ABD and GU Trauma

Abdominal & Genitourinary Trauma EMS Professions Temple College Abdominal Trauma • Most patients survive long enough to reach hospital • Common factors that lead to death – – – – – Delayed resuscitation Inadequate volume Inadequate diagnosis Failure to evaluate Delayed surgery Abdominal Trauma • Death results from increased hemorrhage due to: – – – – solid organ injuries hollow organ injuries abdominal vascular injuries pelvic fractures • Additional Injury – Spillage of hollow organ contents – Peritonitis Prevention Strategies • What are possible strategies for preventing deaths due to abdominal and genitourinary trauma? – What role can EMS Systems play in these strategies? Abdominal Boundaries • • • • • Diaphragm Anterior abdominal wall Pelvic skeletal structures Vertebral column Muscles of the abdomen and flanks Abdominal & Pelvic Cavities • Retroperitoneal – Kidneys, ureters, bladder, reproductive organs, inferior vena cava, abdominal aorta, pancreas • Peritoneal – Bowel, spleen, liver, stomach, gall bladder • Pelvic – Rectum, ureters, pelvic vascular plexus, femoral arteries, femoral veins, pelvic skeletal structures, reproductive organs High Index of Suspicion • Mechanism of Injury – Seat Belts – Steering wheel in unrestrained • Trauma to abdomen, lower chest, back, flank, buttocks, and perineum • Pain in uninjured shoulder – Kehr’s Sx – Murphy’s Sx – Turner’s Sx • Hypovolemic shock or diffusely tender abdomen w/ no identifiable cause  bleeding UPO Mechanisms of Injury • Blunt mechanisms – Forces • Compression forces • Shearing forces • Deceleration forces – Sources • MVCs – Seat belt injury – Steering wheel injury • Falls • Assaults • Blast Mechanisms of Injury • Penetrating mechanisms – Low velocity • knife • ice pick – Medium velocity • gunshot/handgun • shotgun – High velocity • high power hunting rifle • military weapon Mechanisms of Injury • Penetrating Injury - Ballistics – Low velocity • injury usually limited to depth and travel of weapon • injury usually limited to area near penetration – Medium velocity • travel direction easily redirected • greater external soft tissue injury – High velocity • energy wave • cavitation Pathophysiology • Hemorrhage – – – – – – – – Limited external signs Rapid blood loss possible Hypovolemic shock Blood does not result in peritonitis Enzymes, Acids, Bacteria Chemical irritant to peritoneum Localized pain  Generalized abdominal pain Muscular spasm (rigid abdomen) • Spillage of Contents Solid Organ Injuries • Death usually 2° to hemorrhage • May to due to blunt or penetrating mechanism Solid Organ Injuries • Spleen – – – – Frequently injured solid organ Usually due to blunt trauma Often 2° trauma to ribs 9-11 on left side Bleeds easily • Capsule around spleen tends to promote slow development of shock • Rapid shock onset when capsule ruptures – May present with left shoulder pain • diaphragm irritation Solid Organ Injuries • Liver – Largest organ in abdomen – Frequently injured organ • May be due to blunt or penetrating trauma – Often 2° trauma to ribs 8-12 on right side – Bleeding • Slow and contained under capsule • Enters peritoneal cavity Solid Organ Injuries • Pancreas – Lies across lumbar spine – Usually due to penetrating trauma • also due to compression against vertebral column by steering wheel, handle bars, or other object • Sudden deceleration produces straddle injury – Very little hemorrhage – Irritation to peritoneum • fluid loss from leakage of pancreatic enzymes • auto-digestion of tissue Hollow Organ Injuries • Death may result from hemorrhage and/or content spillage • May result from penetrating or blunt trauma Hollow Organ Injuries • Stomach – Usually injured due to blunt trauma – Full stomach prior to incident  risk of injury – Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity • Small and Large Intestines – Usually injured due to penetrating trauma – Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity Hollow Organ Injuries • Colon – Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity – Spillage of bacteria into peritoneal cavity • May take 6 hrs to develop S/S of peritonitis • Small Bowel – Spillage of contents into peritoneal cavity • Immediate pain, tenderness, guarding, and rigidity – Less bacteria • May take 24-48 hours for S/S to manifest Abdominal Vascular Injuries • High mortality due to rapid blood loss – Survival dependent upon extent of injury and time to surgery • abdominal aorta, inferior vena cava, femoral arteries – shearing – dissection – transection Pelvic Injuries • Increase risk of intraperitoneal structure injury – vascular structures – hollow organs Genitourinary Trauma Kidney Trauma • 50% of all GU trauma • Blunt – Direct blow to back, flank, upper abdomen • Suspect in Fx of 10th - 12th ribs or T12, L1, L2 – Acceleration/Deceleration • Shearing of renal artery/vein • Penetrating – Rare, usually associated – GSW or Stab wound Kidney Trauma S/S • Gross Hematuria – 80% of cases – absence does not exclude renal injury • Localized flank/Abdominal pain • Pain/Tenderness of lower ribs, upper lumbar spine, groin, shoulder or flank • Hypovolemia Ureter Trauma • Less than 2% of GU trauma • Usually secondary to penetrating trauma • Rupture – Extraperitoneal – Intraperitoneal Extraperitoneal Rupture • Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum • Dysuria • Hematuria • Suprapubic Tenderness • Induration – redness secondary to tissue damage from urine Intraperitoneal Rupture • Urgency to void, inability to void • Shock • Abdominal distention Bladder Injury • • • • • Most often injured due to blunt trauma Full bladder may increase risk of injury Often associated