28: Abdomen and Genitalia Injuries

28: Abdomen and Genitalia Injuries

Emergency Care and Transportation of the Sick and Injured, 8th Edition AAOS

Cognitive Objectives1. State the steps in the emergency medical care of a patient with a blunt or penetrating abdominal injury.2. Describe how solid and hollow organs can be injured.3. State the steps in the emergency medical care of a patient with an object impaled in the abdomen.4. State the steps in the emergency medical care of a patient with an abdominal evisceration wound.5. State the steps in the emergency medical care of a patient with a genitourinary injury.


Psychomotor Objectives6. Demonstrate proper treatment of a patient who has an object impaled in the abdomen.7. Demonstrate how to apply a dressing to an abdominal evisceration wound.There are no affective objectives for this chapter. All of the objectives in this chapter are noncurriculum objectives.


Hollow Organs in the Abdominal Cavity


Signs of PeritonitisAbdominal painTendernessMuscle spasmDiminished bowel soundsNausea/vomitingDistention


Solid Organs in the Abdominal Cavity


Abdominal QuadrantsThe abdominal cavity is divided into four quadrants.


Injuries of the AbdomenClosed injurySevere blows that damage abdomen without breaking skinOpen injuryForeign body enters abdomen and opens peritoneal cavity to outside


Signs and Symptomsof Abdominal InjuryPainTachycardiaDecreased blood pressurePale, cool, moist skinFirm abdomen on palpationBruising


Blunt Abdominal WoundsSevere bruises of the abdominal wallLaceration of the liver and spleenRupture of the intestineTears in the mesenteryRupture or tearing of the kidneysRupture of the bladderSevere intra-abdominal hemorrhagePeritoneal irritation and inflammation


Care of Blunt Abdominal WoundsPlace patient on backboard.Protect airway.Monitor vital signs.Administer oxygen.Treat for shock.Provide prompt transport.


Seat Belts and AirbagsIf used inappropriately, seat belts may cause injuries.Frontal airbags provide protection only during head-on collisions.


Seat Belt PositionsThe proper position of a seat belt is below the anterior superior iliac spines and against the hip joints (C). A and B show incorrect positions.ABC


Care for Penetrating InjuriesInspect patients back and sides for exit wounds.Apply a dry, sterile dressing to all open wounds.If the penetrating object is still in place, apply a stabilizing bandage around it to control bleeding and minimize movement.


Abdominal EviscerationInternal organs or fat protrude through the open wound.Never try to replace organs.Cover the organs with a moist gauze, then secure with a dressing.Organs must be kept warm and moist.Transport promptly.


Treatment for EviscerationABCD


You are the providerYou and your EMT-B partner are dispatched for a person hit in the abdomen by a flying piece of broken glass.You arrive and quickly determine that the scene is safe and no additional resources are required.


You are the provider continuedWhat is the mechanism of injury? Is this significant?What are your safety considerations?


Scene Size-upObserve for hazards and threats to your safety.If dispatch indicates a possible assault, domestic dispute, or drive-by shooting, be sure that law enforcement has controlled the scene.Determine if additional resources are needed.


You are the provider continuedYou find a 28-year-old man who is alert and oriented. A large piece of glass broke and hit him in the abdomen.He is anxious, lying on the ground with his hands over his lower left quadrant.Patent airway with equal chest rise; good breath sounds bilaterally. Rapid pulse. You see obvious bleeding in his abdominal region.


You are the provider continued (2 of 3)Describe the steps of initial assessment.Are there any life-threatening conditions that you will address?What care will you provide to treat breathing?


You are the provider continued (3 of 3)You ensure that his airway is open. No noted abnormalities. DCAP-BTLS is unremarkable.You check for a distal pulse. It is rapid. Bleeding is noted and controlled. You start oxygen with a nonrebreathing mask due to patients shock status.High-priority transport


Initial AssessmentEvaluate and immediately care for ABCs.Most abdominal injuries will be subtle.Trauma may have occurred hours or days earlier and the pain just became bad enough to seek help.Ask about previous injuries associated with the chief complaint.Note patient position.


ABCsConsider spinal immobilization.Ensure patent airway; keep airway clear of vomitus.Consider use of a BVM device.Trauma to the kidneys, liver, and spleen can cause significant internal bleeding.Evaluate and treat for shock.Cover wounds and control bleeding.


Transport DecisionRapid on-scene time and quick transport are generally indicated.Specific injuries are difficult to identify in the prehospital environment.


You are the provider continued (1 of 2)You perform a rapid physical exam.You remove the patients shirt and find a 4.5 laceration with a moderately sized section of intestine protruding, which is visible.


