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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 Retroperitoneal

– Pancreas– Kidney– Ureter– Inferior vena cava– Abdominal aorta– Urinary bladder– Reproductive organs

Peritoneal– Spleen– Liver– Stomach– Gall bladder– Bowel

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

UreterUrinary 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, L1, L2

– 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