Abdominal injury

GOOD AFTERNOON

ABDOMINAL INJURY

BY- SAMPURNA DAS

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Anterior abdomenFlankBackIntraperitoneal space contentsRetroperitoneal space contentsPelvic cavity contents

Background Anatomy

• Anterior abdomen: Trans-nipple line, Anterior axillary lines,

Inguinal ligaments and Symphysis pubis.• Flank: Anterior and posterior axillary line;

Sixth intercostal to iliac crest.

• Back: Posterior axillary line; Tip of scapula to

Iliac crest.

• Upper Peritoneal cavityCovered by lower aspect of bony thorax. Includes Diaphragm, Liver, Spleen, Stomach, Transverse colon.

• Lower Peritoneal cavity:Small bowel Ascending and Descending colon, Sigmoid colon

• Retroperitoneal space: A Potential space Behind “true” abdominal cavityAbdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas, kidneys, Ureters and posterior aspects of Ascending and Descendingcolons

• Pelvic cavity: Rectum, Bladder, iliac vessels and Internal genitalia in women.

Organs by Abdominal Quadrant

Small & Large IntestineLower part of KidneyHalf of Bladder, Female Reproductive Organs

Small & Large Intestine

Lower part of KidneyHalf of Bladder,

Appendix, Female Reproductive Organs

Stomach,Tail of PancreasTail of LiverSmall & Large IntestineUpper Part of Kidney

Liver, Gallbladder, Stomach (Small Part)

Small & Large Intestine

Head of PancreasUpper Part of Kidney

Upper

Lower

Right Left

Vascular Anatomy1. Abdominal Aorta2. Common Iliac

Artery3. Internal Iliac4. External Iliac5. Superior Gluteal6. Obturator Artery

TYPES OF ABDOMINAL INJURIES

BLUNT TRAUMA PENETRATING TRAUMA•Energy transmitted to surrounding tissue•Results in-Uncontrolled hemorrhageOrgan damageSpillage of hollow organ contentsIrritation & Inflammation of abdominal lining•Liver most commonly affected organ•Common causes -Shotgun Trauma, stab wound, cuts & tears

•Produces least visible signs of injury•Causes

DecelerationContents damaged by change in velocity

CompressionOrgans trapped between other structures

ShearPart of an organ is able to move while another part is fixed

ABDOMINAL ORGAN INJURIES

DIAPHRAGMATIC INJURYDESCRIPTIONS

• Partially protected by bony structures, diaphragm is commonly injured by penetrating trauma (Automobile deceleration may lead to rapid rise in intra-abdominal pressure and a burst injury

• Diaphragmatic tear usually indicates multi-organ involvement

CLINICAL MANIFESTATIONS

• 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

ESOPHAGEAL INJURYDESCRIPTIONS

• 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 INJURYDESCRIPTIONS

• 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 INJURYDESCRIPTIONS

• Most commonly injured organ; blunt injuries (70% of total) usually occur from motor vehicle crashes and steering wheel trauma

• Highest mortality from blunt injury and gunshot wound

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


• Persistent hypotension despite adequate fluid resuscitation

• Guarding over right upper or lower quadrant; rebound abdominal tenderness

• Dullness to percussion

• Abdominal distention and peritoneal irritation

• Persistent thoracic bleed

SPLEEN INJURYDESCRIPTIONS

• 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 INJURYDESCRIPTIONS

• 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 INJURYDESCRIPTIONS

• 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 A INJURYDESCRIPTIONS

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

• More than 90% of incidences are penetrating injuries

• Blunt injuries are often from safety restraints in motor vehicle crashes


• Pain, muscle rigidity• Guarding, rebound

tenderness• Blood on rectal

examination• Fever

RETROPERITONEAL INJURYDESCRIPTIONS

• Blunt or penetrating trauma to the abdomen or posterior abdomen.

• Kidney, ureters, pancreas, or duodenal injuries

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

• Deceleration forces may injure the renal artery


• Haemorrhage usually from pelvic or lumbar fractures:

• Gray turner’s sign – 12 hours or later

• cullen’s sign – 12 hours or later

Renal Injury.

Classification of Injury• Grade I : Contusion or Subcapsular

Hematoma • Grade II: Non Expanding Hematoma, <1

cm deep ,no extravasation• Grade III: Laceration >1cm with urinary

Extravasation• Grade IV: Parenchymal Laceration • Grade V: Renovascular injury

PATHOPHYSIOLOGY OF ABDOMINAL INJURY

DECELERATION• 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.

