Beka Aberra C1 Medical Student bekaaberra@yahoo.com Black Lion Hospital

1. Abdominal
Trauma
By Beka Aberra
1

2. Outline
 Introduction
 Background Anatomy
 Mechanisms and Pathophysiology
 Clinical assessment
 Conclusion

3. INTRODUCTION
 Trauma is the commonest cause of death in
young people.
 ABDOMINAL TRAUMA STANDS THIRD NEXT
TO HEAD INJURY AND CHEST INJURY
 25% of all major trauma victims require
abdominal exploration.
 Abdominal evaluation is the challenging
component of evaluating trauma.
 Penetrating torso injuries b/n nipple & perineum
is a potential intra abdominal injury.
 Mechanism, Force & Location of injury &
Hemodynamic status determine the priority &
best method of assessment. 3

4.  75% OF ALL BLUNT TRAUMA TO ABDOMEN
INVOLVES ROAD TRAFFIC ACCIDENT
 60% OF INJURY OCCUR IN MALES (14-30)
 Trauma related deaths form 3 Peaks
– First Peak accounts 50% die instantly or
very soon.
– Second Peak accounts 30% in hours of
injury due to severe blood loss.
– Third Peak accounts 20% in days to
weeks due to infection/multi organ failure.
4

5. Background
Anatomy
 Anterior abdomen
 Flank
 Back
 Intraperitoneal space contents
 Retroperitoneal space contents
 Pelvic cavity contents
5

6.  Anterior abdomen:
Trans-nipple line, Anterior axillary lines,
Inguinal ligaments and Symphysis pubis.
 Flank:
Anterior and posterior axillary line;
Sixth intercostal to iliac crest.
 Back:
Posterior axillary line; Tip of scapula to
Iliac crest.

7.  Upper Peritoneal cavity
Covered by lower aspect of bony thorax. Includes Diaphragm, Liver,
Spleen, Stomach, Transverse colon.
 Lower Peritoneal cavity:
Small bowel Ascending and Descending colon, Sigmoid colon
 Retroperitoneal space:
A Potential space Behind “true” abdominal cavity
Abdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas,
kidneys, Ureters and posterior aspects of Ascending and Descending
colons
 Pelvic cavity:
Rectum, Bladder, iliac vessels and Internal genitalia in women.

8. The Abdomen
 Everything between diaphragm and
pelvis
 Injuries very difficult to assess
because of large variety of structures
8

9. Abdominal Anatomy
 Abdomen divided into four quadrants
by body mid-line, horizontal plane
through umbilicus
 Organ located by quadrant
9

10. Abdominal Anatomy
 Right Upper Quadrant
– Liver
– Gall Bladder
– Right Kidney
– Ascending Colon
– Transverse Colon
10

11. Abdominal Anatomy
 Left Upper Quadrant
– Spleen
– Stomach
– Pancreas
– Left Kidney
– Transverse Colon
– Descending Colon
11

12. Abdominal Anatomy
 Right Lower Quadrant
– Ascending Colon
– Appendix
– Right Ovary (female)
– Right Fallopian Tube (female)
12

13. Abdominal Anatomy
 Left Lower Quadrant
– Descending Colon
– Sigmoid colon
– Left Ovary (female)
– Left Fallopian Tube (female)
13

14. Abdominal Anatomy
 Organs can be classified as:
– Hollow
– Solid
– Major vascular
14

15. Solid Organs
 Liver
 Spleen
 Kidney
 Pancreas
When solid organs are
injured, they bleed heavily
and cause shock
15

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

17. Major Vascular
Structures
 Aorta
 Inferior vena cava
 Major branches
Injury can cause severe
blood loss ; exsanguination
(bleeding out)
17

18. 1. Abdominal Aorta
2. Common Iliac Artery
Vascular Anatomy 4. External Iliac
3. Internal Iliac
5. Superior Gluteal
6. Obturator Artery

19. Can you tell me
 What are the top 3 most commonly
injured organs in the abdomen?

20. Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)

21. Mechanisms
 Blunt trauma:
Motor Vehicle Accident
Seat belt injury
 Penetrating injuries:
Stab wounds
Gun Shot wounds
 Blast
Bomb
 Crush
Building collapse
 Thermal

