Abdominal Trauma

1
Abdominal Trauma

• Temple College
• EMS Professions

2
The Abdomen

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

3
Abdominal Anatomy

• Abdomen divided into four quadrants by body
  mid-line, horizontal plane through umbilicus
• Organs can be located by quadrant

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Abdominal Anatomy

• Right Upper Quadrant
• Liver
• Gall Bladder
• Right Kidney
• Ascending Colon
• Transverse Colon

5
Abdominal Anatomy

• Left Upper Quadrant
• Spleen
• Stomach
• Pancreas
• Left Kidney
• Transverse Colon
• Descending Colon

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Abdominal Anatomy

• Right Lower Quadrant
• Ascending Colon
• Appendix
• Right Ovary (female)
• Right Fallopian Tube (female)

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Abdominal Anatomy

• Left Lower Quadrant
• Descending Colon
• Sigmoid colon
• Left Ovary (female)
• Left Fallopian Tube (female)

8
Abdominal Anatomy

• Periumbilical area
• Located around (peri) the navel (umbilicus)
• Small bowel lies in all quadrants in
  periumbilical area
• Suprapubic area
• Located just above pubic bone
• Urinary bladder, uterus lie in this area

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Abdominal Cavity

• Peritoneum abdominal cavity lining
• Divides abdomen into two spaces
• Peritoneal cavity
• Retroperitoneal space

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Abdominal Anatomy

• Retroperitoneal
• Pancreas
• Kidney
• Ureter
• Inferior vena cava
• Abdominal aorta
• Urinary bladder
• Reproductive organs

• Peritoneal
• Spleen
• Liver
• Stomach
• Gall bladder
• Bowel

Disease, injury of retroperitoneal organs often
causes back pain
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Abdominal Anatomy

• Organs can be classified as
• Hollow
• Solid
• Major vascular

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Solid Organs

• Liver
• Spleen
• Kidney
• Pancreas

When solid organs are injured, they bleed heavily
and cause shock
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Solid Organs

• Liver
• Largest abdominal organ
• Most frequently injured
• Fractures of ribs 8-12 on right side
• Bleeding can be either
• Slow, contained under capsule
• Free into peritoneal cavity

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Solid Organs

• Spleen
• Frequently injured with trauma ribs 9-11 on left
  side
• Bleeds easily
• Capsule around spleen tends to slow development
  of shock
• Rapid shock onset when capsule ruptures

15
Solid Organs

• Pancreas
• Lies across lumbar spine
• Sudden deceleration produces straddle injury
• Very little hemorrhage
• Leakage of enzymes digests structures in
  retroperitoneal space, causes volume loss, shock

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Hollow Organs

• Stomach
• Gall bladder
• Large, small intestines
• Ureters, urinary bladder

Rupture causes content spillage, inflammation of
peritoneum
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Hollow Organs

• Stomach
• Acid, enzymes
• Immediate peritonitis
• Pain, tenderness, guarding, rigidity

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Hollow Organs

• Colon
• Spillage of bacteria
• May take 6 hrs to develop peritonitis
• Small Bowel
• Fewer bacteria
• May take 24-48 hours to develop peritonitis

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Major Vascular Structures

• Aorta
• Inferior vena cava
• Major branches

Injury can cause severe blood loss
exsanguination (bleeding out)
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Abdominal Trauma

• Most survive to reach hospital
• Most common factors leading to death
• Failure to adequately evaluate
• Delayed resuscitation
• Inadequate volume
• Inadequate diagnosis
• Delayed surgery

21
High Index of Suspicion

• Mechanism
• Trauma to lower chest, back, flank, buttocks, and
  perineum
• Hypovolemic shock with no readily identifiable
  cause
• Diffusely tender abdomen
• Pain in uninjured shoulder

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Mechanism

• Look for signs of injury
• Bruises
• Tire marks
• Obvious open injuries
• Assume any abdominal injury is serious until
  proven otherwise!
• Injury above umbilicus also involves chest until
  proven otherwise

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Unexplained Shock

• Assess vital signs skin color, temperature
  capillary refill
• Tachycardia restlessness cool, moist skin
• In trauma, signs of shock suggest abdominal
  injury if no other obvious causes present

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Signs of Injured Abdomen

• Diffuse tenderness
• Pain
• Pain referred to shoulder Organ under diaphragm
  involved (?spleen)
• Pain referred to back Retroperitoneal organ
  involved (?kidney)

