Chap 27 Abdominal Trauma

7/28/2019 Chap 27 Abdominal Trauma

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Chapter 27Chapter 27

Abdominal TraumaAbdominal Trauma

Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.


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ObjectivesObjectives

Describe mechanisms of injury, signs andDescribe mechanisms of injury, signs and

symptoms, and complications associated withsymptoms, and complications associated with

injuries of:injuries of:

Abdominal solid organsAbdominal solid organs Hollow organsHollow organs

Retroperitoneal organsRetroperitoneal organs

Pelvic organsPelvic organs



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ObjectivesObjectives

Outline the significance of injury toOutline the significance of injury to

intraabdominal vascular structuresintraabdominal vascular structures

Describe assessment priorities for the patientDescribe assessment priorities for the patientsuspected to have abdominal injurysuspected to have abdominal injury

Outline the prehospital care of the patient withOutline the prehospital care of the patient withabdominal traumaabdominal trauma



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ScenarioScenario

The size-up from the first unit on the scene said, OneThe size-up from the first unit on the scene said, Onevehicle into a tree, major damage. Your patient, anvehicle into a tree, major damage. Your patient, anunrestrained male, is still seated in the front of an oldunrestrained male, is still seated in the front of an oldpick-up truck, behind the severely bent steering wheel.pick-up truck, behind the severely bent steering wheel.He is pale, anxious and confused, and has a small headHe is pale, anxious and confused, and has a small headwound. You cant feel a radial pulse, but his carotid iswound. You cant feel a radial pulse, but his carotid isfast and thready. His lungs are clear, but he moansfast and thready. His lungs are clear, but he moanswhen you touch the large reddened area over his upperwhen you touch the large reddened area over his upperabdomen. Get a line set up, you shout to your partnerabdomen. Get a line set up, you shout to your partneras you apply a cervical collar and oxygen, and prepareas you apply a cervical collar and oxygen, and preparefor a rapid extrication. You can sense that time will befor a rapid extrication. You can sense that time will becritical on this call.critical on this call.



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DiscussionDiscussion

Was the mechanism of injury on this callWas the mechanism of injury on this callsuspicious for abdominal injury?suspicious for abdominal injury?

Which abdominal organs may be injured?Which abdominal organs may be injured?

What signs and symptoms lead you to believeWhat signs and symptoms lead you to believethat an abdominal injury is likely?that an abdominal injury is likely?

What are your priorities of care for this man?What are your priorities of care for this man?



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Blunt or penetrating traumaBlunt or penetrating trauma

MVC major cause of abdominal traumaMVC major cause of abdominal trauma

OtherOther Blows to abdomenBlows to abdomen

FallsFalls



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Difficult to evaluate due to:Difficult to evaluate due to: Wide spectrum of potential injuries to multipleWide spectrum of potential injuries to multiple

organsorgans

Physical findings sometimes lacking orPhysical findings sometimes lacking orexaggeratedexaggerated



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Assessment may be compromised by:Assessment may be compromised by:Alcohol and/or recreational drugsAlcohol and/or recreational drugs

Injury to brain, spinal cordInjury to brain, spinal cord

Injury to ribs, spine, pelvisInjury to ribs, spine, pelvis

High degree of suspicion based on mechanismHigh degree of suspicion based on mechanism

of injury and kinematicsof injury and kinematics



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Boundaries of the AbdomenBoundaries of the Abdomen

DiaphragmDiaphragm

Anterior abdominal wallAnterior abdominal wall

Pelvic bonesPelvic bones

Vertebral columnVertebral column

Muscles of theMuscles of the

abdomen and flanksabdomen and flanks



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Surface Anatomy of the AbdomenSurface Anatomy of the Abdomen

QuadrantsQuadrants UpperUpperright, leftright, left

LowerLowerright, leftright, left

XiphoidXiphoid

Symphysis pubisSymphysis pubis

UmbilicusUmbilicus



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Peritoneal CavityPeritoneal Cavity

True abdominal cavityTrue abdominal cavity

QuadrantsQuadrants

UpperUpperright, leftright, left LowerLowerright, leftright, left

Liver, spleen, stomach, small intestine, colon,Liver, spleen, stomach, small intestine, colon,gallbladder, female reproductive organsgallbladder, female reproductive organs



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Pelvic CavityPelvic Cavity

Surrounded by pelvic bonesSurrounded by pelvic bones

Lower part of retroperitonealLower part of retroperitoneal

spacespace

ContentsContents

RectumRectum

BladderBladder

UrethraUrethra

Iliac vesselsIliac vessels In women, internal genitaliaIn women, internal genitalia