22. Blunt Trauma
 Motor vehicle collisions
 Motorcycle collisions
 Pedestrian injuries
 Falls
 Assault
 Blast injuries

23. Penetrating Trauma
 Stab wounds
 Gun Shot wounds
 Surgical Incisions

24. Blunt Abdominal trauma is the
commonest cause of death in younger
population with Polytrauma in RTA.
Blunt abdominal injuries carry a
greater risk of morbidity and
mortality than penetrating
abdominal injuries.
Mostly due to
• Inadequate diagnosis
• Delayed resuscitation
• Delayed surgery

25. Mechanism of Injury:
Blunt
Motor Vehicle Accident
Seatbelt injury

26. Pathophysiology
 1.Compression/Concussive forces
– Direct blow
– External compression vs. fixed object (e.g. lap belt, spinal
column)
Cause
• Tears & Sub capsular hematoma to solid
viscera.
• Deform hollow organs & transiently Inc.
intraluminal pressure.
 2. Deceleration forces
– Stretching & Linear shearing b/n relatively fixed & free object.
 In BAT, Organs that cant yield to impact by elastic
deformation are most likely to be injured i.e. solid
organs
26

27.  Rapid deceleration
Shearing Force created that cause solid, visceral
organs and vascular pedicles to tear at relatively fixed
points of attachment. Differential movements of fixed
and non-fixed structures
(e.g. liver and spleen laceration at sites of supporting ligaments)
 Crushing effect
B/n anterior abdominal wall and vertebral
column/posterior cage
(e.g. direct blow to the epigastrium with crushing of the
pancreas over the spine)
 Compressive effect
Sudden dramatic rise in Intra-abdominal pressure due
to external compression, hollow viscus ruptures
(e.g. direct blow to liver or blowout of the bowel)
27

28. Motor Vehicle
Accidents
 The most common cause of blunt trauma
is the motor vehicle Injuries
 Major global public health challenge but
most of it occurs in low- and middle-income
countries including Ethiopia.
 Every year about 1.2 million people
are killed and more than 20 million
are injured or disabled
28

29. Contributing Factors
 Poor road network
 Absence of knowledge on road traffic safety
 Mixed traffic flow system
 Poor legislation and failure of enforcement
 Poor conditions of vehicles;
 Poor emergency medical services
Traffic accident compulsory insurance law is in
effect Recently.
29

30. Several key Factors:
Themass and speed of the vehicle at the
moment of impact;
Whether the occupants of the vehicle were
restrained;
Whether the occupant was ejected; and
The interaction of the occupant or pedestrian
with vehicle parts.
30

31. Seatbelt injuries
Although seatbelts reduce mortality overall, they
cause a specific pattern of internal injuries.
Patients with seatbelt marks have been found to
have a fourfold increase in thoracic trauma and an
eightfold increase in intra-abdominal trauma
compared with those without seatbelt marks
The three-point shoulder-lap belt is the most
effective restraining system and is associated with
the lowest incidence of abdominal injuries.

32.  Use of seatbelts is thought to reduce the risk
of death or serious injury for front-seat
occupants by approximately 45%.
 Unbelted rear-seat occupants are also at
increased risk of serious injury in motor vehicle
accidents (MVAs); they may be ejected or
thrown forward into the back of the front seat;
the impact from unbelted rear-seat passengers
on front-seat occupants can be a major
determinant of injury.
 It is estimated that, when rear seatbelts are
worn, the risk of death for belted front-seat
occupants is reduced by 80%.
 In direct frontal MVAs, airbags provide a
reduced risk of fatality of approximately 30%. 32

33.  Compression
Of the bowel between the belt and the
vertebral column, an acute short closed-loop
obstruction occurs along with perforation
secondary to the sudden generation of high
intraluminal pressures.

34. Clinically, two symptom patterns emerge.
 ~1/4 of pt. develop evidence of a hemoperitoneum
secondary to mesenteric lacerations.
 In the remainder 3/4 of pt. the intestinal injury most
commonly involves the jejunum contusion or
perforation.
 Rare cases of acute abdominal aortic dissection
with incomplete or complete occlusion have also
been described, and injuries to the lumbar spine are
not uncommon.

