Abdominal Trauma abdominal distention0

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Abdominal Trauma abdominal distention0 Powered By Docstoc
					Anatomy Review
  Boundaries of the abdomen
   • Diaphragm

   • Anterior
   abdominal wall

   • Pelvic skeletal
   structures

   • Vertebral column

   • Muscles of the
   abdomen and
   flanks                     2
Muscles Protecting Abdominal Organs




                                      3
Intraperitoneal Structures
   Liver

   Spleen

   Stomach

   Small bowel

   Colon

   Gallbladder


                             4
5
Retroperitoneal Structures
  Central structures

    • Duodenum

    • Pancreas

    • Major vascular
    structures




                             6
Retroperitoneal Structures
  Lateral structures         Pelvic structures

    • Kidneys                  • Rectum

    • Ureters                  • Ureters

                               • Pelvic vascular plexis
    • Posterior
    ascending and              • Major vascular
    descending colon           structures

                               • Pelvic skeletal
                               structures

                               • Reproductive organs

                                                          7
Morbidity & Mortality
   Injury to abdominal
 structures causes
 morbidity and
 mortality primarily
 due to hemorrhage!

   Generally, death
 results from
 hemorrhage when
 definitive (surgical)
 care is delayed
                         8
Injuries may be subtle /
  difficult to detect, as
such, you should always
  have a high level of
        suspicion!
                            9
Pathophysiology of Abdominal Injury
  Hemorrhage
    • Potential for no external signs

    • Rapid blood loss progresses to hypovolemic shock

    • Blood is not a chemical irritant to the peritoneum
    (therefore, no peritonitis)




                                                           10
Focused History and Physical Examination
  Hemoperitoneum
    • Solid organ or vascular injuries

    • Adult abdomen will accommodate 1.5 liters of blood
    without abdominal distention

    • Often present with normal abdominal exam

    • Unexplained shock

    • Or, if injuries present, shock is “out of proportion”
    to known injuries
                                                              11
Hemoperitoneum
  CT shows liver lacerations with hemoperitoneum
 anterolateral to the liver and spleen (left and right
 images)
Management
  Back to the basics… ABCs!


  Only effective therapy is surgical intervention


  No definitive therapy out of hospital


  Rapid transport is defeated if hospital does not
 have immediate surgical capability

                                                     13
Solid VS. Hollow
   Solid organs
    • Trauma to these organs is associated with hemorrhage
    and shock

    • Highly vascular

    • Includes:
          Liver
          Spleen
          Pancreas
          Kidneys


                                                             14
Solid VS. Hollow
   Hollow organs
    • Trauma to these organs is associated with spillage of
    contents and peritonitis

    • Includes:
          Stomach
          Intestines
          Bladder




                                                              15
Hollow Organ Injury
  Common mechanisms include…
    • Penetrating trauma

    • Blunt trauma

    • Deceleration / shear


   Full stomach or bladder during incident increases
 the risk of injury



                                                       16
Hollow Organ Injury
  Spillage of contents
    • Enzymes

    • Acids

    • Bacteria

    • Chemical irritation to peritoneum (peritonitis)

    • Localized pain sensation via somatic nerve fibers

    • Muscular spasm secondary to peritonitis (rigid
    abdomen)

                                                          17
Hollow Organ Injury
  Peritonitis
    • Pain (subjective symptom from patient)

    • Tenderness (objective sign with percussion / palpation)

    • Guarding / rigidity

    • Distention (late finding)




                                                                18
Anatomy Review
  Quadrants / regions




                        19
Right Upper Quadrant
  Liver
  Gallbladder
  Duodenum
  Head of pancreas
  Right kidney and adrenal
  Hepatic flexure of colon
  Part of ascending and transverse colon
                                           20
Specific Solid Organ Injury - Liver
   Morbidity and mortality results from blood loss

   Caused by both blunt and penetrating trauma




                                                     21
Blunt (Laceration) and Penetrating (Gunshot) Liver Trauma




                                                        22
Gunshot Wound to Right Flank with Liver Injury




                                            23
Liver Injury with Bile Leak




                              24
Specific Solid Organ Injury - Kidney
                         Often presents with
                        hematuria and back pain

                          Blunt trauma (especially
                        associated with sports) is
                        the most frequent cause,
                        even though kidneys are
                        well protected by back
                        muscles and the rib cage



                                                     25
Specific Solid Organ Injury - Kidney




                                       26
Gunshot Injury to the Kidney




                               27
Gunshot injury to abdomen…




                             28
With Bullet Laying in Retroperitoneal Tissue
Between the IVC and Kidney




                                               29
Renal Injury




               30
Specific Solid Organ Injury - Duodenum
   Duodenal rupture is classically encountered
 in the unrestrained driver involved in a frontal
 impact MVC, or…


  Patients with direct abdominal blows (e.g.,
 bicyclists striking handlebars)



                                                    31
Blunt Duodenal Injury




                        32
Left Upper Quadrant
  Stomach
  Spleen
  Left lobe of liver
  Body of pancreas
  Left kidney and adrenal
  Splenic fixture of colon
  Parts of transverse and descending colon
                                             33
Specific Solid Organ Injury - Pancreas
  Most common with
 penetrating injuries

   May also occur in blunt
 trauma, when pancreas is
 compressed against
 vertebral column

