ABDOMINAL InjuryABDOMINAL Injury

Abdominal TraumaAbdominal Trauma

The abdomen is the “Black Box”The abdomen is the “Black Box”– I.e., it is impossible to know I.e., it is impossible to know

what specific injuries have what specific injuries have occurred at initial evaluationoccurred at initial evaluation

The key to saving lives in The key to saving lives in abdominal trauma is NOT to make abdominal trauma is NOT to make an accurate diagnosis, but rather an accurate diagnosis, but rather to recognize that there is an to recognize that there is an abdominal injuryabdominal injury

Examples of Examples of Abdominal InjuriesAbdominal Injuries

Blunt TraumaBlunt Trauma– Aortic ruptureAortic rupture– Splenic ruptureSplenic rupture– Liver rupture or Liver rupture or

lacerationlaceration– Diaphragmatic tearDiaphragmatic tear– Pelvic fracturePelvic fracture– Intestinal tearIntestinal tear– Bladder ruptureBladder rupture

Penetrating TraumaPenetrating Trauma– Laceration of Laceration of

blood vesselsblood vessels– Splenic ruptureSplenic rupture– Liver rupture or Liver rupture or

lacerationlaceration– Kidney lacerationKidney laceration– Intestinal Intestinal

lacerationslacerations– Bladder ruptureBladder rupture

Causes of Abdominal Causes of Abdominal InjuriesInjuries BLUNT

TRAUMA– Motor vehicle

accidents– Auto vs.

pedestrian– Falls– Blast injuries

PENETRATING TRAUMA– Gunshot Gunshot

woundswounds– Stab woundsStab wounds– Shrapnel Shrapnel

woundswounds– ImpalementsImpalements

Types of InjuriesTypes of Injuries Blunt and penetrating abdominal injuries may be Blunt and penetrating abdominal injuries may be

associated with extensive damage to the viscera associated with extensive damage to the viscera resulting in massive blood loss. resulting in massive blood loss.

Blunt or penetrating abdominal injuries are related to Blunt or penetrating abdominal injuries are related to the:the:– Type of force appliedType of force applied– Tissue density of structure injured (e.g., fluid-filled, gas-filled, Tissue density of structure injured (e.g., fluid-filled, gas-filled,

solid, or encapsulated)solid, or encapsulated) The liver and spleen are the most commonly injured The liver and spleen are the most commonly injured

organs from blunt trauma.organs from blunt trauma. The organs of the abdomen are vulnerable to The organs of the abdomen are vulnerable to

penetrating injury not only through the anterior penetrating injury not only through the anterior abdominal wall, but through the back, flank area and abdominal wall, but through the back, flank area and lower chest." lower chest."

The liver, small bowel and stomach are the most The liver, small bowel and stomach are the most commonly injured organs from penetrating trauma.commonly injured organs from penetrating trauma.

Signs and Symptoms Signs and Symptoms of Abdominal Injuriesof Abdominal Injuries

Blunt TraumaBlunt Trauma– Significant Significant

mechanismmechanism– Abdominal painAbdominal pain– DistensionDistension– Discoloration of Discoloration of

abdomen or flankabdomen or flank– Unexplained shockUnexplained shock

Penetrating traumaPenetrating trauma– Visible truncal Visible truncal

injury including injury including chest or abdomenchest or abdomen

– Abdominal painAbdominal pain– BleedingBleeding– Impaled objectImpaled object– EviscerationEvisceration– ShockShock

Diagnostic Procedures Diagnostic Procedures

Diagnostic Peritoneal Ravage Diagnostic Peritoneal Ravage (DPL)(DPL)

Ultrasound Ultrasound CT Scan CT Scan Laparoscopy Laparoscopy

Blunt Abdominal Blunt Abdominal TraumaTrauma

Flank ecchymosis from internal bleeding

Blunt Abdominal Blunt Abdominal TraumaTrauma

Compressive or Compressive or shearing forces may shearing forces may deform and rupture deform and rupture abdominal organsabdominal organs