You are the provider continued (2 of 2)How would you treat this wound?If the shirt were stuck to the wound, what would you do?After the rapid physical exam, what is the next step?


Focused History and Physical Exam (1 of 2)Expose injured regions.Provide privacy as needed.Allow patient to stay in position of comfort if there is no suspected spinal injury.Use DCAP-BTLS.Swelling may indicate significant abdominal injury.In pediatric patients, the liver and spleen are more easily injured.


Focused History and Physical Exam (2 of 2)Inspect skin for wounds.Size of wound does not always correspond to extent of injury.If you find an entry wound, look for an exit wound.Stabilize an impaled object with supportive bandaging.Be professional to help reduce patients anxiety.Obtain baseline vital signs.Obtain SAMPLE history.


InterventionsManage airway and breathing problems.Provide complete spinal stabilization if spinal injuries are suspected.Treat aggressively for shock.If an evisceration is discovered, place a moist, sterile dressing over the wound.Never push an evisceration back into the abdomen.Cover bleeding injuries to genitalia with moist, sterile dressing.Do not delay transport.


You are the provider continued (1 of 2)The SAMPLE history indicates no allergies, no meds, and no prior medical history.Patient stated he felt a cutting sensation and saw bleeding.Stated he last ate 3 hours ago. Pulse 120 beats/min; respirations 22 breaths/min; BP 120/80 mm HgYou cover the evisceration with a saline-moistened dressing per your local protocol.Within a minute, the paramedics arrive and assume care.


You are the provider continued (2 of 2)What is the significance of when the patient ate last in his current situation?What is the patients shock status?If the medics were delayed, what would you do?


Detailed Physical ExamConduct as time permits.


Ongoing AssessmentRepeat initial assessment and reassess vital signs.Communication and documentation.Communicate the MOI.Radio report will depend on local protocols.If assault is suspected, you may have a legal requirement to inform the hospital staff of your suspicion.


Anatomy of the Genitourinary System


Injuries of the Kidney (1 of 2)Suspect kidney damage if patient has a history or physical evidence of:Abrasion, laceration, or contusion in the flankA penetrating wound in the region of the lower rib cage or upper abdomenFractures on either side of the lower rib cage or of the lower thoracic or lumbar vertebraeA hematoma in the flank region


Injuries of the Kidney (2 of 2)Kidney injuries may result from a direct blow, such as in a tackle in football.


Injury of the Urinary Bladder (1 of 2)Either a blunt or penetrating injury can rupture the bladder.Urine will spill into the surrounding tissues.Suspect if you see blood at the urethral opening or physical signs of trauma on the lower abdomen, pelvis, or perineum.Monitor vitals signs.The presence of associated injuries or shock will dictate the urgency of transport.


Injury of the Urinary Bladder (2 of 2)Fracture of the pelvis can result in a laceration of the bladder.


Male Reproductive System


Care for Injury to the External Male GenitaliaThese injuries are painful. Make the patient comfortable.Use sterile, moist compresses to cover areas stripped of skin.Apply direct pressure to control bleeding.Never manipulate any impaled objects.Identify and bring avulsed parts to the hospital.


Female Reproductive System


Care for Injuries of the Female Genitalia (1 of 2)Female internal genitalia is well protected and usually not injured.The exception is the pregnant uterus which is vulnerable to both blunt and penetrating injuries.Keep in mind that the unborn child is also at risk.Expect to see signs and symptoms of shock.Provide all necessary support.Transport promptly.


Care for Injuries of theFemale Genitalia (2 of 2)Injuries to the external genitalia are very painful but not life threatening.Treat lacerations, abrasions, and avulsions with moist, sterile compresses.Use local pressure and a diaper-type bandage to hold the dressing in place.The urgency of transport will be determined by the associated injuries, amount of hemorrhage, and the presence of shock.


Rectal BleedingCommon complaintBlood may appear in undergarments or may be passed during a bowel movement.Can be caused by sexual assault, hemorrhoids, colitis, or ulcers of the digestive tractAcute bleeding should never be passed off as something minor.Pack the crease between the buttocks with compresses and consult with medical control.


Sexual AssaultDo not examine genitalia unless there is obvious bleeding.The patient should not wash the area, defecate, eat, or drink until examined.Offer to call the local rape crisis center.Document carefully and preserve evidence.


ReviewWhich of the following organs would be the MOST likely to bleed profusely if severely injured?

A. LiverB. KidneyC. StomachD. Gallbladder


ReviewAnswer: A

Rationale: The liver is a highly vascular solid organ, and contains approximately 40% of the bodys total blood volume at any given time. If severely injured, bleeding from the liver would be profuse and rapid. Other solid organs, such as the spleen and kidneys, may also produce severe bleeding if injured, though not as rapid as the liver. The stomach and gallbladder are hollow organs; if lacerated, they would spill their contents into the abdominal cavity, resulting in peritonitis.


