Abdominal Trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Division 3Trauma Emergencies


Chapter 26Abdominal Trauma


Topics

Introduction to Abdominal InjuryAbdominal Anatomy and PhysiologyPathophysiology of Abdominal InjuryAssessment of the Abdominal Injury PatientManagement of the Abdominal Injury Patient


Introduction to Abdominal Injury

One of body’s largest cavities.Multiple vital organs.Large volumes of blood can be lost before signs and symptoms manifest.Must be alert for signs of transmitted injury:– Deformity, swelling, and ecchymosis

Prevention:– Highway safety

Seatbelt usageProper application

Airbags


Abdominal Anatomy and Physiology (1 of 2)

Boundaries– Superior: Diaphragm– Inferior: Pelvis– Posterior: Vertebral column and posterior

and inferior ribs– Lateral: Muscles of the flank– Anterior: Abdominal muscles


Abdominal Anatomy and Physiology (2 of 2)

Three Specific Spaces– Peritoneal Space

Organs covered by abdominal (peritoneal) lining

– Retroperitoneal SpaceOrgans posterior to the peritoneal lining

– Pelvic SpaceOrgans contained within pelvis


Organs by Abdominal Quadrant

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

Small and Large IntestineLower part of Kidney

Half of Bladder, Appendix, Female Reproductive

Organs

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

Liver, Gallbladder, Stomach (Small Part)

Small and Large IntestineHead of Pancreas

Upper Part of Kidney

Upper

Lower

Right Left


Hollow and Solid Abdominal Organs

Solid– Liver– Spleen– Pancreas– Kidneys– Ovaries

Hollow– Stomach– Small intestine– Large intestine– Gall bladder– Bladder– Uterus


Abdominal Anatomy and PhysiologyMajor Abdominal Structures

Digestive Tract– AKA: Alimentary canal– Structures

StomachSmall IntestineLarge IntestineRectum

Accessory Organs– Liver– Gallbladder– Pancreas

Urinary System– Kidneys– Ureter– Urinary Bladder– Urethra

Immune System– Spleen

Genitals– Ovaries– Fallopian tubes– Uterus– Vagina


Abdominal Anatomy and PhysiologyDigestive Tract

Function– Churn material to be digested– Excrete digestive juices– Absorb nutrients and water

Components– Stomach

Food mixed with HCl and enzymes to form chyme– Small bowel

Food moved through bowel by peristalsisDuodenumJejunumIleum

– Large bowel (Colon)– Rectum– Anus


Abdominal Anatomy and PhysiologyAccessory Organs (1 of 3)

Liver– Located in upper right quadrant– 2.5% of total body weight– Receives 25% of cardiac output and has greatest blood

reserve– Suspended by ligamentum teres

Can lacerate liver in deceleration trauma– Function

Detoxifies bloodRemoves damaged or aged erythrocytesStores glycogen and agents for metabolism

– Liver tissue will grow to normal size following partial removal.



Gallbladder– Small hollow organ located behind and beneath

liver– Receives bile

Waste product from reprocessing of RBCsUsed to digest fatty foods (emulsification)

Pancreas– Produces endocrine hormones and exocrine

enzymesGlucagonInsulinDigestive enzymes that return the chyme pH to normal and break down proteins



Spleen– Part of immune system– Located behind stomach and lateral to kidney in

upper left quadrant– Function

ImmunologyStores large volume of blood

– Most fragile abdominal organ– Commonly injured in blunt trauma affecting the

left flank


Abdominal Anatomy and PhysiologyUrinary System

Components– Kidneys

Collect waste products in blood streamConcentrate products into urineReabsorb water and saltRegulate body osmotic balanceAdrenal glands

Superior and attached to kidneysComponent of endocrine systemRelease epinephrine and norepinephrine

– Ureters– Urinary bladder

Can contain as much as 500 mL of urine– Urethra


Abdominal Anatomy and Physiology

Genitalia– Female sexual organs

Represent an open passage to the interior of the abdominal cavityComponents

OvariesFallopian tubesUterusVagina

– Male sexual organsExternal to the abdomenComponents

TestesPenis


Abdominal Anatomy and PhysiologyPregnant Uterus (1 of 2)

Uterus and contents grow rapidly after conception and until delivery1st Trimester (0–12 weeks)– Well protected

2nd Trimester (12–24 weeks)– Uterus displaces organs upward

3rd Trimester (24 weeks to term)– Fills entire abdominal cavity– Displaces diaphragm upward


Abdominal Anatomy and PhysiologyPregnant Uterus (2 of 2)

Effects on Maternal Physiology– Increases circulatory blood volume by 45%

Greater volume but fewer RBCsResults in relative anemia

– Cardiac output increases by 40%– Heart rate increases by 15 bpm– Compresses the vena cava in 3rd trimester