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Retroperitoneal SpaceRetroperitoneal Space

Potential spacePotential space

Behind true abdominal cavityBehind true abdominal cavity

ContentsContents Abdominal aortaAbdominal aorta Inferior vena cavaInferior vena cava Most of duodenumMost of duodenum PancreasPancreas KidneysKidneys UretersUreters Ascending and descending colonAscending and descending colon



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Mechanisms of Abdominal InjuryMechanisms of Abdominal Injury

Blunt traumaBlunt trauma Compression orCompression or

crushing forcescrushing forces

Shearing forcesShearing forces Deceleration forcesDeceleration forces

Marks of impact sustained by the front-seat

passenger in a car crash



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Mechanisms of Abdominal InjuryMechanisms of Abdominal Injury

Degree of injury related to:Degree of injury related to: Quantity and duration of forceQuantity and duration of force

Abdominal structure injuredAbdominal structure injured

Fluid filledFluid filled Gas filledGas filled

SolidSolid

HollowHollow



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Blunt TraumaBlunt Trauma

Motor vehicle collisionsMotor vehicle collisions

Motorcycle collisionsMotorcycle collisions

Pedestrian injuriesPedestrian injuries

FallsFalls

AssaultAssault

Blast injuriesBlast injuries



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Penetrating TraumaPenetrating Trauma

Energy imparted to bodyEnergy imparted to body Low velocity: Knife, ice pickLow velocity: Knife, ice pick

Medium velocity: Gunshot wounds, shotgun woundsMedium velocity: Gunshot wounds, shotgun wounds

High velocity: High-power hunting rifles, military weaponsHigh velocity: High-power hunting rifles, military weapons

BallisticsBallistics

TrajectoryTrajectory

DistanceDistance



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Solid and Hollow OrgansSolid and Hollow Organs

Solid organsSolid organs LiverLiver

SpleenSpleen

PancreasPancreas KidneysKidneys

AdrenalsAdrenals

Ovaries (female)Ovaries (female)

Hollow organsHollow organs StomachStomach

IntestinesIntestines

GallbladderGallbladder Urinary bladderUrinary bladder

Uterus (female)Uterus (female)



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Hollow, Solid, and Retroperitoneal OrgansHollow, Solid, and Retroperitoneal Organs



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Hollow, Solid, and Retroperitoneal OrgansHollow, Solid, and Retroperitoneal Organs



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LiverLiver

Largest organ in abdominal cavityLargest organ in abdominal cavity

Right upper quadrantRight upper quadrant

Injured from trauma to:Injured from trauma to: Eighth through twelfth ribs on right side of bodyEighth through twelfth ribs on right side of body

Upper central part of abdomenUpper central part of abdomen



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LiverLiver

Suspect liver injury when:Suspect liver injury when: Steering wheel injurySteering wheel injury

Lap belt injuryLap belt injury

Epigastric traumaEpigastric trauma

After injury, blood and bile leak into peritonealAfter injury, blood and bile leak into peritoneal

cavitycavity ShockShock

Peritoneal irritationPeritoneal irritation



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SpleenSpleen

Upper left quadrantUpper left quadrant

Rich blood supplyRich blood supply

Slightly protected by organs surrounding itSlightly protected by organs surrounding it

and by lower rib cageand by lower rib cage

Most commonly injured organ from blunt traumaMost commonly injured organ from blunt traumaAssociated intraabdominal injuries commonAssociated intraabdominal injuries common



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SpleenSpleen

Suspect splenic injury in:Suspect splenic injury in: Motor vehicle crashesMotor vehicle crashes

Falls or sports injuries involving was an impact toFalls or sports injuries involving was an impact to

the lower left chest, flank, or upper left abdomenthe lower left chest, flank, or upper left abdomen

Kehrs signKehrs sign Left upper quadrant pain radiates to left shoulderLeft upper quadrant pain radiates to left shoulder

Common complaint with splenic injuryCommon complaint with splenic injury



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StomachStomach

Not commonly injured by blunt traumaNot commonly injured by blunt trauma

Protected location in abdomenProtected location in abdomen

Penetrating trauma may cause gastric transection orPenetrating trauma may cause gastric transection or

lacerationlaceration Signs of peritonitis from leakage of gastric contentsSigns of peritonitis from leakage of gastric contents

Diagnosis confirmed during surgeryDiagnosis confirmed during surgery Unless nasogastric drainage returns bloodUnless nasogastric drainage returns blood



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Colon and Small IntestineColon and Small Intestine

