Penetrating and Blunt Abdominal Trauma

22
PENETRATING AND BLUNT ABDOMINAL TRAUMA

description

Nursing notes from semester 1 2012

Transcript of Penetrating and Blunt Abdominal Trauma

Page 1: Penetrating and Blunt Abdominal Trauma

PENETRATING AND BLUNT ABDOMINAL TRAUMA

Page 2: Penetrating and Blunt Abdominal Trauma

ABDOMEN

Divided into three areas Peritoneal space Retroperitoneal space Pelvic region

Page 3: Penetrating and Blunt Abdominal Trauma

PERITONEAL SPACE

Is the space between the peritoneum and the pelvis Includes

Diaphragm Liver Spleen Stomach Transverse colon A prtion of the cavity is also covered by the bony

thorax

Page 4: Penetrating and Blunt Abdominal Trauma

RETROPERITONEAL SPACE

Organs include Aorta Vena carva Pancreas Kidneys Ureters Potions of the duodenum and colon

Page 5: Penetrating and Blunt Abdominal Trauma

PELVIC REGION

Organs include Rectum Bladder Uterus Iliac vessels

Page 6: Penetrating and Blunt Abdominal Trauma

SOLID HOLLOW

LiverPancreasKidneysUreters

IntestinesStomachGall bladderUrinary bladder

ABDOMEN CONTAINS BOTH SOLID AND HOLLOW ORGANS

Page 7: Penetrating and Blunt Abdominal Trauma

COMPICATIONS OF ABDOMINAL TRAUMA

Include: Haemorrhage Shock Sepsis peritonitis

Page 8: Penetrating and Blunt Abdominal Trauma

PENETRATING TRAUMA

Page 9: Penetrating and Blunt Abdominal Trauma

External appearance does not dictate extent of internal injury

Trauma depends on variables such as angle and distance of impact object (e.g. bullet).

Path can vary due impact on bony prominences• e.g. - abdominal trauma should be considered with

presentation of buttock or chest gunshot wound.

Assessment should include establishing entrance and exit wound sites, and possible organs involved

Page 10: Penetrating and Blunt Abdominal Trauma

If patient is stable: Care should be taken to establish path of penetrating

object, examining entire body looking for entry and exit points. Thorough examination includes Skin folds The back The peritoneum The axillae The buttocks

After locating sites of wounds, haemodynamically stable patients can have plain x-ray films taken

Page 11: Penetrating and Blunt Abdominal Trauma

Computed tomography is helpful in defining injuryGunshot wounds are generally more serious than stab

wounds95% of all gunshot wounds to the abdomen cause

serious injury Common complications of gunshot wounds are haemorrhage and

sepsisNecessary for most abdominal gunshot wounds to have

exploratory laparotomy surgeryOnly 50% of stab wounds enter the abdominal cavity

due to the way in which the weapon is held by the assailant, usually right handed therefore affecting upper left quadrant.

Page 12: Penetrating and Blunt Abdominal Trauma

LIVER

Grade I and II injuries often managed non-operatively.

Serial haematocrits with CT abdomen and pelvic examinations to evaluate further

Grade III to VI usually require intervention of embolisation or surgery

Important to control liver haemorrhage

Page 13: Penetrating and Blunt Abdominal Trauma

Grade 1

•Haematomas affect less than 10% surface area, sub-capsular and nonexpanding

•Lacerations non-bleeding, capsular tear less than 1 cm deep

Grade 2

•Haematomas include 10-50% sub-capsular surface, with less than 1cm intrapararenchyma haematoma

•Lacerations are actively bleeding and have capsular tear 1-3cm deep without trabecular involvement

Grade 3

•Haematomas expand to greater than 50% sub-capsular

•Actively bleeding ruptured sub-capsular haematoma

•Intrapararenchyma haematoma greater than or equal to 2 cm and expanding

Grade 4

•Ruptured parenchchyma and actively bleeding

•25%-50% hepatic lobe parenchymal disruption

Grade 5

•Greater than 50% hepatic lobe parenchymal disruption

•Vascular injury includes retrohepatic vena cava and juxtahepatic venous injuries

