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

4. 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

6. Abdominal Anatomy • Right Lower Quadrant • Ascending Colon • Appendix • Right Ovary (female) • Right Fallopian Tube (female)

7. 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

9. Abdominal Cavity • Peritoneum = abdominal cavity lining • Divides abdomen into two spaces • Peritoneal cavity • Retroperitoneal space

10. Retroperitoneal Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs Peritoneal Spleen Liver Stomach Gall bladder Bowel Abdominal Anatomy Disease, injury of retroperitoneal organs often causes back pain

11. Abdominal Anatomy • Organs can be classified as: • Hollow • Solid • Majorvascular

12. Solid Organs • Liver • Spleen • Kidney • Pancreas When solid organs are injured, they bleed heavily and cause shock

13. 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

14. 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

16. Hollow Organs • Stomach • Gall bladder • Large, small intestines • Ureters, urinary bladder Rupture causes content spillage, inflammation of peritoneum

17. Hollow Organs • Stomach • Acid, enzymes • Immediate peritonitis • Pain, tenderness, guarding, rigidity

18. 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

19. Major Vascular Structures • Aorta • Inferior vena cava • Major branches Injury can cause severe blood loss; exsanguination (bleeding out)

20. 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

22. 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

23. 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

24. 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 • NOTreliable • Bleeding may not cause rigidity if free hemoglobin absent • Bleeding in retroperitoneal space may not cause rigidity

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

27. 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

28. Impaled Object • Leave in place • Shorten if necessary for transport • Leave part of object exposed

29. Evisceration • With large laceration abdominal contents may spill out • Do NOTtry to replace

30. 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

31. Genitourinary Trauma

32. Kidney Ureter Urinary Bladder Urethra Urinary System

33. Kidney Trauma • 50% of all GU trauma

34. 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

37. 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

41. 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

50. 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