Usually injured by penetrating traumaUsually injured by penetrating trauma

May be injured by compression forces:May be injured by compression forces:

High-speed motor vehicle crashesHigh-speed motor vehicle crashes Deceleration injuries associated with wearingDeceleration injuries associated with wearing

personal restraintspersonal restraints

Bacterial contamination commonBacterial contamination common



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Retroperitoneal Organ InjuryRetroperitoneal Organ Injury

Blunt or penetrating trauma to:Blunt or penetrating trauma to:Anterior abdomenAnterior abdomen

Posterior abdomenPosterior abdomen

Particularly flankParticularly flank Thoracic spineThoracic spine



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KidneysKidneys

High on posterior wall of abdominal cavity inHigh on posterior wall of abdominal cavity in

retroperitoneal spaceretroperitoneal space Held in place by renal fasciaHeld in place by renal fascia

Cushioned by layer of adipose tissueCushioned by layer of adipose tissue Partially protected by lower rib cagePartially protected by lower rib cage



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KidneysKidneys

Injuries may involve fracture and lacerationInjuries may involve fracture and laceration Resulting in hemorrhage, urine extravasation, or bothResulting in hemorrhage, urine extravasation, or both

Contusions usually self-limitingContusions usually self-limiting Heal with bed rest and forced fluidsHeal with bed rest and forced fluids

Fractures and lacerations may need surgicalFractures and lacerations may need surgicalrepairrepair



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UretersUreters

Hollow organsHollow organs

Rarely injured in blunt traumaRarely injured in blunt trauma

Flexible structureFlexible structure

Injury from penetrating abdominal or flankInjury from penetrating abdominal or flank

wounds (stab wounds, firearm injuries)wounds (stab wounds, firearm injuries)



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PancreasPancreas

Solid organ in peritoneal spaceSolid organ in peritoneal space

Blunt injury usually from crushing injuryBlunt injury usually from crushing injury

between spine and a steering wheel, handlebar,between spine and a steering wheel, handlebar,or blunt weaponor blunt weapon

Most pancreatic injuries are due to penetratingMost pancreatic injuries are due to penetratingtraumatrauma



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DuodenumDuodenum

Lies across lumbar spineLies across lumbar spine

Seldom injured due to location in retroperitonealSeldom injured due to location in retroperitoneal

area, near pancreasarea, near pancreas

May be crushed or lacerated when great force ofMay be crushed or lacerated when great force of

blunt trauma or penetrating injury occursblunt trauma or penetrating injury occurs Usually associated with pancreatic traumaUsually associated with pancreatic trauma



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Pelvic Organ InjuryPelvic Organ Injury

Usually from motor vehicle crashes thatUsually from motor vehicle crashes that

produce pelvic fracturesproduce pelvic fractures

Less frequent causesLess frequent causes Penetrating traumaPenetrating trauma

Straddle-type injuries from fallsStraddle-type injuries from falls

Pedestrian accidentsPedestrian accidents

Some sexual actsSome sexual acts



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Urinary BladderUrinary Bladder

Hollow organHollow organ

Ruptured by blunt or penetrating trauma or pelvicRuptured by blunt or penetrating trauma or pelvic

fracturefracture Rupture more likely if bladder is distended at time ofRupture more likely if bladder is distended at time of

injuryinjury

Suspect bladder injury in inebriated patientsSuspect bladder injury in inebriated patientssubjected to lower abdominal traumasubjected to lower abdominal trauma



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Vascular Structure InjuryVascular Structure Injury

Intraabdominal arterial and venous injuries may beIntraabdominal arterial and venous injuries may belife threateninglife threatening

Usually occur from penetrating traumaUsually occur from penetrating trauma

Also from compression or deceleration forces appliedAlso from compression or deceleration forces appliedto abdomento abdomen

Often presents as hypovolemiaOften presents as hypovolemia

May be a palpable abdominal massMay be a palpable abdominal mass



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Vascular Structure InjuryVascular Structure Injury

Major vessels most frequently injured:Major vessels most frequently injured:AortaAorta

Inferior vena cavaInferior vena cava

Renal, mesenteric, and iliac arteries and veinsRenal, mesenteric, and iliac arteries and veins



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Pelvic FracturesPelvic Fractures

Disruption of pelvis from:Disruption of pelvis from: Motorcycle crashesMotorcycle crashes Pedestrian-vehicle collisionsPedestrian-vehicle collisions Direct crushing injury to pelvisDirect crushing injury to pelvis