Grade 6

•Vascular hepatic avulsion

•Considered to be incompatible with life

LIVER INJURY SCALE

Page 14: Penetrating and Blunt Abdominal Trauma

SPLEEN

Like the liver, it is a dense, solid intrathoracic abdominal organ

Protected by the lower ribs (8-12)Loses blood rapidly due to it’s vascularity60% of victims of splenic injury have left

shoulder painPrimary function is to clear blood borne

bacteria, essential to immune system

Page 15: Penetrating and Blunt Abdominal Trauma

SPLENIC INJURY SCALE

Grade 1

•Haematoma are sub-capsular, less than 10% surface area

• Capsular tear, less than 1cm parenchymal depth

Grade 2

•Haematoma are subcapsular, 10-50% surface area

•Intraparenchymal les than 5cm diameter

•Lacerations are 1-3cm parenchymal depth not involving a parenchymal vessel

Grade 3

•Greater than 50% expanding sub capsular , ruptured sub-capsular haematoma with active bleeding. Intrapenchymal haematomas >= 2cm and expanding

•Lacerations greater than 3cm deep or involving trabecular vessels

Grade 4

•Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen)

Grade 5

•Completely shattered spleen

•Hilar vascular injury which devascularized spleen

Page 16: Penetrating and Blunt Abdominal Trauma

GENITOURINARY TRAUMA

Also abbreviated as ‘GU trauma’Most commonly involved organ is the kidneyInjury to urinary system indicated when

haematuria is present, although 10-25% of cases with significant renal damage to dot display haematuria

In urban setting, approx 25% or penetrating injuries result in renal damage, e.g. gunshot or stab wounds

Page 17: Penetrating and Blunt Abdominal Trauma

KIDNEY INJURY SCALE

Grade 1

•Contusions diagnosed with normal urologic studies with level or haematuria noted

•Sub-capsular non-expanding haematomas without parenchymal lacerations

Grade 2

•Non-expanding perirenal haematoma confined to retroperitoneum

•Laceration <1cm deep without system rupture or urinary extravasation

Grade 3

•Lacerations >1cm deep without system rupture or urinary extravasation

Grade 4

•Lacerations extending through the cortex, medulla and collecting system

•Main arterial or venous injury with contained haemorrhage

Grade 5

•Completely shattered kidney

•Avulsion of renal hilium

•Devascularised kidney

Page 18: Penetrating and Blunt Abdominal Trauma

STAGES OF RENAL FAILURE

• Decreased circulation and ischemia to kidneys• Trauma victims at higher risk due to

hypovolaemia, hypotension and cardiac failure Prerenal• Kidneys being affected by physiologic events

such as antibiotics and contrast media dye, both of which are nephrotoxic

• Rabdomyolysis can be a contributing factorIntrarena

l • Obstruction in venous blood flow from the

kidney or urine flow from the collection ducts to the external urethral orifice --> decreased urinary outputPostrenal

Page 19: Penetrating and Blunt Abdominal Trauma

GASTROINTESTINAL SYSTEM

Before considering a bowel injury rule out decline in: Respirations Haemodynamic status Neurologic statusAs these pose a much more dangerous risk than bowel injury

Injury to bowel can cause life threatening haemorrhage, it does not change managemnt of resuscitation of the patient

Gunshot wounds cause injury 90% of the time to the GI system, whereas stab wounds only about 50% of the time

Early accurate diagnosis of GI injuries reducdes the risk of sepsis, the most common complication

Page 20: Penetrating and Blunt Abdominal Trauma

PANCREAS

Incidence of injury from penetrating trauma is much higher than from blunt force trauma

Located in close proximity to the aorta, portal vein, inferior vena cava, renal veins, left kidney, liver, duodenum and spleen.

Injury to pancreas indicates injury to other organs in the area

Most deaths from pancreatic trauma result from injury to surrounding blood vessels and haemorrhage within 48hours

Page 21: Penetrating and Blunt Abdominal Trauma

PANCREATIC INJURY SCALE

Grade 1

•Hematoma - Minor contusion without duct injury

•Laceration - Superficial laceration without duct injury

Grade 2

•Haematomas are major contusions

•Lacerations without duct injury or tissue loss

Grade 3

•Injuries characterised by distal transecting laceration or parenchymal injury

Grade 4

•Injuries include proximal transecting lacerations or parenchymal injury involving the papilla

Grade 5

•Laceration is a massive disruption to the pancreatic head

Page 22: Penetrating and Blunt Abdominal Trauma

GALL BLADDER

Injury is rareProtected by sheltered location and smaller

sizeCholecysystectomy usually performed for

injuries only when injuries disrupt structure or associated anatomy and vasculature