35. Mechanism of Injury:
Penetrating
Kinetic Energy imparted to body
•Low velocity: Knife
Ice pick
•Medium velocity: Gunshot wounds
Shotgun wounds
•High velocity: High-power hunting rifles
Military weapons

36. Pathophysiology
Depends on the
•Type of weapon
•Velocity of bullet
•Distance b/n assailant & victim
Typically follow the tract/trajectory of the
inflicting instrument & thus involve
contiguous structures.

37. Stab Wounds
 Multiple in 20% of cases
 Involve the chest in up to 10% of cases
 Most stab wounds do not cause an
intraperitoneal injury
 The incidence varies with the direction of
entry into the peritoneal cavity
 The liver, followed by the small bowel, is the
organ most often damaged by stab wounds.

38.  Knives are not the sole implement
used in stabbings.
 Ice picks, pens, coat hangers,
screwdrivers, and broken bottles.
 Most commonly in the upper
quadrants, the left more commonly
than the right???

39. Gunshot Wounds
 Handguns, Rifles, and Shotguns
“crush” Bones
The degree of injury depends on
 Amount of kinetic energy imparted by the
bullet to the victim
 Mass of the bullet and the square of its
“stretch” Tissues
velocity
 Distance

40. General Principles of GSW
 Low-velocity injury (<1000ft/sec), damage is
confined to missile tract.
 High-velocity injury (<2000ft/sec), blast effect
& cavitation occur in addition to damage by
missile tract.
 85% of ant. GSW violate the peritoneum; of
these 95% require repair of intra abdominal
injury.
 Organs occupying the most space are more
often injured
• Small bowel(29%)
• Liver(28%)
• Colon(23%) 40

41.  Type I wounds : long range (>7 yards) , a
penetration of subcutaneous tissue and
deep fascia only.
 Type II wounds : distance of (3 to 7 yards)
and may create a large number of
perforated structures.
 Type III wounds : occur at point-blank
range (<3 yards) and involve a massive
destruction of tissue
*1yard=0.9meter

42. Small bowel injury is the most
common injury resulting from ___
abdominal trauma.
 penetrating
 blunt

43. Small bowel injury is the most
common injury resulting from ___
abdominal trauma.
 penetrating
 blunt

44. CLINICAL ASSESSMENT
 HISTORY
 PHYSICAL EXAMINATION

45.  Primary goal is to identify that an injury
exists, not necessarily making an accurate
diagnosis.
 The patient's history may be unobtainable,
elusive, or temporarily abandoned while
resuscitative measures are carried out.
 History from prehospital care team or
transferring hospital : the vital signs,
physical assessment, prehospital course,
and response to therapy should be obtained
 Mechanism of injury is an important factor
in developing a high index of suspicion; thus
a detailed history is helpful if available.

46. Assessment: History
Mechanism
MVC:
 Speed
 Type of collision (Frontal, Lateral,
Sideswipe, Rear, Rollover)
 Vehicle intrusion into passenger
compartment
 Types of restraints
 Deployment of air bag
 Patient's position in vehicle
 Kehr’s Sign???

47. In blunt trauma: MVA
Details about accident
Fatality at the scene
Vehicle type and velocity
Whether the vehicle rolled over
Patient's location within the vehicle
Extent of intrusion into the passenger compartment
Extent of damage to the vehicle
Steering wheel deformity
Whether seat belts were used and, if so, what type
Whether front or side air bags were deployed
All patients involved in deceleration injuries and
bicycle injuries should be suspected of having
intraabdominal injury

48. In penetrating trauma: GSW/MSW
 No. of shots or stabs?
 Type of weapon?
 Number of shots heard?
 Position of the patient when shot?
 Distance of the patient from the gun?
 What instrument was used?
 How long and how wide was the instrument?
 How was the patient positioned during the
stabbing?
 What path did the implement travel?

