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Abdominal Trauma

Gram McGregor, 1Lt, WA ANG
Critical Care Air Transport Nurse

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Abdominal Trauma

  1. 1. Abdominal Trauma Gram McGregor, 1Lt, WA ANG Critical Care Air Transport Nurse
  2. 2. The Abdomen <ul><li>Everything between diaphragm and pelvis </li></ul><ul><li>Injuries very difficult to assess because of large variety of structures </li></ul>
  3. 3. Abdominal Anatomy <ul><li>Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus </li></ul><ul><li>Organ located by quadrant </li></ul>
  4. 4. Abdominal Anatomy <ul><li>Right Upper Quadrant </li></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Gall Bladder </li></ul></ul><ul><ul><li>Right Kidney </li></ul></ul><ul><ul><li>Ascending Colon </li></ul></ul><ul><ul><li>Transverse Colon </li></ul></ul>
  5. 5. Abdominal Anatomy <ul><li>Left Upper Quadrant </li></ul><ul><ul><li>Spleen </li></ul></ul><ul><ul><li>Stomach </li></ul></ul><ul><ul><li>Pancreas </li></ul></ul><ul><ul><li>Left Kidney </li></ul></ul><ul><ul><li>Transverse Colon </li></ul></ul><ul><ul><li>Descending Colon </li></ul></ul>
  6. 6. Abdominal Anatomy <ul><li>Right Lower Quadrant </li></ul><ul><ul><li>Ascending Colon </li></ul></ul><ul><ul><li>Appendix </li></ul></ul><ul><ul><li>Right Ovary (female) </li></ul></ul><ul><ul><li>Right Fallopian Tube (female) </li></ul></ul>
  7. 7. Abdominal Anatomy <ul><li>Left Lower Quadrant </li></ul><ul><ul><li>Descending Colon </li></ul></ul><ul><ul><li>Sigmoid colon </li></ul></ul><ul><ul><li>Left Ovary (female) </li></ul></ul><ul><ul><li>Left Fallopian Tube (female) </li></ul></ul>
  8. 8. Abdominal Anatomy <ul><li>Organs can be classified as: </li></ul><ul><ul><li>Hollow </li></ul></ul><ul><ul><li>Solid </li></ul></ul><ul><ul><li>Major vascular </li></ul></ul>
  9. 9. Solid Organs <ul><li>Liver </li></ul><ul><li>Spleen </li></ul><ul><li>Kidney </li></ul><ul><li>Pancreas </li></ul>When solid organs are injured, they bleed heavily and cause shock
  10. 10. Solid Organs <ul><li>Liver </li></ul><ul><ul><li>Largest abdominal organ </li></ul></ul><ul><ul><li>Most frequently injured </li></ul></ul><ul><ul><li>Fractures of ribs 8-12 on right side </li></ul></ul><ul><ul><li>Bleeding can be either: </li></ul></ul><ul><ul><ul><li>Slow, contained under capsule </li></ul></ul></ul><ul><ul><ul><li>Free into peritoneal cavity </li></ul></ul></ul>
  11. 11. Solid Organs <ul><li>Spleen </li></ul><ul><li>Frequently injured with trauma ribs 9-11 on left side </li></ul><ul><ul><li>Bleeds easily </li></ul></ul><ul><ul><li>Capsule around spleen tends to slow development of shock </li></ul></ul><ul><ul><li>Rapid shock onset when capsule ruptures </li></ul></ul>
  12. 12. Solid Organs <ul><li>Pancreas </li></ul><ul><ul><li>Lies across lumbar spine </li></ul></ul><ul><ul><li>Sudden deceleration produces straddle injury </li></ul></ul><ul><ul><li>Very little hemorrhage </li></ul></ul><ul><ul><li>Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock </li></ul></ul>
  13. 13. Hollow Organs <ul><li>Stomach </li></ul><ul><li>Gall bladder </li></ul><ul><li>Large, small intestines </li></ul><ul><li>Ureters, urinary bladder </li></ul>Rupture causes content spillage , inflammation of peritoneum
  14. 14. Hollow Organs <ul><li>Stomach </li></ul><ul><ul><li>Acid, enzymes </li></ul></ul><ul><ul><li>Immediate peritonitis </li></ul></ul><ul><ul><li>Pain, tenderness, guarding, rigidity </li></ul></ul>