25
Abdominal Rigidity

• NOT reliable
• Bleeding may not cause rigidity if free
  hemoglobin absent
• Bleeding in retroperitoneal space may not cause
  rigidity

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Abdominal Trauma Management

• Less important to diagnose exact injury
• Treat clinical findings
• Management same regardless of specific organ(s)
  injured

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Abdominal Trauma Management

• Airway
• C-Spine if mechanism indicates
• High flow O2
• Assist ventilations if needed
• Give nothing by mouth
• MAST may be helpful in slowing intraabdominal
  bleeding with shock

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Impaled Object

• Leave in place
• Shorten if necessary for transport
• Leave part of object exposed

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Evisceration

• With large laceration abdominal contents may
  spill out
• Do NOT try to replace

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Evisceration

• Cover exposed organs with saline moistened
  multi-trauma dressing
• Do NOT use 4 x 4s
• Cover first dressing with second DRY dressing or
  aluminum foil

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Genitourinary Trauma
32
Urinary System
33
Kidney Trauma

• 50 of all GU trauma

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Kidney Trauma

• Penetrating
• GSW
• Stab wound
• Rare, usually associated with trauma to other
  abdominal organs

35
Kidney Trauma

• Blunt
• Direct blow to back, flank, upper abdomen
• Suspect with fractures of 10th - 12th ribs or
  T12, L1, L2
• Acceleration/Deceleration
• Shearing of renal artery/vein

36
Kidney Trauma

• Signs and Symptoms
• Gross Hematuria
• 80 of cases
• Absence does NOT exclude renal injury
• Localized flank/abdominal pain
• Palpable mass

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Kidney Trauma

• Signs and Symptoms
• Tenderness Lower ribs, upper L-spine, flank
• Pain groin, shoulder, back, flank

38
Ureter Trauma

• Less than 2 of GU trauma
• Usually secondary to penetrating trauma
• Indicator
• Wound to lower back with urine escaping

39
Urinary Bladder Trauma

• Mechanisms
• Blunt injury to lower abdomen
• Seat belts
• Pelvic fracture
• Penetrating trauma to lower abdomen or perineum
  (pelvic floor)

40
Extraperitoneal Bladder Rupture

• Urine in umbilicus, anterior thighs, scrotum,
  inguinal canals, perineum
• Dysuria
• Hematuria
• Suprapubic tenderness
• Swelling, redness secondary to tissue damage from
  urine

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Intraperitoneal Bladder Rupture

• Urgency to void
• Inability to void
• Shock
• Abdominal distension

42
Urethral Trauma

• Mechanisms
• Sudden decelerations
  (bladder shears off urethra)
• Straddle injuries

43
Urethral Trauma

• Signs and Symptoms
• Blood at external meatus
• Perineal bruising (butterfly bruise)
• Scrotal hematoma

44
Reproductive System Trauma

• Can occur to both external and internal
  reproductive systems
• External
• More common
• Pain, extensive bleeding
• Internal
• Rarely injured

45
Reproductive System Trauma

• Treat like blunt or penetrating soft tissue
  injuries elsewhere on body

46
Male Genitalia Trauma

• Usually NOT life-threatening
• Very painful
• Great source of concern to patient

47
Male Genitalia Trauma

• Avulsion of skin of penis, scrotum
• Cover with a moist, sterile dressing
• Complete amputation of penis
• Treat as any amputated part

48
Male Genitalia Trauma

• Blunt trauma to penis, scrotum
• Apply ice pack
• Urethral foreign bodies
• Do NOT remove
• Penis entrapped in zipper
• If 1 or 2 teeth involved, try to unzip
• If more involved, cut zipper out of trousers,
  transport

49
Female Genitalia Trauma

• Internal
• Rarely injured
• External
• Can cause pain, extensive bleeding
• Usually not life-threatening
• Treat with compresses, pressure

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Sexual Assault

• Avoid examining genitalia unless obvious bleeding
  present
• Ask patient to NOT wash, douche, urinate,
  defecate
• Ask patient NOT to change clothes
• Record history, but avoid extensive questioning
  about incident

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PowerPoint Source

• Slides for this presentation from Temple College
  EMS http//www.templejc.edu/dept/ems/pages/power
  point.html