PEER GROUP PRESENTATION ON

ABDOMINAL INJURY

Submitted by-Sampurna Das

MSc. Nursing 2nd year

College Of Nursing

Medical College & Hospital

INTRODUCTION:

Abdominal injury account for a large percentage of trauma related injuries and death. The visceral organs contained within the abdomen can be classified as either hollow or solid.

Damage to a hollow organ can result in acute peritonitis leading to shock within a few hours & damage to solid organs can result in lethal haemorrhage.

The abdomen can be injured in many ways. The abdomen alone may be injured or injuries elsewhere in the body may also occur. Injuries can be relatively mild or very severe.

ANATOMY & PHYSIOLOGY OF ABDOMEN:

The abdomen  constitutes the part of the body between the thorax(chest) and pelvis, in humans and in other vertebrates.

The region enclosed by the abdomen is termed the abdominal cavity. The abdomen stretches from the thorax at the thoracic diaphragm to the pelvis at the pelvic brim.

The pelvic brim stretches from the lumbosacral joint (theintervertebral disc between L5 and S1) to the pubic symphysis and is the edge of the pelvic inlet. The space above this inlet and under the thoracic diaphragm is termed the abdominal cavity.

The boundary of the abdominal cavity is the abdominal wall in the front and the peritoneal surface at the rear.

The abdomen contains most of the tubelike organs of the digestive tract, as well as several solid organs.

Hollow abdominal organs include the stomach, the small intestine, and the colon with its attached appendix.

Organs such as the liver, its attached gallbladder, and the pancreas function in close association with the digestive tract and communicate with it via ducts.

The spleen, kidneys, and adrenal glands also lie within the abdomen, along with many blood vessels including the aorta and inferior vena cava.

Anatomists may consider the urinary bladder, uterus, fallopian tubes, andovaries as either abdominal organs or as pelvic organs.

Finally, the abdomen contains an extensive membrane called the peritoneum. A fold of peritoneum may completely cover certain organs, whereas it may cover only one side of (retroperitoneal) organs that usually lie closer to the abdominal wall. Both the abdominal and pelvic cavities are lined by a serous membrane known as the parietal peritoneum. This membrane is continuous with the visceral peritoneum lining the organs.

Digestive tract: Stomach, small intestine, large intestine with cecum and appendix Accessory organs of the digestive tract: Liver, gallbladder and pancreas Urinary system: Kidneys and ureters - but technically located in retroperitoneum - outside

peritoneal membrane. Other organs: Spleen.

 In vertebrates, the abdomen is a large cavity enclosed by the abdominal muscles, ventrally and laterally, and by the vertebral column dorsally. Lower ribs can also enclose ventral and lateral walls. The abdominal cavity is upper part of the pelvic cavity. It is attached to the thoracic cavity by the diaphragm. Structures such as the aorta, superior vena cava and esophagus pass through the diaphragm. The abdomen in vertebrates contains a number of organs belonging, for instance, to the digestive tract and urinary system.

Muscles

In human anatomy, the layers of the abdominal wall are (from superficial to deep):

Skin Subcutaneous tissue Fascia

Camper's fascia - fatty superficial layer. Scarpa's fascia - deep fibrous layer.

Muscle External oblique abdominal muscle Internal oblique abdominal muscle Rectus abdominis Transverse abdominal muscle Pyramidalis muscle

Fascia transversalis Peritoneum

TYPES OF ABDOMINAL INJURIES:

A. PENETRATING Vs. BLUNT TRAUMA:

BLUNT TRAUMA :

Involves a direct blow (for example, a kick) , impact with an object (for example, a fall onto bicycle handlebars), or a sudden decrease in speed (for example, a fall from a height or a motor vehicle crash).

Trauma to the abdomen is usually associated with extra – abdominal injuries ( i.e. chest, head & extremity injuries) & severe concomitant trauma to multiple intraperitoneal organs. The spleen & liver are the two most commonly injured organs. Hollow organs are less likely to be injured. Causes more delayed complications, especially if there is injury to liver, spleen & blood vessels , which can lead to substantial blood loss into the peritoneal cavity.