ReviewWhich of the following organs would be the MOST likely to bleed profusely if severely injured?

LiverRationale: Correct answerB. KidneyRationale: This will produce bleeding, but not as rapidly as the liver.C. StomachRationale: This hollow organ will spill its contents into the abdominal cavity.D. GallbladderRationale: This hollow organ will spill its contents into the abdominal cavity.


Review2. Which of the following statements regarding intraabdominal bleeding is FALSE?

A. Intraabdominal bleeding often causes abdominal distentionB. Intraabdominal bleeding is common following blunt force traumaC. The absence of pain and tenderness rules out intraabdominal bleedingD. Bruising may not occur immediately following blunt abdominal trauma


ReviewAnswer: C

Rationale: Intraabdominal bleeding is common following blunt trauma to the abdomen. Signs include abdominal distention, rigidity, bruising (may not occur immediately), and in some cases, pain to palpation. However, unlike gastric juices and bacteria, blood within the abdominal cavity does not provoke an inflammatory response; therefore, the absence of pain and tenderness does not rule out internal bleeding.


Review2. Which of the following statements regarding intraabdominal bleeding is FALSE?

Intraabdominal bleeding often causes abdominal distentionRationale: You may see evidence of abdominal distention.B. Intraabdominal bleeding is common following blunt force traumaRationale: This is a common condition following blunt trauma. C. The absence of pain and tenderness rules out intraabdominal bleedingRationale: Correct answerD. Bruising may not occur immediately following blunt abdominal traumaRationale: This may not occur immediately.


Review3. Other than applying a moist, sterile dressing covered with a dry dressing to treat an abdominal evisceration, an alternative form of management may include:

A. placing dry towels over the open wound.B. cleaning the exposed bowel with sterile saline.C. applying the PASG to stop the associated bleeding.D. applying an occlusive dressing, secured by trauma dressings.


ReviewAnswer: D

Rationale: Although the preferred management for an abdominal evisceration includes the application of a moist, sterile dressing covered by a dry dressing, protocols in some EMS systems call for an occlusive dressing, secured by trauma dressings. An occlusive dressing may help prevent the loss of body heat through the abdominal wound.


Review3. Other than applying a moist, sterile dressing covered with a dry dressing to treat an abdominal evisceration, an alternative form of management may include:

placing dry towels over the open wound.Rationale: Treatment is a moist, sterile dressing over the open wound.B. cleaning the exposed bowel with sterile saline.Rationale: EMS should not clean any exposed abdominal organs.C. applying the PASG to stop the associated bleeding.Rationale: PASG inflation is contraindicated with an abdominal evisceration.D. applying an occlusive dressing, secured by trauma dressings.Rationale: Correct answer


Review4. You are transporting a patient with possible peritonitis following trauma to the abdomen. Which position will he MOST likely prefer to assume?

A. Sitting upB. Legs drawn upC. Legs outstretchedD. On his right side


ReviewAnswer: B

Rationale: Patients with peritonitis often lie very still and tend to have their legs drawn up into the abdomen. This relieves strain on the abdominal muscles and may provide pain relief.


Review4. You are transporting a patient with possible peritonitis following trauma to the abdomen. Which position will he MOST likely prefer to assume?

Sitting upRationale: Lying very still with the legs drawn up will help relieve the patients pain.B. Legs drawn upRationale: Correct answerC. Legs outstretchedRationale: The patients legs drawn up or flexed will help relieve pain.D. On his right sideRationale: The patients legs drawn up or flexed will help relieve pain.


Review5. A 16-year-old boy was playing football and was struck in the left flank during a tackle. His vital signs are stable; however, he is in severe pain. You should be MOST concerned that he has injured his:

A. liver.B. spleen.C. kidney.D. bladder.


ReviewAnswer: C

Rationale: The flanks are located laterally in the back and overlie the kidneys. During football, spearing injuries occur when a player is struck in the flank by another players helmet. This can result in injury to the kidney ranging from bruising to severe bleeding. Injury to the liver, spleen, and bladder would more likely occur following blunt trauma to the anterior abdomen.


Review5. A 16-year-old boy was playing football and was struck in the left flank during a tackle. His vital signs are stable; however, he is in severe pain. You should be MOST concerned that he has injured his:liver.Rationale: The liver is associated with an injury to the anterior abdomen and right upper quadrant.B. spleen.Rationale: The spleen is associated with an injury to the anterior abdomen and left upper quadrant.C. kidney.Rationale: Correct answerD. bladder. Rationale: The bladder is associated with an injury to the anterior abdomen and midline in the lower quadrants.