  15. 15. Hollow Organs <ul><li>Colon </li></ul><ul><ul><li>Spillage of bacteria </li></ul></ul><ul><ul><li>May take 6 hrs to develop peritonitis </li></ul></ul><ul><li>Small Bowel </li></ul><ul><ul><li>Fewer bacteria </li></ul></ul><ul><ul><li>May take 24-48 hours to develop peritonitis </li></ul></ul>
  16. 16. Major Vascular Structures <ul><li>Aorta </li></ul><ul><li>Inferior vena cava </li></ul><ul><li>Major branches </li></ul>Injury can cause severe blood loss ; exsanguination (bleeding out)
  17. 17. Abdominal Trauma <ul><li>Many survive to reach hospital </li></ul><ul><li>Most common factors leading to death </li></ul><ul><ul><li>Failure to adequately evaluate </li></ul></ul><ul><ul><li>Delayed resuscitation </li></ul></ul><ul><ul><li>Inadequate volume </li></ul></ul><ul><ul><li>Inadequate diagnosis </li></ul></ul><ul><ul><li>Delayed surgery </li></ul></ul>
  18. 18. High Index of Suspicion <ul><li>Mechanism </li></ul><ul><li>Tachycardia early , hypotension, and pale, diaphoretic skin late </li></ul><ul><li>Hypovolemic shock with no readily identifiable cause </li></ul><ul><li>Diffusely tender abdomen </li></ul><ul><li>Pain in uninjured shoulder </li></ul>
  19. 19. Mechanism <ul><li>Look for signs of injury </li></ul><ul><ul><li>Bruises </li></ul></ul><ul><ul><li>Tire marks </li></ul></ul><ul><ul><li>Obvious open injuries </li></ul></ul><ul><li>Assume any abdominal injury is serious until proven otherwise! </li></ul><ul><li>Injury above umbilicus also involves chest until proven otherwise </li></ul>
  20. 20. Adequate* Assessment key <ul><li>D-eformity </li></ul><ul><li>C-ontusions </li></ul><ul><li>A-brasions </li></ul><ul><li>P-enetrating Injuries </li></ul><ul><li>*per BTLS Guidelines </li></ul><ul><li>B-urns </li></ul><ul><li>T-enderness </li></ul><ul><li>L-acerations </li></ul><ul><li>S-welling </li></ul>
  21. 21. Blast Injuries <ul><li>Most commonly found in ear, lungs and hollow abdominal organs. </li></ul><ul><li>Abdominal injuries include hemorrhage and hollow organ rupture. </li></ul>
  22. 22. Unexplained Shock <ul><li>Assess vital signs; skin color, temperature; capillary refill </li></ul><ul><li>Tachycardia; restlessness; cool, moist skin </li></ul><ul><li>In trauma, signs of shock suggest abdominal injury if no other obvious causes present </li></ul>
  23. 23. Signs of Injured Abdomen <ul><li>Diffuse tenderness </li></ul><ul><li>Pain </li></ul><ul><ul><li>Pain referred to shoulder = Organ under diaphragm involved (?spleen) </li></ul></ul><ul><ul><li>Pain referred to back = Retroperitoneal organ involved (?kidney) </li></ul></ul>
  24. 24. Abdominal Rigidity <ul><li>NOT reliable </li></ul><ul><li>Bleeding may not cause rigidity if free hemoglobin absent </li></ul><ul><li>Bleeding in retroperitoneal space may not cause rigidity </li></ul>
  25. 25. Abdominal Trauma Management <ul><li>Most Important fact in treating ALL types of abdominal trauma… </li></ul><ul><li>Initiation of life support measures including establishment and maintenance of adequate airway, breathing and circulatory support. </li></ul>
  26. 26. Abdominal Trauma Management <ul><li>Less important to diagnose exact injury </li></ul><ul><li>Treat clinical findings-as able </li></ul><ul><li>Management same regardless of specific organ(s) injured </li></ul>
  27. 27. Abdominal Trauma Management <ul><li>Airway </li></ul><ul><li>C-Spine if mechanism indicates </li></ul><ul><li>High flow O 2 </li></ul><ul><li>Assist ventilations if needed </li></ul><ul><li>Give nothing by mouth </li></ul>
  28. 28. Impaled Object <ul><li>Leave in place </li></ul><ul><ul><li>Shorten if necessary for transport </li></ul></ul><ul><ul><li>Leave part of object exposed </li></ul></ul><ul><ul><li>Stabilize </li></ul></ul>
