Provincial Reciprocity Attainment ProgramProvincial Reciprocity Attainment Program

Abdominal

Abdominal Organs

ADUKPIEADUKPIE

Types of Abdominal Organs

O V A R IE S

K ID N E Y S

P A N C R E A S

S P L E E N

L IV E R

S O L ID O R G A N S

B L A D D E R

L A R G E IN TE S TIN E

S M A L L IN TE S TIN E

G A L L B L A D D E R

S TO M A C H

H O L L O W O R G A N S

A B D O M IN A L O R G A N S

Abdominal Organs

Spleen

Stomach

Kidney

Part of the Liver

Kidney

Large Intestine

Small Intestine

Part of the Pancreas

Lt Ureter

Large Intestine

Small Intestine

Femoral Artery/Vein to Left Leg

Liver

Gall Bladder

Kidney

Part of the Pancreas

Large Intestine

Appendix

Large Intestine

Rt Ureter

Small Intestine

Femoral Artery/Vein to Rt Leg

LUQRUQ

RLQ LLQ

Traumatic Injuries

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

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

Boundaries of the Abdomen

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

Surface Anatomy of Abdomen

Quadrants Upper - right, left Lower - right, left

Xiphoid Symphysis pubis Umbilicus

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

Pelvic Cavity

Surrounded by the pelvic bones Lower part of retroperitoneal space Contents:

Rectum Bladder Urethra Iliac vessels In women, internal genitalia

Retroperitoneal Space

Potential space behind the “true” abdominal cavity Contents (ADUCKPIE):

Abdominal aorta Duodenum Ureter Colon Kidneys Pancreas Inferior vena cava Esophagus

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)

Blunt Trauma

Motor vehicle collisions Motorcycle collisions Pedestrian injuries Falls Assault Blast injuries

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

Solid & Hollow Organs

Solid Organs Liver Spleen Pancreas Kidneys Adrenals Ovaries (female)

Hollow Organs Stomach Intestines Gallbladder Urinary bladder Uterus (female)

Solid Organ Injury

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

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

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

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

Kehr’s sign Left upper quadrant pain with radiation to left

shoulder Common complaint associated with splenic

injury

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

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

Hollow Organ Injury

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

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

Retroperitoneal Organ Injury

May occur because of blunt or penetrating trauma to the: Anterior abdomen Posterior abdomen (particularly the flank

area) or Thoracic spine

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)

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

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

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

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

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

Vascular Structure Injury

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

veins

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

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

Pelvic injury

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

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

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

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

Critical Findings

Rapid assessment and transport Detailed assessment On-going assessment

Noncritical Findings

Focused history and physical examination

Other interventions and transport considerations

Comprehensive Assessment

Vital signs Inspection Auscultation Percussion Palpation

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

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

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

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

ABD and Renal Disease

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

Hiatal Hernia

Treatment ABC’s Position of comfort O2 Rule out ischemia Treat for shock if applicable Transport

Inguinal Hernia

Herniation of intestine into inguinal canal S/S

Pain and/or discomfort Mass may increase with strenuous activity N/V

Treatment ABC’s O2 Position of comfort

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: ABC’s Pt comfort O2 if necessary

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

Bowel Obstruction

Treatment: ABC’s O2 Position of comfort IV ALS ? (May need gravol or pain relief)

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

Diverticulitis

Treatment: ABC’s Position of comfort Treat for shock IV ? ALS ? (Pain, N/V)

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

Intussusception

Treatment: ABC’s O2 Position of comfort ALS ?

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

Reflux

Weakness of esophageal sphincter allowing gastric contents to enter esophagus

S/S: Heartburn Burning sensation Burping N/V etc

IBS

Spastic colon S/S:

Stress Change in bowel habits ABD pain or cramping Excessive gas Decrease in appetite

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

Colitis

Inflammation of the large intestine S/S:

Diarrhea Loss of appetite Rectal bleeding Signs of shock if severe

Chrone’s 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

Acute Peritonitis

Acute inflammation of the peritoneum S/S:

ABD pain Tenderness Guarding Is severe signs of shock

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)

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

Renal Calculi

Kidney stones S/S:

Abdominal pain starting in back and radiating to groin

Infection Hematurea Severe may show signs of sepsis

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

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

Cirrhosis

Necrosis of the liver cells S/S:

Fatigue Anorexia GI bleed Ascites Jaundice Signs of shock (late)

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

Renal Failure

Kidney failure S/S:

Oliguria leading to anurea Edema Acidosis Metabolic changes Leading to MOF May see

LOC changes N/V…..

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

Testicular Torsion

Twisting of spermatic cord depleting supply of blood

S/S: Swelling SEVERE PAIN N/V Hematuria

Glomerulonephritis

Inflammation of the glomerulus S/S:

N/V Edema Decrease in output (may be absent) Hypertension

Nephrotic Syndrome

Increase in permeability of nephrons S/S:

Proteinuria Edema Swelling of the scrotum Distention May see signs of shock

Flank Pain

N/V