  Products of pancreas          Gunshot injury to pancreatic head
 have an irritating effect on
 peritoneum, auto-digestion
 of tissue occurs
                                                                    34
Specific Solid Organ Injury - Spleen
   Most frequently injured organ, typically by blunt
 trauma

   Commonly associated with other intra abdominal
 injuries

   May present with left shoulder pain, which results
 from diaphragm irritation




                                                        35
Spleen Laceration from MVC




                             36
Ruptured Spleen following MVC




                                37
Colon Injury from Pellet Gun in 5-Year-Old




                                             38
Specific Solid Organ Injury – Small Bowel
  Generally results from sudden deceleration with
 subsequent tearing near a fixed point of attachment

  Incidence increases with incorrectly applied seat
 belts

   Appearance of transverse, linear ecchymoses on
 the abdominal wall (seat belt sign) should alert you
 to the possibility of intestinal injury

                                                        39
Right Lower Quadrant
  Cecum
  Appendix
  Right ovary and tube
  Right ureter




                         40
Left Lower Quadrant
  Part of descending colon
  Sigmoid colon
  Left ovary and tube
  Left ureter




                             41
Focused History and Physical Examination
  Other findings that suggest potentially serious
 abdominal trauma:
    • Abrasions

    • Ecchymosis

    • Visible wounds

    • Significant mechanism
    of injury

    • Unexplained shock
                                                    42
Focused History and Physical Examination




                                           43
Seat Belt Injury

  Associated
  with ruptured
  diaphragm,
  spleen
  laceration,
  and multiple
  rib fractures




                   44
Focused History and Physical Examination
  “Critical” findings on assessment
    • Rapid assessment and transport

    • Detailed and on-going assessment


  “Non-critical” findings on assessment
    • Focused history and physical examination

    • Other interventions and transport considerations



                                                         45
Indications for Rapid Transport
  “Critical” findings

  Surgical intervention required to control hemorrhage
 and / or contamination

  High index of suspicion for injury or high
 mechanism of injury

  Unexplained shock

  Physical signs of abdominal injury
                                                         46
Specific Solid Organ Injury - Diaphragm
   Tears from blunt
 trauma may occur in any
 portion of either
 diaphragm

   The left hemidiaphragm
 is more commonly
 injured

  Herniation of
 abdominal contents into
 chest may occur
                                          47
Abdominal Wall Injury - Eviscerations
  Do not replace organs back into abdomen

  Protect organs from further damage

  Cover with dressing moistened with sterile saline, as
 cell death occurs if viscera becomes dry




                                                          48
Abdominal Wall Injury - Eviscerations
  Carefully remove clothing from around wound




                                                49
Abdominal Wall Injury - Eviscerations
  Cover the wound with a dressing soaked with sterile
 saline to prevent drying




                                                        50
Abdominal Wall Injury - Eviscerations
  Cover the moistened dressing with a sterile occlusive
 dressing to prevent evaporative drying




                                                          51
Impaled Objects
  Blind removal of an impaled object may cause
 severe, additional trauma

  Prehospital personnel should support the impaled
 object and immobilize it (manually or mechanically) to
 prevent further movement

  Direct pressure should be applied around the object
 with the flat of the hand should bleeding occur

  No palpation of abdomen in these circumstances!
                                                          52
Injury to Vascular Structures

                                 Abdominal aorta
                                and vena cava

                                  Prone to direct,
                                blunt or
                                penetrating
                                trauma

                                 Blood
                                accumulation
                                beneath
                                diaphragm



                                                     53
Case Study
  Single motor vehicle crash; vehicle struck a tree
 head-on at a high rate of speed

  Driver is only occupant, approximately 20-years-old

  Scene is safe

  Vehicle is noted to have significant frontal intrusion
 and damage to the passenger compartment


       What actions would you take?                        54
Case Study
   The driver is found to be restrained by a lap belt and
 is trapped by his legs, requiring extrication

   Patient is unconscious but responds with localization
 to painful stimuli

  Initial vital signs:
    • Pulse rate = 86 bpm
    • Respiratory rate = 20
    • Systolic blood pressure = 120 mm Hg



   Is this patient a candidate for rapid extrication?       55
Case Study
  You successfully extricate the patient and complete a
 secondary survey

  A seat belt contusion of the abdomen is assessed
 above the level of the iliac crests, otherwise,
 abdominal assessment is unremarkable

   The patient is noted to have facial contusions and
 swelling, anterior chest contusion, and an obvious
 fracture of the left femur

                                                          56
Case Study
  Does this patient require transport to a trauma
 center?

   Have life-threatening injuries been ruled out in this
 individual?

   Does this patient have the potential for abdominal
 injuries?

  If so, how likely is it that abdominal injuries are
 present, and what type of injuries may exist?
                                                           57
Case Study
   Response to only painful stimuli and obvious head
 trauma are signs of a closed head injury; this would
 indicate transport to a trauma center


  The individual is not tachycardic and has a normal
 systolic blood pressure; it may offer a false sense of
 security, as these do not rule out the possibility of
 early, compensated shock in a young, healthy person



                                                          58
Case Study
  Potential for intra-abdominal injuries is very high!
    • Small and large bowel perforation

    • Duodenal and pancreatic damage

    • Mesenteric tears with hemorrhage

   Several of these structures are located in the
 retroperitoneum and injuries may not cause any
 abdominal physical findings for hours or days;
 absence of abnormal exam at this time does not rule
 out any of these injuries!
                                                         59
The End.

				
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Description: Abdominal Trauma abdominal distention0