with pelvic fractures Should not attempt urinary catheterization Localized pelvic pain Urethra • Usually due to pelvic fracture, deceleration or straddle injuries • Blood at external meatus • Perineal bruising – Butterfly bruise • Scrotal Hematoma Urethra • Urinary catheter’s should not be passed if these are present. • Rectal exam should be performed before passing a urinary catheter in a patient whose urethra may be disrupted Male External Genitalia • Accidental or Intentional Injury • Highly vascular w/rich sensory nerve supply – Pain – Psychological issues – Hemorrhage Male External Genitalia • Penile/Scrotal – – – – Zipper Foreign body Avulsion/Amputation Fracture • Scrotal/Testicular – Penetrating injury – Blunt injury • Management – Control bleeding / Indirect ice / Analgesia – Psychological and Modesty Concerns Female External Genitalia • Usually intentional 2° assault • Primarily soft tissue injury – Hemorrhage likely – Look for other injuries • Sexual Assault – Emotional state provides additional challenge • Managed as other soft tissue bleeding – control hemorrhage – facility with trained personnel (sexual assault) Abdominal Trauma Assessment • Less important to diagnose exact injury • Treat clinical findings • Management the same regardless of specific organ injured Abdominal Rigidity • Do not rely on rigidity • Bleeding may not cause rigidity if free hemoglobin is not present • Bleeding in retroperitoneal space will not cause rigidity – May cause flank ecchymosis • Adult can accommodate 1.5 liters w/o distention Bowel Sounds • Little value, if any, in pre-hospital assessment of trauma patient – Absent if shock is present, regardless of abdominal injury – Requires minutes for adequate assessment – Does not give any information you cannot get some other way Abdominal Trauma Assessment • Evidence may be masked by other injuries or intoxicants – – – – head injury hypoxia alcohol drugs Abdominal Trauma Assessment • Mechanism & Kinematics • History and Physical Exam – Patient Complaints – Inspection • External signs of injury – – – – – – abrasions, ecchymosis, “seat belt sign” distention wounds impaled object evisceration perineal blood, blood at meatus Abdominal Trauma Assessment • History and Physical Exam – Gentle palpation – Percussion and Auscultation of little value – Evidence of shock • out of proportion to obvious injuries – Guarding – Evidence of peritonitis – Pelvic instability Abdominal Trauma Management • • • • • • C-Spine Motion Restriction IF indicated Airway Assist ventilations if needed High flow O2 Control External Bleeding Determine need for rapid transport/surgery – Not all need trauma center • Transport to appropriate Facility Abdominal Trauma Management • En route – Treat shock – MAST/PASG application w/o inflation • May be helpful in pelvic fracture – IV of LR/NS enroute • Titrate fluids to BP ~ 90 mm Hg – Indirect ice may be helpful in genitalia injury • Collect and package amputated genitalia Abdominal Trauma Management • Abdominal Evisceration – Do not replace organs into abdomen – Cover exposed bowel with saline moistened multi trauma dressing – Cover first dressing with second dry dressing – Do not use 4 x 4 Abdominal Trauma Management • Leave impaled objects in place – Shorten if necessary for transport – Leave part of object exposed • NPO • Caution with – Sedatives – Narcotic Analgesics Trauma In Pregnancy Leading cause of death during pregnancy MVCs result in 50% of prenatal mortality Trauma In Pregnancy • Most common cause of fetal death from trauma is maternal death • Consider possibility of pregnancy in any female trauma patient of childbearing age – Sexual assault may be the cause of trauma • What is best for mom is best for baby • Treatment for pregnant patient same as non pregnant patient – Consideration for emergent C-section Alterations In Pregnancy • Pregnant uterus can compress inferior vena cava when patient supine – Decreases cardiac output by 30 - 40% • Blood volume increases by 40-50% – 30% blood loss may occur before symptoms develop Alterations In Pregnancy • Blood flow to uterus and placenta can be selectively reduced • Fetus can be in distress while mother appears to be stable Alterations In Pregnancy • As uterus increases in size and blood flow – Increased risk of: • • • • Penetration Rupture Placental abruption Premature rupture of membranes – 10-20% increase in oxygen demand • Decreased peristalsis and delayed gastric emptying – Increased risk of emesis and aspiration Pregnancy Trauma Management • C-spine Motion Restriction – Transport with patient on left side or elevate right side of board • Airway – anticipate vomiting &  risk of aspiration • Assist ventilation as needed • High flow O2 – 3rd trimester O2 demand increases 10-20% Pregnancy Trauma Management • Control External Bleeding • Determine need for rapid transport/surgery – Not all need trauma center – Consider needs of sexual assault victim • Transport to appropriate Facility – Consider need for emergent C-section • Mark height of fundus on mother’s abdomen – Reassess frequently Pregnancy Trauma Management • Treat for Shock – Aggressive fluid resuscitation • Increased intravascular volume • Increased volume requirements to resuscitate – Consider MAST (legs only) • Prepare for complications of pregnancy – Premature labor & delivery – Hemorrhage complications • abruptio placenta • uterine rupture Pregnancy Trauma Management • Increased fundal height, uterine tenderness could be placental abruption • Initial management is always directed at the resuscitation and stabilization of the mother – If baby is delivered • may be premature • may need volume resuscitation