  29. 29. Evisceration <ul><li>With large laceration abdominal contents may spill out </li></ul><ul><li>Do NOT try to replace </li></ul>
  30. 30. Evisceration <ul><li>Cover exposed organs with saline moistened multi-trauma dressing </li></ul><ul><li>Cover first dressing with second DRY dressing or nonpermeable item </li></ul>
  31. 31. Genitourinary Trauma Gram McGregor, 1Lt, WA ANG Critical Care Air Transport Nurse
  32. 32. Urinary System Kidney Ureter Urinary Bladder Urethra
  33. 33. Kidney Trauma <ul><li>50% of all GU trauma </li></ul>
  34. 34. Kidney Trauma <ul><li>Penetrating </li></ul><ul><ul><li>GSW </li></ul></ul><ul><ul><li>Stab wound </li></ul></ul><ul><ul><li>Blast injuries similar to other solid organs </li></ul></ul><ul><li>Rare, usually associated with trauma to other abdominal organs </li></ul>
  35. 35. Kidney Trauma <ul><li>Blunt </li></ul><ul><ul><li>Direct blow to back, flank, upper abdomen </li></ul></ul><ul><ul><ul><li>Suspect with fractures of 10th - 12th ribs or T 12 , L 1 , L 2 </li></ul></ul></ul><ul><ul><li>Acceleration/Deceleration </li></ul></ul><ul><ul><ul><li>Shearing of renal artery/vein </li></ul></ul></ul>
  36. 36. Kidney Trauma <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Gross Hematuria </li></ul></ul><ul><ul><ul><li>80% of cases </li></ul></ul></ul><ul><ul><ul><li>Absence does NOT exclude renal injury </li></ul></ul></ul><ul><ul><li>Localized flank/abdominal pain </li></ul></ul><ul><ul><li>Palpable mass </li></ul></ul>
  37. 37. Kidney Trauma <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Tenderness: Lower ribs, upper L-spine, flank </li></ul></ul><ul><ul><li>Pain: groin, shoulder, back, flank </li></ul></ul>
  38. 38. Ureter Trauma <ul><li>Less than 2% of GU trauma </li></ul><ul><li>Usually secondary to penetrating trauma </li></ul><ul><li>Indicator </li></ul><ul><ul><li>Wound to lower back with urine escaping </li></ul></ul>
  39. 39. Urinary Bladder Trauma <ul><li>Mechanisms </li></ul><ul><ul><li>Blunt injury to lower abdomen </li></ul></ul><ul><ul><li>Seat belts </li></ul></ul><ul><ul><li>Pelvic fracture </li></ul></ul><ul><ul><li>Penetrating trauma to lower abdomen or perineum (pelvic floor) </li></ul></ul><ul><ul><li>Can display hollow or solid organ blast injuries dependant upon urine in bladder </li></ul></ul>
  40. 40. Extraperitoneal Bladder Rupture <ul><li>Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum </li></ul><ul><li>Dysuria </li></ul><ul><li>Hematuria </li></ul><ul><li>Suprapubic tenderness </li></ul><ul><li>Swelling, redness secondary to tissue damage from urine </li></ul>
  41. 41. Intraperitoneal Bladder Rupture <ul><li>Urgency to void </li></ul><ul><li>Inability to void </li></ul><ul><li>Shock </li></ul><ul><li>Abdominal distension </li></ul>
  42. 42. Urethral Trauma <ul><li>Mechanisms </li></ul><ul><ul><li>Sudden decelerations (bladder shears off urethra) </li></ul></ul><ul><ul><li>Straddle injuries </li></ul></ul>
  43. 43. Urethral Trauma <ul><li>Signs and Symptoms </li></ul><ul><ul><li>Blood at external meatus </li></ul></ul><ul><ul><li>Perineal bruising (butterfly bruise) </li></ul></ul><ul><ul><li>Scrotal hematoma </li></ul></ul>
  44. 44. Questions?
  45. 45. References <ul><li>Elsayed, N. (1997) Toxicology of overpressure. </li></ul><ul><li>Mayorga, M. (1997) The pathology of primary blast overpressure injury. </li></ul><ul><li>Phillips, Y.Y. and Zajtuk, J.T. (1991) The management of primary blast injury. </li></ul><ul><li>Browner, B.D. (2002) Emergency care and treatment of the sick and injured. </li></ul>

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