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.