
• Infection
• Hemorrhage
• Complications to other organs
• Acites

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Renal Calculi

• Kidney stones
• S/S
• Abdominal pain starting in back and radiating to
  groin
• Infection
• Hematurea
• Severe may show signs of sepsis

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Hepatitis

• Inflammation of the liver
• S/S
• Fatigue
• Anorexia
• General malaise
• N/V
• Photophobia
• Muscle and joint pain
• Dark urine
• RUQ pain
• Clay colored stools
• Jaundice

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Hepatic Failure

• Liver failure due to disease or insult
• S/S
• Jaundice
• Fatigue
• Edema
• Metabolic changes (expect EKG changes)
• Hepatomegaly
• Febrile
• Severe may show shock

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Cirrhosis

• Necrosis of the liver cells
• S/S
• Fatigue
• Anorexia
• GI bleed
• Ascites
• Jaundice
• Signs of shock (late)

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Cholecystitis

• Inflammation of the gall bladder
• S/S
• URQ pain radiating to the right shoulder
• History of gall stones
• Febrile
• Fatty food intolerance
• N/V
• Severe may be shocky

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Renal Failure

• Kidney failure
• S/S
• Oliguria leading to anurea
• Edema
• Acidosis
• Metabolic changes
• Leading to MOF
• May see
• LOC changes
• N/V..

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Pelvic Inflammatory Disease

• Inflammation of the female pelvic organs
• S/S
• ABD pain with rebound
• Guarding
• Febrile
• Pain with intercourse
• Changes in menstruation
• Painful urination

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Testicular Torsion

• Twisting of spermatic cord depleting supply of
  blood
• S/S
• Swelling
• SEVERE PAIN
• N/V
• Hematuria

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Glomerulonephritis

• Inflammation of the glomerulus
• S/S
• N/V
• Edema
• Decrease in output (may be absent)
• Hypertension

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Nephrotic Syndrome

• Increase in permeability of nephrons
• S/S
• Proteinuria
• Edema
• Swelling of the scrotum
• Distention
• May see signs of shock

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Flank Pain
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N/V