49. Assessment: Physical
Exam

50. PHYSICAL EXAMINATION
General Examination : Relating to
hemodynamic stability (Vital Signs)
Abdominal findings:
• Inspection :
For abdominal distension
For contusions or abrasions
Lap belt ecchymosis
Mesenteric, Bowel, and Lumbar spine injuries
Periumblical (Cullen sign) and
Flank (Grey Turner Sign) ecchymosis –
Retroperitoneal hematoma

51. PHYSICAL EXAMINATION
cont.
• Palpation :
For tenderness, guarding and/or rigidity,
rebound tenderness –
hemoperitoneum
• Percussion :
Dullness/ shifting dullness
Intraabdominal collection
• Auscultation : Where to auscultate &
What to listen for??? All four quadrants

52. The classical
‘seatbelt’ sign.
The bruising on
the left breast is
from the shoulder
belt and the low
bruising to the
abdominal wall is
from the lap belt.

53. PHYSICAL
EXAMINATION cont..
Rectal findings
 Check for gross blood - Pelvic fracture
 Determine prostate position – High riding
prostate – Urethral injury
 Assess sphincter tone – Neurologic status
Distal pulses
- Assess for absence or asymmetry
Assessment of other associated injuries i.e.
multiple fractures, spinal injuries etc.

54. Associated with
fractures
 Left lower six ribs Spleen
 Right lower six ribs Liver
 Upper Lumbar Pancreas and
vertebra Duodenum
 Transverse Kidneys
Process
Bladder
 Pelvis Urethra
Rectum 54

55. Reliability of clinical
evaluation
 Low sensitivity
 Unreliable in 35/45% of pt.
 Why??
– Head Injury
Caution
– Spinal A missed abdominal
– Alcohol injury can cause a
preventable death.
– Drug
 Repeated physical examination is
55
Mandatory.

56. The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:
 abdominal pain and tenderness
 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may
result from confined hemorrhage)

57. The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:
 abdominal pain and tenderness
 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may
result from confined hemorrhage)

58. High Index of Suspicion
 Mechanism
 Tachycardia early, hypotension, and
pale, diaphoretic skin late
 Hypovolemic shock with no readily
identifiable cause
 Diffusely tender abdomen
 Pain in uninjured shoulder
58

59. Blunt Abdominal Trauma
 Direct impact or
movement of organs
 Compressive, stretching
or shearing forces
 Solid Organs > Blood
Loss
 Hollow Organs > Blood
Loss and Peritoneal
Contamination
 Retroperitoneal > Often
asymptomatic initially

60. Blunt Abdominal Trauma
 Direct impact or
movement of organs
 Compressive, stretching
or shearing forces
 Solid Organs > Blood
Loss
 Hollow Organs > Blood
Loss and Peritoneal
Contamination
 Retroperitoneal > Often
asymptomatic initially

61. Blunt Abdominal Trauma
 Direct impact or
movement of organs
 Compressive, stretching
or shearing forces
 Solid Organs > Blood
Loss
 Hollow Organs > Blood
Loss and Peritoneal
Contamination
 Retroperitoneal > Often
asymptomatic initially

62. Blunt Abdominal Trauma
 Direct impact or
movement of organs
 Compressive, stretching
or shearing forces
 Solid Organs > Blood
Loss
 Hollow Organs > Blood
Loss and Peritoneal
Contamination
 Retroperitoneal > Often
asymptomatic initially

63. Blunt Abdominal Trauma
 Direct impact or
movement of organs
 Compressive, stretching
or shearing forces
 Solid Organs > Blood
Loss
 Hollow Organs > Blood
Loss and Peritoneal
Contamination
 Retroperitoneal > Often
asymptomatic initially

64. Conclusion
 Abdominal trauma is often difficult
to evaluate in the prehospital
setting. Therefore the paramedic
must exercise a high degree of
suspicion based on the mechanism
of injury and kinematics.
 Death from abdominal injury usually
results from hemorrhage and
delayed surgical repair.

65. The KEY to Saving
Lives
 The abdomen is the “Black Box”
– i.e, its impossible to know what specific
injuries have occurred at initial evaluation.
 The Key to saving lives in abdominal
trauma is NOT to make an accurate
diagnosis, but rather to recognize that
there is an abdominal injury.
65