PENETRATING TRAUMA :

This implies that either a gunshot wound (or other high velocity missile/ fragment ), sharpe or a stub wound has entered the abdominal cavity.

A gunshot wound is associated with high energy transfer & the extent of intraabdominal injuries is difficult to predict. Shotgun injuries ,especially at close range, are frequently associated with massive tissue damage & should be regarded as high energy transfer injuries.

Stab wound injuries can be inflicted by many objects other than knives, including knitting needles, garden forks, wire, fence railing, pipes & pencils. Blunt or penetrating injuries may cut or rupture abdominal organs & / or blood vessels. Blunt injury may cause blood to collect inside the structure of a solid organ (for example the liver) or in the wall of a hollow organ (such as the small intestine). Such collections of blood are called hematomas.

Cuts & tears begin bleeding immediately. More serious injuries may cause massive bleeding with shock & sometimes death. Bleeding from abdominal injury is mostly internal (within the abdominal cavity). When there is a penetrating injury, a small amount of external bleeding may occur through the wound.

When a hollow organ is injured, the contents of the organ (for example, stomach acid, stool, or urine) may enter the abdominal cavity & cause irritation & inflammation (peritonitis).

B. CLASSIFICATION AS PER STRUCTURE INVOLVED:

The types of structures include

the abdominal wall solid organs (liver, spleen, pancreas, or kidneys) hollow organs (stomach , small intestine, bladder, colon, ureters) blood vessels

Injuries to the AbdomenORGAN OR TISSUE

COMMON INJURIES SYMPTOMS

Diaphragm Partially protected by bony structures, the diaphragm is most commonly injured by penetrating trauma (particularly gunshot wounds to the lower chest)

Automobile deceleration may lead to rapid rise in intra-abdominal pressure and a burst injury

Diaphragmatic tear usually indicates multi-organ involvement

Decreased breath sounds Abdominal peristalsis heard in

thorax Acute chest pain and shortness of

breath may indicate diaphragmatic tear

May be hard to diagnose because of multisystem trauma or the liver may "plug" the defect and mask it

Esophagus Penetrating injury is more common than blunt injury

May be caused by knives, bullets, foreign body obstruction

May be caused by iatrogenic perforation May be associated with cervical spine

injury

Pain at site of perforation Fever Difficulty swallowing Cervical tenderness Peritoneal irritation

Stomach Penetrating injury is more common than blunt injury; in one-third of patients, both the anterior and the posterior walls are penetrated

May occur as a complication from cardiopulmonary resuscitation or from gastric dilation

Epigastric pain Epigastric tenderness Signs of peritonitis Bloody gastric drainage

Liver Most commonly injured organ (both blunt and penetrating injuries); blunt

Persistent hypotension despite adequate fluid resuscitation

ORGAN OR TISSUE

COMMON INJURIES SYMPTOMS

injuries (70% of total) usually occur from motor vehicle crashes and steering wheel trauma

Highest mortality from blunt injury (more common in suburban areas) and gunshot wound (more common in urban areas)

Hemorrhage is most common cause of death from liver injury; overall mortality 10%–15%

Guarding over right upper or lower quadrant; rebound abdominal tenderness

Dullness to percussion Abdominal distention and

peritoneal irritation Persistent thoracic bleeding

Spleen Most commonly injured organ with blunt abdominal trauma

Injured in penetrating trauma of the left upper quadrant

Hypotension, tachycardia, shortness of breath

Peritoneal irritation Abdominal wall tenderness Left upper quadrant pain Fixed dullness to percussion in left

flank; dullness to percussion in right flank that disappears with change of position

Pancreas Most often penetrating injury (gunshot wounds at close range)

Blunt injury from deceleration; injury from steering wheel

Often associated (40%) with other organ damage (liver, spleen, vessels)