Bruising across the Bruising across the lower abdomen is lower abdomen is characteristic of a characteristic of a seat belt injuryseat belt injury

Visible signs may Visible signs may not reflect severity not reflect severity of underlying injuryof underlying injury The Seat Belt Sign

Penetrating Abdominal Penetrating Abdominal TraumaTrauma

Visible wounds may Visible wounds may not reflect severity not reflect severity of underlying injuryof underlying injury

Significant internal Significant internal bleeding likelybleeding likely

Bowel injury likelyBowel injury likely Patient may be in Patient may be in

shockshock

Evaluation and Evaluation and ExaminationExamination

Visually note wounds Visually note wounds and abrasionsand abrasions

Palpate abdomen for Palpate abdomen for localized vs. diffuse localized vs. diffuse tendernesstenderness

Consider possible Consider possible internal injuriesinternal injuries

Diffuse, severe Diffuse, severe tenderness is a sign tenderness is a sign of internal bleedingof internal bleeding

Don’t forget the backDon’t forget the back

Turn the casualty over when you can Turn the casualty over when you can do so safelydo so safely

Visually inspect backVisually inspect back Palpate ribs, spine, sacrum for Palpate ribs, spine, sacrum for

tenderness and irregularities tenderness and irregularities Dress the wound with an occlusive Dress the wound with an occlusive

dressingdressing

Impalement Impalement InjuryInjury

Impalement InjuriesImpalement Injuries

DO NOT REMOVE DO NOT REMOVE OBJECT OR EXERT OBJECT OR EXERT ANY FORCE UPON IT!ANY FORCE UPON IT!– Severe bleeding may Severe bleeding may

occur causing shockoccur causing shock Check pulses distal to Check pulses distal to

impaled objectimpaled object Immobilize the objectImmobilize the object Apply bulky support Apply bulky support

bandages to hold in bandages to hold in placeplace

Impalement InjuriesImpalement Injuries

Make a box shape large Make a box shape large enough to surround the enough to surround the object and dressingsobject and dressings

Cut V notches into box Cut V notches into box toptop

Place box over object and Place box over object and dressings and tape in dressings and tape in placeplace

Tie cravats or Wraps Tie cravats or Wraps around torso for stability, around torso for stability, using V notches in box to using V notches in box to ensure stabilityensure stability

EviscerationEvisceration

Extrusion of abdominal contents secondary to penetrating abdominal

trauma

Management of Management of Evisceration InjuriesEvisceration Injuries Use sterile side of dressing to place Use sterile side of dressing to place

protruding organs near the wound protruding organs near the wound (NOT into wound)(NOT into wound)

Cover organs and wound completely Cover organs and wound completely with sterile or clean moist dressingwith sterile or clean moist dressing

DO NOT APPLY PRESSURE TO WOUND DO NOT APPLY PRESSURE TO WOUND or expose internal partsor expose internal parts

Tie dressing tails loosely around Tie dressing tails loosely around woundwound

Prepare evacuation to surgical assetsPrepare evacuation to surgical assets

Hepatic InjuriesHepatic Injuries Because of its size and location, the liver is Because of its size and location, the liver is

frequently injured when force is applied to the frequently injured when force is applied to the abdomen. abdomen.

The friability of liver tissue, the extensive blood The friability of liver tissue, the extensive blood supply, and the blood storage capacity cause supply, and the blood storage capacity cause hepatic injury to result in profuse hemorrhage. hepatic injury to result in profuse hemorrhage. These types of injuries require surgical control of These types of injuries require surgical control of bleeding.bleeding.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS• • Upper right quadrant painUpper right quadrant pain• • Abdominal wall muscle rigidity, spasm, or Abdominal wall muscle rigidity, spasm, or

involuntary guardinginvoluntary guarding• • Rebound tendernessRebound tenderness• • Hypoactive or absent bowel soundsHypoactive or absent bowel sounds• • Signs of hemorrhage and/or hypovolemic shockSigns of hemorrhage and/or hypovolemic shock

Splenic InjuriesSplenic Injuries Injury to the spleen is usually associated with blunt Injury to the spleen is usually associated with blunt

trauma, but may also be associated with penetrating trauma, but may also be associated with penetrating trauma. trauma.

