Abdominal Trauma
Temple College EMS Professions
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The Abdomen
Everything between diaphragm and pelvis Injury, illness very difficult to assess because of large variety of structures
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Abdominal Anatomy
Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus Organs can be located by quadrant
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Abdominal Anatomy
Right Upper Quadrant
– Liver – Gall Bladder – Right Kidney – Ascending Colon – Transverse Colon
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Abdominal Anatomy
Left Upper Quadrant
– Spleen – Stomach – Pancreas – Left Kidney – Transverse Colon – Descending Colon
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Abdominal Anatomy
Right Lower Quadrant
– Ascending Colon – Appendix – Right Ovary (female) – Right Fallopian Tube (female)
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Abdominal Anatomy
Left Lower Quadrant
– Descending Colon – Sigmoid colon – Left Ovary (female) – Left Fallopian Tube (female)
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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
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Abdominal Cavity
Peritoneum = abdominal cavity lining Divides abdomen into two spaces
– Peritoneal cavity – Retroperitoneal space
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Abdominal Anatomy
Peritoneal
– – – – – Spleen Liver Stomach Gall bladder Bowel
Retroperitoneal
– – – – – – – Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs
Disease, injury of retroperitoneal organs often causes back pain
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Abdominal Anatomy
Organs can be classified as:
– Hollow – Solid – Major vascular
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Solid Organs
Liver Spleen Kidney Pancreas
When solid organs are injured, they bleed heavily and cause shock
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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
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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
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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
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Hollow Organs
Stomach Gall bladder Large, small intestines Ureters, urinary bladder
Rupture causes content spillage, inflammation of peritoneum
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Hollow Organs
Stomach
– Acid, enzymes – Immediate peritonitis – Pain, tenderness, guarding, rigidity
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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
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Major Vascular Structures
Aorta Inferior vena cava Major branches
Injury can cause severe blood loss ; exsanguination (bleeding out)
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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
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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
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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
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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
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Signs of Injured Abdomen
Diffuse tenderness Pain
– Pain referred to shoulder = Organ under diaphragm involved (?spleen) – Pain referred to back = Retroperitoneal organ involved (?kidney)
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Abdominal Rigidity
NOT reliable Bleeding may not cause rigidity if free hemoglobin absent Bleeding in retroperitoneal space may not cause rigidity
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Abdominal Trauma Management
Less important to diagnose exact injury Treat clinical findings Management same regardless of specific organ(s) injured
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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
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Impaled Object
Leave in place
– Shorten if necessary for transport – Leave part of object exposed
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Evisceration
With large laceration abdominal contents may spill out Do NOT try to replace
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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
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Genitourinary Trauma
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Urinary System
Kidney
Ureter Urinary Bladder
Urethra
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Kidney Trauma
50% of all GU trauma
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Kidney Trauma
Penetrating
– GSW – Stab wound
Rare, usually associated with trauma to other abdominal organs
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Kidney Trauma
Blunt
– Direct blow to back, flank, upper abdomen
• Suspect with fractures of 10th - 12th ribs or T12, L 1, L 2
– Acceleration/Deceleration
• Shearing of renal artery/vein
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Kidney Trauma
Signs and Symptoms
– Gross Hematuria
• 80% of cases • Absence does NOT exclude renal injury
– Localized flank/abdominal pain – Palpable mass
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Kidney Trauma
Signs and Symptoms
– Tenderness: Lower ribs, upper L-spine, flank – Pain: groin, shoulder, back, flank
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Ureter Trauma
Less than 2% of GU trauma Usually secondary to penetrating trauma Indicator
– Wound to lower back with urine escaping
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Urinary Bladder Trauma
Mechanisms
– Blunt injury to lower abdomen – Seat belts – Pelvic fracture – Penetrating trauma to lower abdomen or perineum (pelvic floor)
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Extraperitoneal Bladder Rupture
Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum Dysuria Hematuria Suprapubic tenderness Swelling, redness secondary to tissue damage from urine
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Intraperitoneal Bladder Rupture
Urgency to void Inability to void Shock Abdominal distension
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Urethral Trauma
Mechanisms
– Sudden decelerations (bladder shears off urethra) – Straddle injuries
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Urethral Trauma
Signs and Symptoms
– Blood at external meatus – Perineal bruising (butterfly bruise) – Scrotal hematoma
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Reproductive System Trauma
Can occur to both external and internal reproductive systems
– External
• More common • Pain, extensive bleeding
– Internal
• Rarely injured
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Reproductive System Trauma
Treat like blunt or penetrating soft tissue injuries elsewhere on body
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Male Genitalia Trauma
Usually NOT life-threatening Very painful Great source of concern to patient
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Male Genitalia Trauma
Avulsion of skin of penis, scrotum
– Cover with a moist, sterile dressing
Complete amputation of penis
– Treat as any amputated part
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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
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Female Genitalia Trauma
Internal
– Rarely injured
External
– Can cause pain, extensive bleeding – Usually not life-threatening
Treat with compresses, pressure
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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
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