Pain over pancreas Paralytic ileus Symptoms may occur late (after 24

hr); epigastric pain radiating to back; nausea, vomiting

Tenderness to deep palpation

Small intestines Duodenum, ileum, and jejunum; hollow viscous structure most often injured by penetrating trauma

Gunshot wounds account for 70% of cases

Incidence of injury is third only to liver and spleen injury

When small bowel ruptures from blunt injury, rupture occurs most often at proximal jejunum and terminal ileum

Testicular pain Referred pain to shoulders, chest,

back Mild abdominal pain Peritoneal irritation Fever, jaundice, intestinal

obstruction

Large intestines One of the more lethal injuries because of fecal contamination; occurs in 5% of abdominal injuries

More than 90% of incidences are

Pain, muscle rigidity Guarding, rebound tenderness Blood on rectal examination Fever

ORGAN OR TISSUE

COMMON INJURIES SYMPTOMS

penetrating injuries Blunt injuries are often from safety

restraints in motor vehicle crashes

Retroperitoneal injuries:

Blunt or penetrating trauma to the abdomen or posterior abdomen.

Kidney, ureters, pancreas, or duodenal injuries.

Haemorrhage usually from pelvic or lumbar fractures:

Gray turner’s sign – 12 hours or later

cullen’s sign – 12 hours or later

Renal injuries Associated with posterior posterior rib fractures & lumbar vertebral injuries.

Deceleration forces may injure the renal artery

PATHOPHYSIOLOGY:

Intra abdominal injuries secondary to blunt force are attributed to collisions between the injured person & external environment & to acceleration or decelaration forces acting on the person’s internal organs. Blunt force injuries to the abdomen can generally be explained by 3 mechanisms.

1. The first mechanism is decelaration. Rapid decelaration causes differential movement among adjacent structures. As a result, shear forces are created & cause hollow, solid, visceral organs & vascular pedicles to tear, especially at relatively fixed points of attachment. For example, the distal aorta is attached to the thoracic spine & decelerates much more quickly than the relatively mobile aortic arch. As a result, shear forces in the aorta may cause it to rupture. Similar situations can occur at the renal pedicles & at the cervicothoracic junction of the spinal cord. Classic deceleration injuries include hepatic tear along the ligamentam teres & intimal injuries to the renal arteries. As bowel loops travel from their mesenteric attachments, thrombosis & mesenteric tears, with resultant splanchnic vessels injuries, can result.2. The second mechanism involves crushing. Intra abdominal contents are crushed between the anterior abdominal wall & the vertebral column or posterior thoracic cage. This produces a crushing effect, to which solid viscera (eg. spleen, liver, kidneys) are especially vulnerable.3. The third mechanism is external compression, whether from direct blows or from external compression against a fixed object (eg. lap belt, spinal column). External compressive forces result in a sudden & dramatic rise in intraabdominal pressure & culminate in rupture of a hollow organ (i.e., in accordance with the principles of Boyle law).

SYMPTOMS:1. Pain or tenderness

Pain is often mild, & person may not notice or complain about it because of other more painful injuries (such as fractures) or because the person is not fully conscious.

2. People may have lost a large amount of blood may have : A rapid heart rate Rapid breathing Sweating Cold, clammy, pale or bluish skin Confusion or low level of alertness

3. Blunt trauma may cause bruising.4. Cullen’s sign5. Grey turner’s sign6. Kehr’s sign7. Shock.

COMPLICATIONS:

1. Hematoma rupture 2. Peritonitis3. Intra abdominal collection of pus (abcess)4. Intestinal blockage (obstruction)5. Abdominal compartment syndrome

COLLABORATIVE MANAGEMENT:

HISTORY TAKING

For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. AMPLE is a useful mnemonic in trauma assessment: Allergies, Medications, Past medical history, Last meal, and Events leading to presentation. Information regarding the type of trauma (blunt or penetrating) is helpful. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient was restrained, the patient's position in the vehicle, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a helmet. In cases of traumatic injuries from falls, determine the point of impact, the distance of the fall, and the type of landing surface. If the patient has been shot, ask the paramedics or police for ballistics information, including the caliber of the weapon and the range at which the person was shot.PHYSICAL EXAMINATION