Review6. While inspecting the interior of a wrecked automobile, you should be MOST suspicious that the driver experienced an abdominal injury if you find:

A. a deformed steering wheel. B. that the airbags deployed. C. a crushed instrument panel. D. damage to the lower dashboard.


ReviewAnswer: A

Rationale: Airbags save lives when used in conjunction with properly worn seatbelts. Unfortunately, however, not all drivers wear their seatbelts. If unrestrained, the drivers abdomen may strike the steering wheel, resulting in significant trauma. Suspect this if you lift the airbag and note that the lower part of the steering wheel is deformed.


Review6. While inspecting the interior of a wrecked automobile, you should be MOST suspicious that the driver experienced an abdominal injury if you find:

a deformed steering wheel. Rationale: Correct answerB. that the airbags deployed. Rationale: Typically, the face and chest are impacted by airbags if safety belts are worn properly.C. a crushed instrument panel. Rationale: This would indicate the possibility of leg and hip injuries.D. damage to the lower dashboard. Rationale: This would indicate the possibility of leg and hip injuries.


Review7. When caring for a female with trauma to the external genitalia, the EMT-B should:

A. use local pressure to control bleeding.B. carefully pack the vagina to reduce bleeding.C. remove any impaled objects from the vagina.D. cover any open wounds with moist, sterile dressings.


ReviewAnswer: A

Rationale: Bleeding from the external genitalia should be controlled by applying a dry, sterile dressing and local direct pressure. Never pack anything into the vagina to try to control bleeding; this increases the risk of infection, and anything you place into the vagina will only need to be removed at the hospital. Impaled objects in the genitalia should be carefully stabilized in place, not removed.


Review7. When caring for a female with trauma to the external genitalia, the EMT-B should:

use local pressure to control bleeding.Rationale: Correct answerB. carefully pack the vagina to reduce bleeding.Rationale: Never pack anything into the vagina.C. remove any impaled objects from the vagina.Rationale: Impaled objects are stabilized in place and are not removed.D. cover any open wounds with moist, sterile dressings. Rationale: Apply dry, sterile dressings with local direct pressure.


Review8. Peritonitis would MOST likely result following injury to the:

A. liver.B. spleen.C. kidney.D. stomach.


ReviewAnswer: D

Rationale: In general, solid organs bleed when injured and hollow organs spill their contents into the abdominal cavity, resulting in peritonitisinflammation of the intraabdominal lining. Of the choices listed, the stomach is the only hollow organ.


Review8. Peritonitis would MOST likely result following injury to the:

liver.Rationale: The liver typically bleeds into the abdominal cavity.B. spleen.Rationale: The spleen typically bleeds into the abdominal cavity.C. kidney.Rationale: The kidneys typically bleed into the retroperitoneal space and not into the abdomen.D. stomach. Rationale: Correct answer


Review9. The term hematuria is defined as:

A. blood in the stool.B. blood in the urine.C. vomiting up blood.D. urinary bladder rupture.


ReviewAnswer: B

Rationale: Blood in the urine is called hematuria. Following trauma, the presence of hematuria suggests injury to the urinary bladder or kidneys. Bright red blood in the stool is called hematochezia; dark, tarry stools are called melena. Vomiting up blood is called hematemesis.


Review9. The term hematuria is defined as:

blood in the stool.Rationale: This is known as hematochezia or melena (dark stools).B. blood in the urine.Rationale: Correct answerC. vomiting up blood.Rationale: This is known as hematemesis.D. urinary bladder rupture. Rationale: This will produce abdominal pain and eventually peritonitis due to a leaking into the abdominal cavity. It will also cause a lack of/or a reduction of urinary output.


Review10. Even when seatbelts are worn properly and the airbags deploy, injury may occur to the:

A. chest. B. extremities.C. iliac crests. D. lower ribcage.


ReviewAnswer: C

Rationale: Seatbelts should be positioned over the iliac crests of the pelvis. If they are positioned higher, significant intraabdominal injury can occur. Even when seatbelts are properly positioned and the airbags deploy, injury to the iliac crests may occur as the locking mechanism of the seatbelt engages during a motor-vehicle crash that involves rapid deceleration.


Review10. Even when seatbelts are worn properly and the airbags deploy, injury may occur to the:

chest. Rationale: If the seatbelts are worn too high, then abdominal injuries may occur.B. extremities.Rationale: The extremities are not likely to be injured if seatbelts are worn properly.C. iliac crests. Rationale: Correct answerD. lower ribcage.Rationale: If seatbelts are worn too high, then abdominal injuries may occur.


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28: Abdomen and Genitalia Injuries

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