Reduces venous returnSupine hypotensive syndrome


Abdominal Anatomy and PhysiologyVasculature (1 of 2)

Key Vessels– Abdominal aorta

Blood supply to abdomenLeft of spinal column

– Iliac arteriesBifurcation of aorta at the upper sacral level

– Inferior vena cavaAdjacent to spinal column


Abdominal Anatomy and PhysiologyVasculature (2 of 2)

Portal System– Venous subsystem– Collects venous blood, fluid, and

nutrients absorbed by the bowel– Transports to liver

Detoxification, storage of excess nutrients Adds deficient nutrients


Abdominal Arteries


Abdominal Anatomy and PhysiologyPeritoneum

Serous membrane that surrounds the interior of most of the abdominal cavityCovers most of small bowel and some of the abdominal organsSmall amount of fluid between peritoneal layersMesentery– Double fold of peritoneum– Supports and suspends small bowel from posterior

abdominal wall– Omentum

Additional foldInsulates and protects anterior surface of abdomen


Retroperitoneal Structures

KidneysDuodenumPancreasUrinary BladderPosterior portions of ascending and

descending colonRectumMajor vascular structures


Reflections of the Peritoneum


Pathophysiology of Abdominal InjuryMechanism of Injury (1 of 3)

Penetrating Trauma– Energy transmitted to surrounding tissue– Projectile cavitation, pitch, and yaw– Results in:

Uncontrolled hemorrhageOrgan damageSpillage of hollow organ contentsIrritation and inflammation of abdominal lining

– Liver most commonly affected organ– Shotgun trauma

Multiple projectiles



Blunt Trauma– 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 fixedExample: ligamentum teres



Blast Injuries– Blunt and penetrating MOIs– Irregular shaped shrapnel and debris– Pressure wave

Compresses and relaxes air-filled organsContuses or ruptures organs

– Abdominal injury is secondary concern during blast injury.


Pathophysiology of Abdominal Injury (1 of 12)

Injury to the Abdominal Wall– Skin and muscles transmit blunt trauma to internal

structures.Typically only show erythema.Visible swelling and ecchymosis occur over several hours.

– Penetrating trauma may appear minimal externally in comparison to internal trauma.

Muscle may mask the size of the external wound.Evisceration may be present.

– Trauma to thorax, buttocks, flanks, and back may penetrate abdomen.

Lower chest may injure spleen, liver, stomach, or gallbladder.– Diaphragmatic tears:

Herniation of abdominal contents into thorax.



Injury to the Hollow Organs– May rupture with compression from blunt forces– May tear due to penetrating trauma– Spillage of contents into:

Retroperitoneal spacePeritoneal spacePelvic space

– Intestines have a large amount of bacteria:Leakage can result in sepsis

– Manifestations of Blood LossHematochezia: blood in stoolHematemesis: blood in emesisHematuria: blood in the urine



Injury to the Solid Organs– Dense and less strongly held together– Prone to contusion

BleedingFracture (rupture)

– Unrestricted hemorrhage if organ capsule is ruptured

– Specific OrgansSpleen: pain referred to left shoulderPancreas: pain radiates to backKidneys: pain radiates from flank to groin and hematuriaLiver: pain referred to the right shoulder



Injury to the Vascular Structures– Abdominal aorta and vena cava:

Prone to direct blunt or penetrating traumaMay be injured in deceleration injuries

– Blood accumulates beneath diaphragm.Irritation of muscular structuresProduces referred pain in the shoulder regionGreater volume of blood can be lostPresence of blood in abdomen stimulates vagus nerve resulting in slowing of heart rate

– Blood can isolate in any of the abdominal spaces.



Injury to the Mesentery and Bowel– Provides bowel with circulation, innervation, and

attachment– Disrupts blood vessels supplying the bowel

Leads to ischemia, necrosis, or rupture

– Blood loss minimalPeritoneal layers contain hemorrhage

– Tear of mesentery may rupture bowel– Penetrating trauma to the lateral abdomen likely

to injure large bowel



Injury to the Peritoneum– Delicate and sensitive lining of anterior abdomen– Peritonitis

Inflammation of the peritoneum due to:Bacterial irritation

Due to torn bowel or open woundChemical irritation

Caustic nature of digestive enzymesUrine initiates inflammatory response

Blood does not induce peritonitisProgression

Slight tenderness at location of injuryRebound tendernessGuardingRigid, board-like feel



Injury to the Pelvis– Serious skeletal injury

Life-threatening hemorrhagePotential injury to pelvic organs

UretersBladderUrethraFemale genitaliaProstateRectumAnus



Injury During Pregnancy– Trauma is the number one killer of pregnant

females.Penetrating abdominal trauma accounts for 36% of maternal mortality.