INVESTIGATIONS

Test Normal Result Abnormality With Condition Explanation

Contrast-enhanced computed tomography scan

Normal and intact abdominal structures

Injured or ruptured organs; accumulation of blood or air in the peritoneum, in the retroperitoneum, or above the diaphragm

Provides detailed pictures of the intra-abdominal and retroperitoneal structures, the presence of bleeding, hematoma

Test Normal Result Abnormality With Condition Explanation

formation, and the grade of injury

Focused abdominal sonogram for trauma (FAST); four acoustic windows (pericardiac, perihepatic, perisplenic, pelvic)

No fluid seen in four acoustic windows

Accumulation of blood in the peritoneum

Provides rapid evaluation of hemoperitoneum; experts consider FAST's accuracy equal to that of diagnostic peritoneal lavage (DPL) (see below)

Diagnostic peritoneal lavage (DPL); indicated in spinal cord injury, multiple injuries with unexplained shock, intoxicated or unresponsive patients with possible abdominal injury

Negative lavage without presence of excessive bleeding or bilious or fecal material

Direct aspiration of 15 to 20 mL of blood, bile, or fecal material from a peritoneal catheter; following lavage with 1 L of normal saline, the presence of 100,000 red cells or 500 white cells per mL is a positive lavage; this is 90% sensitive for detecting intra-abdominal hemorrhage

Determines presence of intra-abdominal hemorrhage or rupture of hollow organs; contraindicated when there are existing indications for laparotomy

Other Tests:  

1. Complete blood count: Normal haemoglobin & haematocrit results do not rule out significant haemorrhage. Blood transfusions should not be withheld in patients who have relatively normal haematocrit but have evidence of clinical shock, serious injuries or significant blood loss.

2. Blood glucose determination: important for patients with altered mental status.3. Urinanalysis: indications for diagnostic urinanalysis 4. Coagulation profile5. Blood grouping, typing & cross matching6. Arterial blood gas analysis7. Drug & alcohol screens8. Rigid sigmoidoscopy: is indicated for patients presenting with injuries in the pelvis or if

blood is found on rectal examination. 9. magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct injuries10. chest, and cervical spine radiographs11. Arteriographs

EMERGENCY DEPARTMENT CARE

Upon the patient’s arrival in the emergency department or trauma center, a rapid primary survey should be performed to identify immediate life threatening problems.

a) The initial care of the patient with abdominal trauma follows the ABCs (airway, breathing, circulation) of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion include the establishment of an effective airway and a supplemental oxygen source, support of breathing,

b) Control of the source of blood loss, and replacement of intravascular volume.

c) Titrate intravenous fluids to maintain a systolic blood pressure of 100 mm Hg; overaggressive fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

MANGEMENT BASED ON ORGANS:

Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years. Esophageal injury is often managed with gastric decompression with a nasogastric tube,

antibiotic therapy, and surgical repair of the esophageal tear. Gastric injury is managed similarly to esophageal injury, although a partial gastrectomy may be

needed if extensive injury has occurred. Liver injury may be managed nonoperatively or operatively, depending on the degree of injury

and the amount of bleeding. Patients with liver injury are apt to experience problems with albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation, resistance to infection, and nutritional balance.

Management of injuries to the spleen depends on the patient's age, stability, associated injuries, and type of splenic injury. Because removal of the spleen places the patient at risk for immune compromise, splenectomy is the treatment of choice only when the spleen is totally separated from the blood supply, when the patient is markedly hemodynamically unstable, or when the spleen is totally macerated.

Treatment of pancreatic injury depends on the degree of pancreatic damage, but drainage of the area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage from pancreatic enzymes.

Small and large bowel perforation or lacerations are managed by surgical exploration and repair. Preoperative and postoperative antibiotics are administered to prevent sepsis.