Falls from heights greater than 12 feetFalls from heights greater than 12 feet

Blunt or penetrating injury may result in:Blunt or penetrating injury may result in: FractureFracture Severe hemorrhageSevere hemorrhageAssociated injury to urinary bladder and urethraAssociated injury to urinary bladder and urethra



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Pelvic FracturesPelvic Fractures

Suspicion of pelvic injury should be based on:Suspicion of pelvic injury should be based on: Mechanism of injuryMechanism of injury Presence of tenderness on palpation of iliac crestsPresence of tenderness on palpation of iliac crests

Direct or indirect forceDirect or indirect force

Assessment findingsAssessment findings

ManagementManagement



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EviscerationEvisceration

Protrusion of internalProtrusion of internal

organ through woundorgan through wound Common with stab woundsCommon with stab wounds

Do not replace organs intoDo not replace organs into

abdomenabdomen Protect from damageProtect from damage

Cover with sterile salineCover with sterile saline

dressingdressing



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Focused History and PhysicalFocused History and Physical

Head injury, drugs, alcohol mask signs andHead injury, drugs, alcohol mask signs and

symptomssymptoms

Hemoperitoneum (solid organ/vascular injuries)Hemoperitoneum (solid organ/vascular injuries)Adult abdomen holds 1.5 L with no distentionAdult abdomen holds 1.5 L with no distention

May have normal abdominal examMay have normal abdominal exam

Unexplained shockUnexplained shock

Shock out of proportion to known injuriesShock out of proportion to known injuries



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PeritonitisPeritonitisSigns and SymptomsSigns and Symptoms

Pain (subjective symptom from patient)Pain (subjective symptom from patient) Tenderness (objective sign with percussion/palpation)Tenderness (objective sign with percussion/palpation) Guarding/rigidityGuarding/rigidity Distention (late finding)Distention (late finding) AbrasionsAbrasions EcchymosisEcchymosis Visible woundsVisible wounds Mechanism of injuryMechanism of injury Unexplained shockUnexplained shock



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Critical FindingsCritical Findings

Rapid assessment and transportRapid assessment and transport

Detailed assessmentDetailed assessment

Ongoing assessmentOngoing assessment



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Noncritical FindingsNoncritical Findings

Focused history and physical examinationFocused history and physical examination

Other interventions and transport considerationsOther interventions and transport considerations



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Comprehensive AssessmentComprehensive Assessment

Vital signsVital signs

InspectionInspection

AuscultationAuscultation

PercussionPercussion

PalpationPalpation



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Comprehensive AssessmentComprehensive Assessment

Absence of signs and symptoms does notAbsence of signs and symptoms does not

rule out abdominal injuriesrule out abdominal injuries

Remember to examine the backRemember to examine the back

Differential diagnosisDifferential diagnosis

Continued managementContinued management



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Management/Treatment PlanManagement/Treatment Plan

Surgical intervention only effective therapySurgical intervention only effective therapy

Rapid evaluationRapid evaluation

Shock resuscitationShock resuscitation

Rapid packaging and transport to nearest appropriateRapid packaging and transport to nearest appropriatefacilityfacility

Facility must have immediate surgical capabilityFacility must have immediate surgical capability

Crystalloid fluid en route (per protocol)Crystalloid fluid en route (per protocol)



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Indications for Rapid TransportIndications for Rapid Transport

Critical findingsCritical findings Surgical intervention required to control hemorrhageSurgical intervention required to control hemorrhage

and/or contaminationand/or contamination

High index of suspicion for abdominal injuryHigh index of suspicion for abdominal injury Unexplained shockUnexplained shock

Physical signs of abdominal injuryPhysical signs of abdominal injury



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Indications for Rapid TransportIndications for Rapid Transport

HemorrhageHemorrhage

Survival related to time from injury to surgicalSurvival related to time from injury to surgical

control of hemorrhagecontrol of hemorrhageAny delay in the field negatively affects this timeAny delay in the field negatively affects this time

periodperiod



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ConclusionConclusionAbdominal trauma is often difficult to evaluateAbdominal trauma is often difficult to evaluate

in the prehospital setting. Therefore thein the prehospital setting. Therefore the

paramedic must exercise a high degree ofparamedic must exercise a high degree ofsuspicion based on the mechanism of injurysuspicion based on the mechanism of injury

and kinematics. Death from abdominal injuryand kinematics. Death from abdominal injury

usually results from hemorrhage and delayedusually results from hemorrhage and delayed

surgical repair.surgical repair.



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Questions?Questions?

Copyright 2007 2006 2001 1994 by Mosby Inc an affiliate of Elsevier Inc

Chap 27 Abdominal Trauma

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