GSW account for 40–70% of penetrating trauma.Blunt trauma due to improperly worn seatbelts.

Auto collisions are leading cause of mortality.

– Changing dimensions of uterus:Protects abdominal organs.Endangers uterus and fetus.



Injury During Pregnancy– Maternal Changes

Increasing size and weight of uterusCompresses inferior vena cavaReduces venous return to heart

Increasing maternal blood volumeProtects mother from hypovolemia30–35% of blood loss necessary before signs of shock

Uterus is thick and muscularDistributes forces of trauma uniformly to fetus

Reduces chances for injury



Injury During Pregnancy– Risk of uterine and fetal injury increases with the

length of gestation.Greatest risk during 3rd trimester

– Penetrating trauma may cause fetal and maternal blood mixing.

– Blunt trauma complications:Uterine ruptureAbruptio placentaePremature rupture of amniotic sac



Injury to Pediatric Patients– Children have poorly developed abdominal

musculature and smaller diameter– Rib cage more cartilaginous

Transmits injury to organs beneath easier– Increased incidence of injury to

LiverKidneySpleen

– ShockCompensate well for blood lossMay not show signs and symptoms until 50% of blood is lost


Assessment of the Abdominal Injury Patient (1 of 6)

Scene Size-up– Must evaluate MOI to assess seriousness of

injury– Identify strength and direction of forces

Velocity of impactFocus observations and palpation on that siteDevelop a mental list of possible organs involved

– If auto crashDetermine if seatbelts used properlyInterior signs of impact

Steering wheel and dashboard deformity



Scene Size-up– Auto Crash Injury Patterns

Frontal impactCompress abdomenLiver, spleen, and rupture of hollow organs

Right impactLiver, ascending colon, and pelvis

Left impactSpleen, descending colon, and pelvis

Children and pedestriansAbdominal injuries common

– Gunshot WoundsType and caliber of weapon Check whether assailant still on scene



Initial Assessment– LOC– Drug or alcohol use– Evaluate ABCs and immediate threats



Rapid Trauma Assessment– Rapid and full trauma assessment.– Closely examine regions with a high index of

suspicion.– Expose and examine for DCAP-BTLS.

If suspected pelvic injury, DO NOT test pelvis.Palpate entire abdomen.Evaluate for entrance and exit wounds.

– OPQRST AssessmentCharacteristics of pain

Tenderness versus rebound tenderness

– SAMPLE History– Vital Assessment



Considerations with Pregnant Patients– Be observant for

Signs of shockPRETREAT: signs may not develop until 30% of blood volume lostBody begins shunting blood from GI/GU to primary organs

Supine hypotensive syndromePremature contractionsVaginal hemorrhage

Uterine rupture versus abruptio placentaeUterus development

Abnormal asymmetry



Ongoing Assessment– Trend vital signs

Every 5 minutes for critical patients– Evaluate for

Progressive peritonitisProgressive hemorrhage

BP and capillary refillPulse rate and pulse oximetryMental statusSkin conditionIneffective aggressive fluid resuscitation


Management of the Abdominal Injury Patient (1 of 2)

General Management– Position patient

Position of comfort unless spinal injuryFlex knees or left lateral recumbent

– General shock care– PASG application– Specific injury care

Impaled objects or eviscerations


Management of the Abdominal Injury Patient (2 of 2)

Fluid Resuscitation– Large-bore IV with isotonic solution

Consider 2 bolus if pulse does not slow– Large-bore IV lock for use if patient’s BP

drops below 80 mmHg– Fluid challenge 250 mL or 20 mL/kg

Limit to 3 L– Titrate to SBP of 80 mmHg


Evisceration Care


Management of the Abdominal Injury Patient – PASG

Contraindications– Concurrent

penetrating chest trauma

– Abdomen inflation contraindicated in pregnancy

Inflate legs only

Indications– Evisceration

If SBP <60 mmHg

– Intra-abdominal bleeding

– Shock

Incremental inflation titrated to BP and Pulse


Management of the Abdominal Injury Patient

Management of the Pregnant Patient– Positioning:

Left lateral recumbent.If on backboard tilt backboard.

Facilitates venous return

– Oxygenation:High-flow O2.

Consider PPV by BVM if hypoxia ensues.

– Maintain high index of suspicion for intra-abdominal bleeding.

Consider IV and PASG.


Summary

Introduction to Abdominal InjuryAbdominal Anatomy and PhysiologyPathophysiology of Abdominal InjuryAssessment of the Abdominal Injury PatientManagement of the Abdominal Injury Patient

Abdominal Trauma

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