Fractures of the left 10th to 12th ribs are associated Fractures of the left 10th to 12th ribs are associated with underlying damage to the spleen. with underlying damage to the spleen.

The most serious splenic injury is a severely fractured The most serious splenic injury is a severely fractured spleen or vascular tear, producing splenic ischemia spleen or vascular tear, producing splenic ischemia and massive blood loss. and massive blood loss.

Nonoperative management of the patient with an Nonoperative management of the patient with an isolated splenic injury mandates that the patient be isolated splenic injury mandates that the patient be hemdynamically stable This may involve bed rest and hemdynamically stable This may involve bed rest and possibly blood transfusions.possibly blood transfusions.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS– Signs of hemorrhage or hypovolemic shockSigns of hemorrhage or hypovolemic shock– Pain in the left shoulder (Kehr's sign)Pain in the left shoulder (Kehr's sign)– Tenderness in the upper left quadrantTenderness in the upper left quadrant– Abdominal wall muscle rigidity, spasm, or involuntary Abdominal wall muscle rigidity, spasm, or involuntary

guardingguarding

Hollow Organ InjuriesHollow Organ Injuries Forces causing trauma to hollow organs may Forces causing trauma to hollow organs may

result in either blunt or penetrating injuries.result in either blunt or penetrating injuries. The small bowel is the hollow organ most The small bowel is the hollow organ most

frequently injured. Deceleration may lead to frequently injured. Deceleration may lead to shearing, which causes avulsion or tearing of shearing, which causes avulsion or tearing of the small bowel. the small bowel.

Seat belts causing compression have Seat belts causing compression have resulted in rupture of the small bowel or resulted in rupture of the small bowel or colon.colon.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS– Peritoneal irritation manifested by abdominal wall Peritoneal irritation manifested by abdominal wall

muscle rigidity, spasm, involuntary guarding, muscle rigidity, spasm, involuntary guarding, rebound tenderness, and/or painrebound tenderness, and/or pain

– Evisceration of the small bowel or stomachEvisceration of the small bowel or stomach– Diagnostic Peritoneal Lavage (DPL) may show Diagnostic Peritoneal Lavage (DPL) may show

presence of bile, feces, or food fiberspresence of bile, feces, or food fibers

Renal InjuriesRenal Injuries The most common injury to the kidney The most common injury to the kidney

is a blunt contusion, Suspect renal is a blunt contusion, Suspect renal injury if there are fractures of the injury if there are fractures of the posterior ribs or lumbar vertebrae. posterior ribs or lumbar vertebrae.

Renal parenchyma can be damaged by Renal parenchyma can be damaged by shearing and compression forces shearing and compression forces causing lacerations or contusion. causing lacerations or contusion.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS– Ecchymosis over the flankEcchymosis over the flank– Flank or abdominal tenderness elicited Flank or abdominal tenderness elicited

during palpationduring palpation– Gross or microscopic hematuria—the Gross or microscopic hematuria—the

absence of hematuria does not rule out absence of hematuria does not rule out renal injuryrenal injury

Bladder and Urethral Bladder and Urethral InjuriesInjuries

The majority of bladder injuries are blunt. The majority of bladder injuries are blunt. If a distended bladder ruptures are perforated, If a distended bladder ruptures are perforated,

urine is likely to extravasate into the abdomen. urine is likely to extravasate into the abdomen. Most ruptures of the bladder occur in association Most ruptures of the bladder occur in association

with pelvic fractures.with pelvic fractures. Urethral trauma is more common in males than Urethral trauma is more common in males than

females because the male urethra is longer and females because the male urethra is longer and less protected. less protected.

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS– Suprapubic painSuprapubic pain– Urge, but inability to urinateUrge, but inability to urinate– Hematuria (may be microscopic)Hematuria (may be microscopic)– Blood at the urethral meatusBlood at the urethral meatus– Blood in scrotumBlood in scrotum– Rebound tendernessRebound tenderness