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Abdominal Abdominal TraumaTrauma

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The AbdomenThe Abdomen

• Everything between diaphragm and pelvisEverything between diaphragm and pelvis

• Injury, illness very difficult to assess because Injury, illness very difficult to assess because of large variety of structuresof large variety of structures

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Abdominal AnatomyAbdominal Anatomy

• Abdomen divided into four quadrants by body Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicusmid-line, horizontal plane through umbilicus

• Organs can be located by quadrantOrgans can be located by quadrant

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Abdominal AnatomyAbdominal Anatomy

• Right Upper QuadrantRight Upper Quadrant– LiverLiver– Gall Bladder Gall Bladder – Right KidneyRight Kidney– Ascending ColonAscending Colon– Transverse ColonTransverse Colon

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Abdominal AnatomyAbdominal Anatomy

• Left Upper QuadrantLeft Upper Quadrant– SpleenSpleen– StomachStomach– PancreasPancreas– Left KidneyLeft Kidney– Transverse ColonTransverse Colon– Descending ColonDescending Colon

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Abdominal AnatomyAbdominal Anatomy

• Right Lower QuadrantRight Lower Quadrant– Ascending ColonAscending Colon– AppendixAppendix– Right Ovary (female)Right Ovary (female)– Right Fallopian Tube (female)Right Fallopian Tube (female)

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Abdominal AnatomyAbdominal Anatomy

• Left Lower QuadrantLeft Lower Quadrant– Descending ColonDescending Colon– Sigmoid colonSigmoid colon– Left Ovary (female)Left Ovary (female)– Left Fallopian Tube (female)Left Fallopian Tube (female)

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Abdominal AnatomyAbdominal Anatomy

• Periumbilical areaPeriumbilical area– Located around (peri) the navel (umbilicus)Located around (peri) the navel (umbilicus)– Small bowel lies in all quadrants in periumbilical Small bowel lies in all quadrants in periumbilical

areaarea

• Suprapubic areaSuprapubic area– Located just above pubic boneLocated just above pubic bone– Urinary bladder, uterus lie in this areaUrinary bladder, uterus lie in this area

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Abdominal CavityAbdominal Cavity

• Peritoneum = abdominal cavity liningPeritoneum = abdominal cavity lining

• Divides abdomen into two spacesDivides abdomen into two spaces– Peritoneal cavityPeritoneal cavity– Retroperitoneal spaceRetroperitoneal space

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Abdominal AnatomyAbdominal Anatomy• RetroperitonealRetroperitoneal

– PancreasPancreas

– KidneyKidney

– UreterUreter

– Inferior vena cavaInferior vena cava

– Abdominal aortaAbdominal aorta

– Urinary bladderUrinary bladder

– Reproductive organsReproductive organs

• PeritonealPeritoneal– SpleenSpleen

– LiverLiver

– StomachStomach

– Gall bladderGall bladder

– BowelBowel

Disease, injury of retroperitoneal organs often causes back pain

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Abdominal AnatomyAbdominal Anatomy

• Organs can be classified as: Organs can be classified as: – HollowHollow– SolidSolid– Major vascularMajor vascular

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Solid OrgansSolid Organs

• LiverLiver

• SpleenSpleen

• KidneyKidney

• PancreasPancreas

When solid organs are injured, they bleed heavily

and cause shock

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Solid OrgansSolid Organs

• Liver Liver – Largest abdominal organLargest abdominal organ– Most frequently injuredMost frequently injured– Fractures of ribs 8-12 on right sideFractures of ribs 8-12 on right side– Bleeding can be either: Bleeding can be either:

• Slow, contained under capsuleSlow, contained under capsule

• Free into peritoneal cavityFree into peritoneal cavity

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Solid OrgansSolid Organs

• SpleenSpleen– Frequently injured with trauma ribs 9-11 on left Frequently injured with trauma ribs 9-11 on left

sideside– Bleeds easilyBleeds easily– Capsule around spleen tends to slow Capsule around spleen tends to slow

development of shockdevelopment of shock– Rapid shock onset when capsule rupturesRapid shock onset when capsule ruptures

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• PancreasPancreas– Lies across lumbar spineLies across lumbar spine– Sudden deceleration produces straddle injurySudden deceleration produces straddle injury– Very little hemorrhageVery little hemorrhage– Leakage of enzymes digests structures in Leakage of enzymes digests structures in

retroperitoneal space, causes volume loss, retroperitoneal space, causes volume loss, shockshock

Solid OrgansSolid Organs

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Hollow OrgansHollow Organs

• StomachStomach

• Gall bladderGall bladder

• Large, small intestinesLarge, small intestines

• Ureters, urinary bladderUreters, urinary bladder

Rupture causes content spillage, inflammation of

peritoneum

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Hollow OrgansHollow Organs

• Stomach Stomach – Acid, enzymesAcid, enzymes– Immediate peritonitisImmediate peritonitis– Pain, tenderness, guarding, rigidityPain, tenderness, guarding, rigidity

