Abdominal & Genitourinary Trauma

1. Abdominal & Genitourinary Trauma EMS Professions Temple College

2. Abdominal Trauma • Most patients survive long enough to reach hospital • Common factors that lead to death • Delayed resuscitation • Inadequate volume • Inadequate diagnosis • Failure to evaluate • Delayed surgery

3. Abdominal Trauma • Death results from increased hemorrhage due to: • solid organ injuries • hollow organ injuries • abdominal vascular injuries • pelvic fractures • Additional Injury • Spillage of hollow organ contents • Peritonitis

4. Prevention Strategies • What are possible strategies for preventing deaths due to abdominal and genitourinary trauma? • What role can EMS Systems play in these strategies?

5. Abdominal Boundaries • Diaphragm • Anterior abdominal wall • Pelvic skeletal structures • Vertebral column • Muscles of the abdomen and flanks

6. Abdominal & Pelvic Cavities • Retroperitoneal • Kidneys, ureters, bladder, reproductive organs, inferior vena cava, abdominal aorta, pancreas • Peritoneal • Bowel, spleen, liver, stomach, gall bladder • Pelvic • Rectum, ureters, pelvic vascular plexus, femoral arteries, femoral veins, pelvic skeletal structures, reproductive organs

7. High Index of Suspicion • Mechanism of Injury • Seat Belts • Steering wheel in unrestrained • Trauma to abdomen, lower chest, back, flank, buttocks, and perineum • Pain in uninjured shoulder • Kehr’s Sx • Murphy’s Sx • Turner’s Sx • Hypovolemic shock or diffusely tender abdomen w/ no identifiable cause  bleeding UPO

8. Mechanisms of Injury • Blunt mechanisms • Forces • Compression forces • Shearing forces • Deceleration forces • Sources • MVCs • Seat belt injury • Steering wheel injury • Falls • Assaults • Blast

9. Mechanisms of Injury • Penetrating mechanisms • Low velocity • knife • ice pick • Medium velocity • gunshot/handgun • shotgun • High velocity • high power hunting rifle • military weapon

10. Mechanisms of Injury • Penetrating Injury - Ballistics • Low velocity • injury usually limited to depth and travel of weapon • injury usually limited to area near penetration • Medium velocity • travel direction easily redirected • greater external soft tissue injury • High velocity • energy wave • cavitation

11. Pathophysiology • Hemorrhage • Limited external signs • Rapid blood loss possible • Hypovolemic shock • Blood does not result in peritonitis • Spillage of Contents • Enzymes, Acids, Bacteria • Chemical irritant to peritoneum • Localized pain  Generalized abdominal pain • Muscular spasm (rigid abdomen)

12. Solid Organ Injuries • Death usually 2° to hemorrhage • May to due to blunt or penetrating mechanism

13. Solid Organ Injuries • Spleen • Frequently injured solid organ • Usually due to blunt trauma • Often 2° trauma to ribs 9-11 on left side • Bleeds easily • Capsule around spleen tends to promote slow development of shock • Rapid shock onset when capsule ruptures • May present with left shoulder pain • diaphragm irritation

14. Solid Organ Injuries • Liver • Largest organ in abdomen • Frequently injured organ • May be due to blunt or penetrating trauma • Often 2° trauma to ribs 8-12 on right side • Bleeding • Slow and contained under capsule • Enters peritoneal cavity

15. Solid Organ Injuries • Pancreas • Lies across lumbar spine • Usually due to penetrating trauma • also due to compression against vertebral column by steering wheel, handle bars, or other object • Sudden deceleration produces straddle injury • Very little hemorrhage • Irritation to peritoneum • fluid loss from leakage of pancreatic enzymes • auto-digestion of tissue

16. Hollow Organ Injuries • Death may result from hemorrhage and/or content spillage • May result from penetrating or blunt trauma

17. Hollow Organ Injuries • Stomach • Usually injured due to blunt trauma • Full stomach prior to incident  risk of injury • Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity • Small and Large Intestines • Usually injured due to penetrating trauma • Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity

18. Hollow Organ Injuries • Colon • Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity • Spillage of bacteria into peritoneal cavity • May take 6 hrs to develop S/S of peritonitis • Small Bowel • Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity • Less bacteria • May take 24-48 hours for S/S to manifest

19. Abdominal Vascular Injuries • High mortality due to rapid blood loss • Survival dependent upon extent of injury and time to surgery • abdominal aorta, inferior vena cava, femoral arteries • shearing • dissection • transection

20. Pelvic Injuries • Increase risk of intraperitoneal structure injury • vascular structures • hollow organs

21. Genitourinary Trauma

22. Kidney Trauma • 50% of all GU trauma • Blunt • Direct blow to back, flank, upper abdomen • Suspect in Fx of 10th - 12th ribs or T12, L1, L2 • Acceleration/Deceleration • Shearing of renal artery/vein • Penetrating • Rare, usually associated • GSW or Stab wound

23. Kidney Trauma S/S • Gross Hematuria • 80% of cases • absence does not exclude renal injury • Localized flank/Abdominal pain • Pain/Tenderness of lower ribs, upper lumbar spine, groin, shoulder or flank • Hypovolemia

24. Ureter Trauma • Less than 2% of GU trauma • Usually secondary to penetrating trauma • Rupture • Extraperitoneal • Intraperitoneal

25. Extraperitoneal Rupture • Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum • Dysuria • Hematuria • Suprapubic Tenderness • Induration • redness secondary to tissue damage from urine