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.

EXTERNAL COMPRESSION• 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 .

SYMPTOMS• Pain or tenderness• A rapid heart rate• Rapid breathing• Sweating• Cold, clammy, pale or bluish skin • Confusion or low level of alertness• Blunt trauma may cause bruising.• Cullen’s sign• Grey turner’s sign• Kehr’s sign

COMPLICATIONS:

Hematoma rupture Peritonitis

Intra abdominal collection of pus (abcess)

Intestinal blockage

(obstruction)

Abdominal compartment

syndrome

DIAGNOSTIC STUDIES

HISTORY TAKING

AMPLE History• A: Allergy• M: Medications• P: Past medical history• L: Last meal• E: Event - What happened

General Examination : Relating to hemodynamic stability (Vital Signs)Abdominal findings:• Inspection :

For abdominal distension For contusions or abrasionsLap belt ecchymosis

Mesenteric, Bowel, and Lumbar spine injuries Periumblical (Cullen sign) and

Flank (Grey Turner Sign) ecchymosis – Retroperitoneal hematoma

PHYSICAL EXAMINATION

• Palpation : For tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum

• Percussion : Dullness/ shifting dullness Intraabdominal collection

• Auscultation : Where to auscultate & What to listen for??? All four quadrants for the +/- nce of bowel sounds

PHYSICAL EXAMINATION cont.

The classical ‘seatbelt’ sign. The bruising on the left breast is from the shoulder belt and the low bruising to the abdominal wall is from the lap belt.

• Left lower six ribs

• Right lower six ribs • Upper Lumbar

vertebra• Transverse

Process

• Pelvis

SpleenLiverPancreas and DuodenumKidneys

Bladder Urethra Rectum 30

Associated with fractures

Diagnostic studies• CECT• FAST• DPL• Complete blood count• Blood glucose determination• Urinanalysis • Coagulation profile• Blood grouping, typing & cross matching• Arterial blood gas analysis

Diagnostic studies• Drug & alcohol screens• Rigid sigmoidoscopy: is indicated for

patients presenting with injuries in the pelvis or if blood is found on rectal examination.

• magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct injuries

• chest, and cervical spine radiographs• Arteriographs

COLLABORATIVE MANAGEMENT

Initial Assessment and Resuscitation

Primary survey Identification & treatment of life threatening

conditions • Airway , with cervical spine precautions• Breathing • Circulation • Disability• Exposure

Emergency Care• I V fluids • Control external bleeding • Dressing of wounds• Protect eviscerated organs with a sterile dressing• Stabilize an impaled object in place• Give high flow oxygen• Immobilize the patient with a fractured pelvis• Keep the patient warm• Analgesics

MANGEMENT BASED ON ORGANS• DIAPHRAGMATIC TEARS : repaired surgically to prevent visceral

herniation in later years.• ESOPHAGEAL INJURY: gastric decompression with a nasogastric

tube, antibiotic therapy surgical repair of the esophageal tear. • GASTRIC INJURY:partial gastrectomy may be needed if

extensive injury has occurred.

MANGEMENT BASED ON ORGANS

• LIVER INJURY managed nonoperatively or operatively, depending on

the degree of injury and the amount of bleeding. Albumin transfusion Blood glucose regulation

• SPLEEN INJURY• splenectomy is the treatment of choice when the

patient is markedly hemodynamically unstable, or when the spleen is totally macerated.

MANGEMENT BASED ON ORGANS• 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.Colostomy

Common operative procedures

1. Restrictive thoracotomy

2. Laparatomy & definitive repair

OTHER TREATMENT

Nutritional supplementation:TPNEnteral feedingAntibioticsIntravenous fluid infusionBlood components transfusion

NURSING MANAGEMENT

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

Increased risk of sepsis related to acute inflammatory process and peritonitis.

Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.

Pain and bowel distention , related to diagnosis.

Risk for imbalanced body temperature related to infection

Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness

Impaired elimination due to abdominal & retroperitoneal injury , nerve injury

Body image disturbance related to presence of colostomy bag, wound.

Deficient knowledge about abdominal injury, recovery, and the rehabilitation process

Anxiety related to the symptoms of disease and fear of death.

Thank You…

Abdominal injury

Healthcare

Transcript of Abdominal injury