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Hollow OrgansHollow Organs

• Colon Colon – Spillage of bacteriaSpillage of bacteria– May take 6 hrs to develop peritonitisMay take 6 hrs to develop peritonitis

• Small BowelSmall Bowel– Fewer bacteriaFewer bacteria– May take 24-48 hours to develop peritonitisMay take 24-48 hours to develop peritonitis

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Major Vascular StructuresMajor Vascular Structures

• AortaAorta

• Inferior vena cavaInferior vena cava

• Major branchesMajor branches

Injury can cause severe blood loss; exsanguination (bleeding out)

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Abdominal TraumaAbdominal Trauma

• Most survive to reach hospitalMost survive to reach hospital

• Most common factors leading to deathMost common factors leading to death– Failure to adequately evaluateFailure to adequately evaluate– Delayed resuscitationDelayed resuscitation– Inadequate volumeInadequate volume– Inadequate diagnosisInadequate diagnosis– Delayed surgeryDelayed surgery

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High Index of SuspicionHigh Index of Suspicion

• MechanismMechanism

• Trauma to lower chest, back, flank, Trauma to lower chest, back, flank, buttocks, and perineumbuttocks, and perineum

• Hypovolemic shock with no readily Hypovolemic shock with no readily identifiable causeidentifiable cause

• Diffusely tender abdomenDiffusely tender abdomen

• Pain in uninjured shoulderPain in uninjured shoulder

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MechanismMechanism

• Look for signs of injury Look for signs of injury – BruisesBruises– Tire marksTire marks– Obvious open injuriesObvious open injuries

• Assume any abdominal injury is serious until Assume any abdominal injury is serious until proven otherwise!proven otherwise!

• Injury above umbilicus also involves chest Injury above umbilicus also involves chest until proven otherwiseuntil proven otherwise

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Unexplained ShockUnexplained Shock

• Assess vital signs; skin color, temperature; Assess vital signs; skin color, temperature; capillary refillcapillary refill

• Tachycardia; restlessness; cool, moist skinTachycardia; restlessness; cool, moist skin

• In trauma, signs of shock suggest abdominal In trauma, signs of shock suggest abdominal injury if no other obvious causes presentinjury if no other obvious causes present

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Signs of Injured AbdomenSigns of Injured Abdomen

• Diffuse tendernessDiffuse tenderness

• PainPain– Pain referred to shoulder = Organ under Pain referred to shoulder = Organ under

diaphragm involved (?spleen)diaphragm involved (?spleen)– Pain referred to back = Retroperitoneal organ Pain referred to back = Retroperitoneal organ

involved (?kidney)involved (?kidney)

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Abdominal RigidityAbdominal Rigidity

• NOTNOT reliable reliable

• Bleeding may not cause rigidity if free Bleeding may not cause rigidity if free hemoglobin absenthemoglobin absent

• Bleeding in retroperitoneal space may not Bleeding in retroperitoneal space may not cause rigiditycause rigidity

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Abdominal Trauma ManagementAbdominal Trauma Management

• Less important to diagnose exact injuryLess important to diagnose exact injury

• Treat clinical findingsTreat clinical findings

• Management same regardless of specific Management same regardless of specific organ(s) injuredorgan(s) injured

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Abdominal Trauma ManagementAbdominal Trauma Management

• AirwayAirway

• C-Spine if mechanism indicates C-Spine if mechanism indicates

• High flow OHigh flow O22

• Assist ventilations if neededAssist ventilations if needed

• Give nothing by mouthGive nothing by mouth

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Impaled ObjectImpaled Object

• Leave in placeLeave in place– Shorten if necessary for transportShorten if necessary for transport– Leave part of object exposedLeave part of object exposed

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EviscerationEvisceration

• With large laceration abdominal contents With large laceration abdominal contents may spill outmay spill out

• Do Do NOTNOT try to replace try to replace

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EviscerationEvisceration

• Cover exposed organs with saline Cover exposed organs with saline moistened multi-trauma dressingmoistened multi-trauma dressing

• Do Do NOTNOT use 4 x 4s use 4 x 4s

• Cover first dressing with second Cover first dressing with second DRYDRY dressing or aluminum foildressing or aluminum foil

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Genitourinary TraumaGenitourinary Trauma

Kidney

UreterUrinary Bladder

Urethra

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Kidney TraumaKidney Trauma

• 50% of all GU trauma50% of all GU trauma

• PenetratingPenetrating– GSWGSW– Stab woundStab wound

• Rare, usually associated with trauma to Rare, usually associated with trauma to other abdominal organsother abdominal organs

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Kidney TraumaKidney Trauma

• BluntBlunt– Direct blow to back, flank, upper abdomenDirect blow to back, flank, upper abdomen