OPERATIVE MANAGEMENT:

Restrictive thoracotomy Laparotomy & definitive repair

NUTRITIONAL:Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to eliminate gastrointestinal feedings for extended periods of time depending on the injury and the surgical intervention required. Total parenteral nutrition may be used to provide nutritional requirements.

NURSING MANAGEMENT:

Nursing Assessment1. Assess for history of the injury, onset and progression of the symptoms.2. Assess presence of signs and symptoms of internal bleeding or acute abdomen (pain, bowel distention, muscle rebound) .3. Assess abdomen wall for presence of wounds and hematomas.4. Assess vital signs, CVP, fluid balance and urine output.5. Assess diagnostic tests and procedures for abnormal values (US, x-ray, CT, etc.).

Nursing Diagnosis1. Increased risk of hypovolemia and shock related to abdominal trauma and internal bleeding..

2.Increased risk of sepsis related to acute inflammatory process and peritonitis.3. Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.4. Pain and bowel distention , related to diagnosis. 5.Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain 6. Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness 7. Deficient knowledge about abdominal injury, recovery, and the rehabilitation process8. Anxiety related to the symptoms of disease and fear of death.

Goals:1. Promote adequate respiratory and cardiovascular function.2. Provide measures for prevention of the shock and sepsis.3. Prevent avoidable injury and complications.4. If surgical intervention prescribed, prevent postoperative complications.5. Relief or diminish symptoms.

7. Decreased anxiety with increased knowledge of disease, it treatment, and follow-up.

Interventions1. Assess, report , and record signs and symptoms and reactions to treatment.2. Monitor fluids input and output closely, insert urinary catheter and IV catheter.3. Provide positioning of the client in semi-Fowler position.4. Monitor client for pain and signs of gastrointestinal decompensation.5. Administer antibiotics and other medications as prescribed, monitor for side effects.6. Monitor client’s vital signs and signs of possible hemorrhage, sepsis and shock closely, report immediately.7. Observe patency of tubes and drains, and drainage characteristics.8. Monitor client’s laboratory tests results for abnormal values.9. Keep client NPO as ordered.10. Administer IV therapy and blood transfusions as prescribed.11. Prepare client and his family for surgical intervention if required.12. For client after surgical intervention provide postoperative care and teach about possible postoperative complications.13. Instruct client for cough and deep breathing to prevent respiratory complications.14. Provide appropriate skin care to prevent possibility of skin lesions.15. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.16. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, restrictions and follow-up.

CONCLUSION:

Abdominal trauma can be life-threatening because abdominal organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. Solid abdominal organs, such as the liver and kidneys, bleed profusely when cut or torn, as do major blood vessels such as the aorta and vena cava. Hollow organs such as the stomach, while not as likely to result in shock from profuse bleeding, present a serious risk of infection, especially if such an injury is not treated promptly. Gastrointestinal organs such as the bowel can spill their contents into the abdominal cavity. Hemorrhage and systemic infection are the main causes of deaths that result fromabdominal trauma. One or more of the intra-abdominal organs may be injured in abdominal trauma. The characteristics of the injury are determined in part by which organ or organs are injured. Abdominal injury can be from mild to severe, depeding on that treatment also range from first aid to surgery with lifelong rehabilitation. So health teaching to patient & family is very necessary to make the client able to return in a normal life.

BIBLIOGRAPHY:

1. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Textbook of medical-Surgical Nursing. 11 th ed. New Delhi:Wolters kluwer;2008. p. 2180-85.

2. Lewis LS, Heitkmper MM, Dirksen SR, Brien PG, Bucher L. Medical Surgical Nursing. 7 th ed. Noida: Elsevier;2009. P. 1485-89.

3.Black JM, Hawks JH. Medical Surgical Nursing. 8th ed. Noida: Elsevier;2009. P. 1933-39

4.Available in: https://www.google.co.in/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=nursing+care+plan+for+abdominal+pain

5.Abdominal trauma.Available in: https://en.wikipedia.org/wiki/Abdominal_trauma6. Penetrating abdominal trauma.Available in: http://emedicine.medscape.com/article/2036859-treatment