26. Intraperitoneal Rupture • Urgency to void, inability to void • Shock • Abdominal distention

27. Bladder Injury • Most often injured due to blunt trauma • Full bladder may increase risk of injury • Often associated with pelvic fractures • Should not attempt urinary catheterization • Localized pelvic pain

28. Urethra • Usually due to pelvic fracture, deceleration or straddle injuries • Blood at external meatus • Perineal bruising • Butterfly bruise • Scrotal Hematoma

29. Urethra • Urinary catheter’s should not be passed if these are present. • Rectal exam should be performed before passing a urinary catheter in a patient whose urethra may be disrupted

30. Male External Genitalia • Accidental or Intentional Injury • Highly vascular w/rich sensory nerve supply • Pain • Psychological issues • Hemorrhage

31. Male External Genitalia • Penile/Scrotal • Zipper • Foreign body • Avulsion/Amputation • Fracture • Scrotal/Testicular • Penetrating injury • Blunt injury • Management • Control bleeding / Indirect ice / Analgesia • Psychological and Modesty Concerns

32. Female External Genitalia • Usually intentional 2° assault • Primarily soft tissue injury • Hemorrhage likely • Look for other injuries • Sexual Assault • Emotional state provides additional challenge • Managed as other soft tissue bleeding • control hemorrhage • facility with trained personnel (sexual assault)

33. Abdominal Trauma Assessment • Less important to diagnose exact injury • Treat clinical findings • Management the same regardless of specific organ injured

34. Abdominal Rigidity • Do notrely on rigidity • Bleeding may not cause rigidity if free hemoglobin is not present • Bleeding in retroperitoneal space will not cause rigidity • May cause flank ecchymosis • Adult can accommodate 1.5 liters w/o distention

35. Bowel Sounds • Little value, if any, in pre-hospital assessment of trauma patient • Absent if shock is present, regardless of abdominal injury • Requires minutes for adequate assessment • Does not give any information you cannot get some other way

36. Abdominal Trauma Assessment • Evidence may be masked by other injuries or intoxicants • head injury • hypoxia • alcohol • drugs

37. Abdominal Trauma Assessment • Mechanism & Kinematics • History and Physical Exam • Patient Complaints • Inspection • External signs of injury • abrasions, ecchymosis, “seat belt sign” • distention • wounds • impaled object • evisceration • perineal blood, blood at meatus

38. Abdominal Trauma Assessment • History and Physical Exam • Gentle palpation • Percussion and Auscultation of little value • Evidence of shock • out of proportion to obvious injuries • Guarding • Evidence of peritonitis • Pelvic instability

39. Abdominal Trauma Management • C-Spine Motion Restriction IF indicated • Airway • Assist ventilations if needed • High flow O2 • Control External Bleeding • Determine need for rapid transport/surgery • Not all need trauma center • Transport to appropriate Facility

40. Abdominal Trauma Management • En route • Treat shock • MAST/PASG application w/o inflation • May be helpful in pelvic fracture • IV of LR/NS enroute • Titrate fluids to BP ~ 90 mm Hg • Indirect ice may be helpful in genitalia injury • Collect and package amputated genitalia

41. Abdominal Trauma Management • Abdominal Evisceration • Do not replace organs into abdomen • Cover exposed bowel with saline moistened multi trauma dressing • Cover first dressing with second dry dressing • Do not use 4 x 4

42. Abdominal Trauma Management • Leave impaled objects in place • Shorten if necessary for transport • Leave part of object exposed • NPO • Caution with • Sedatives • Narcotic Analgesics

43. Trauma In Pregnancy Leading cause of death during pregnancy MVCs result in 50% of prenatal mortality

44. Trauma In Pregnancy • Most common cause of fetal death from trauma is maternal death • Consider possibility of pregnancy in any female trauma patient of childbearing age • Sexual assault may be the cause of trauma • What is best for mom is best for baby • Treatment for pregnant patient same as non pregnant patient • Consideration for emergent C-section

45. Alterations In Pregnancy • Pregnant uterus can compress inferior vena cava when patient supine • Decreases cardiac output by 30 - 40% • Blood volume increasesby 40-50% • 30% blood loss may occur before symptoms develop

46. Alterations In Pregnancy • Blood flow to uterus and placenta can be selectively reduced • Fetus can be in distress while mother appears to be stable

47. Alterations In Pregnancy • As uterus increases in size and blood flow • Increased risk of: • Penetration • Rupture • Placental abruption • Premature rupture of membranes • 10-20% increase in oxygen demand • Decreased peristalsis and delayed gastric emptying • Increased risk of emesis and aspiration

48. Pregnancy Trauma Management • C-spine Motion Restriction • Transport with patient on left side or elevate right side of board • Airway • anticipate vomiting &  risk of aspiration • Assist ventilation as needed • High flow O2 • 3rd trimester O2 demand increases 10-20%

49. Pregnancy Trauma Management • Control External Bleeding • Determine need for rapid transport/surgery • Not all need trauma center • Consider needs of sexual assault victim • Transport to appropriate Facility • Consider need for emergent C-section • Mark height of fundus on mother’s abdomen • Reassess frequently

50. Pregnancy Trauma Management • Treat for Shock • Aggressive fluid resuscitation • Increased intravascular volume • Increased volume requirements to resuscitate • Consider MAST (legs only) • Prepare for complications of pregnancy • Premature labor & delivery • Hemorrhage complications • abruptio placenta • uterine rupture