• Suspect with fractures of 10th - 12th ribs or TSuspect with fractures of 10th - 12th ribs or T1212, L, L11, L, L22

– Acceleration/DecelerationAcceleration/Deceleration• Shearing of renal artery/veinShearing of renal artery/vein

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Kidney TraumaKidney Trauma

• Signs and SymptomsSigns and Symptoms– Gross HematuriaGross Hematuria

• 80% of cases 80% of cases

• Absence does Absence does NOTNOT exclude renal injury exclude renal injury

– Localized flank/abdominal painLocalized flank/abdominal pain– Palpable massPalpable mass

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Kidney TraumaKidney Trauma

• Signs and SymptomsSigns and Symptoms– Tenderness: Lower ribs, upper L-spine, flankTenderness: Lower ribs, upper L-spine, flank– Pain: groin, shoulder, back, flankPain: groin, shoulder, back, flank

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Ureter TraumaUreter Trauma

• Less than 2% of GU traumaLess than 2% of GU trauma

• Usually secondary to penetrating traumaUsually secondary to penetrating trauma

• IndicatorIndicator– Wound to lower back with urine escapingWound to lower back with urine escaping

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Urinary Bladder TraumaUrinary Bladder Trauma

• MechanismsMechanisms– Blunt injury to lower abdomenBlunt injury to lower abdomen– Seat beltsSeat belts– Pelvic fracturePelvic fracture– Penetrating trauma to lower abdomen or Penetrating trauma to lower abdomen or

perineum (pelvic floor)perineum (pelvic floor)

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Extraperitoneal Bladder RuptureExtraperitoneal Bladder Rupture

• Urine in umbilicus, anterior thighs, scrotum, Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineuminguinal canals, perineum

• DysuriaDysuria• HematuriaHematuria• Suprapubic tendernessSuprapubic tenderness• Swelling, redness secondary to tissue damage Swelling, redness secondary to tissue damage

from urinefrom urine

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Intraperitoneal Bladder RuptureIntraperitoneal Bladder Rupture

• Urgency to voidUrgency to void

• Inability to voidInability to void

• ShockShock

• Abdominal distensionAbdominal distension

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Urethral TraumaUrethral Trauma

• Mechanisms Mechanisms – Sudden decelerations Sudden decelerations

(bladder shears off urethra)(bladder shears off urethra)– Straddle injuriesStraddle injuries

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Urethral TraumaUrethral Trauma

• Signs and SymptomsSigns and Symptoms– Blood at external meatusBlood at external meatus– Perineal bruising (butterfly bruise)Perineal bruising (butterfly bruise)– Scrotal hematomaScrotal hematoma

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Reproductive System TraumaReproductive System Trauma

• Can occur to both external and internal Can occur to both external and internal reproductive systemsreproductive systems– ExternalExternal

• More commonMore common

• Pain, extensive bleedingPain, extensive bleeding

– InternalInternal• Rarely injuredRarely injured

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Reproductive System TraumaReproductive System Trauma

• Treat like blunt or penetrating soft tissue Treat like blunt or penetrating soft tissue injuries elsewhere on bodyinjuries elsewhere on body

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Male Genitalia TraumaMale Genitalia Trauma

• Usually Usually NOTNOT life-threatening life-threatening

• Very painfulVery painful

• Great source of concern to patientGreat source of concern to patient

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Male Genitalia TraumaMale Genitalia Trauma

• Avulsion of skin of penis, scrotumAvulsion of skin of penis, scrotum– Cover with a moist, sterile dressingCover with a moist, sterile dressing

• Complete amputation of penisComplete amputation of penis– Treat as any amputated partTreat as any amputated part

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Male Genitalia TraumaMale Genitalia Trauma

• Blunt trauma to penis, scrotumBlunt trauma to penis, scrotum– Apply ice packApply ice pack

• Urethral foreign bodiesUrethral foreign bodies– Do Do NOTNOT remove remove

• Penis entrapped in zipperPenis entrapped in zipper– If 1 or 2 teeth involved, try to unzipIf 1 or 2 teeth involved, try to unzip– If more involved, cut zipper out of trousers, If more involved, cut zipper out of trousers,

transporttransport

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Female Genitalia TraumaFemale Genitalia Trauma

• InternalInternal– Rarely injured Rarely injured

• ExternalExternal– Can cause pain, extensive bleedingCan cause pain, extensive bleeding– Usually not life-threateningUsually not life-threatening

• Treat with compresses, pressureTreat with compresses, pressure

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Sexual AssaultSexual Assault

• Avoid examining genitalia unless obvious Avoid examining genitalia unless obvious bleeding presentbleeding present

• Ask patient to Ask patient to NOTNOT wash, douche, urinate, wash, douche, urinate, defecatedefecate

• Ask patient Ask patient NOTNOT to change clothes to change clothes

• Record history, but avoid extensive Record history, but avoid extensive questioning about incidentquestioning about incident

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QUESTIONSQUESTIONS

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