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Abdominal Trauma

Gram McGregor, 1Lt, WA ANG

Critical Care Air Transport Nurse

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The Abdomen Everything between diaphragm and

pelvis Injuries very difficult to assess

because of large variety of structures

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Abdominal Anatomy Abdomen divided into four quadrants

by body mid-line, horizontal plane through umbilicus

Organ located by quadrant

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Abdominal Anatomy Right Upper Quadrant

– Liver– Gall Bladder – Right Kidney– Ascending Colon– Transverse Colon

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Abdominal Anatomy Left Upper Quadrant

– Spleen– Stomach– Pancreas– Left Kidney– Transverse Colon– Descending Colon

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Abdominal Anatomy Right Lower Quadrant

– Ascending Colon– Appendix– Right Ovary (female)– Right Fallopian Tube (female)

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Abdominal Anatomy Left Lower Quadrant

– Descending Colon– Sigmoid colon– Left Ovary (female)– Left Fallopian Tube (female)

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Abdominal Anatomy Organs can be classified as:

– Hollow– Solid– Major vascular

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Solid Organs Liver Spleen Kidney Pancreas

When solid organs are injured, they bleed heavily

and cause shock

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Solid Organs Liver

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

Slow, contained under capsule Free into peritoneal cavity

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Solid Organs Spleen Frequently injured with trauma ribs 9-11

on left side– Bleeds easily– Capsule around spleen tends to slow

development of shock– Rapid shock onset when capsule ruptures

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Solid Organs

Pancreas– Lies across lumbar spine– Sudden deceleration produces straddle

injury– Very little hemorrhage– Leakage of enzymes digests structures in

retroperitoneal space, causes volume loss, shock

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Hollow Organs Stomach Gall bladder Large, small intestines Ureters, urinary bladder

Rupture causes content spillage, inflammation of

peritoneum

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Hollow Organs Stomach

– Acid, enzymes– Immediate peritonitis– Pain, tenderness, guarding, rigidity

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Hollow Organs Colon

– Spillage of bacteria– May take 6 hrs to develop peritonitis

Small Bowel– Fewer bacteria– May take 24-48 hours to develop

peritonitis

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Major Vascular Structures Aorta Inferior vena cava Major branches

Injury can cause severe blood loss ; exsanguination

(bleeding out)

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Abdominal Trauma

Many survive to reach hospital Most common factors leading to death

– Failure to adequately evaluate– Delayed resuscitation– Inadequate volume– Inadequate diagnosis– Delayed surgery

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High Index of Suspicion Mechanism Tachycardia early, hypotension, and

pale, diaphoretic skin late Hypovolemic shock with no readily

identifiable cause Diffusely tender abdomen Pain in uninjured shoulder

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Mechanism Look for signs of injury

– Bruises– Tire marks– Obvious open injuries

Assume any abdominal injury is serious until proven otherwise!

Injury above umbilicus also involves chest until proven otherwise

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Adequate* Assessment key

D-eformity C-ontusions A-brasions P-enetrating

Injuries

*per BTLS Guidelines

B-urns T-enderness L-acerations S-welling

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Blast Injuries Most commonly found in ear, lungs

and hollow abdominal organs.

Abdominal injuries include hemorrhage and hollow organ rupture.

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Unexplained Shock Assess vital signs; skin color,

temperature; capillary refill Tachycardia; restlessness; cool, moist

skin In trauma, signs of shock suggest

abdominal injury if no other obvious causes present

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Signs of Injured Abdomen

Diffuse tenderness Pain

– Pain referred to shoulder = Organ under diaphragm involved (?spleen)

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

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Abdominal Rigidity

NOT reliable Bleeding may not cause rigidity if free

hemoglobin absent Bleeding in retroperitoneal space may

not cause rigidity

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Abdominal Trauma Management

Most Important fact in treating ALL types of abdominal trauma…

Initiation of life support measures including establishment and maintenance of adequate airway, breathing and circulatory support.

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Abdominal Trauma Management

Less important to diagnose exact injury

Treat clinical findings-as able Management same regardless of

specific organ(s) injured

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Abdominal Trauma Management

Airway C-Spine if mechanism indicates High flow O2

Assist ventilations if needed Give nothing by mouth

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Impaled Object Leave in place

– Shorten if necessary for transport– Leave part of object exposed– Stabilize

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Evisceration With large laceration abdominal

contents may spill out Do NOT try to replace

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Evisceration Cover exposed organs with saline

moistened multi-trauma dressing

Cover first dressing with second DRY dressing or nonpermeable item

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Genitourinary Trauma

Gram McGregor, 1Lt, WA ANG

Critical Care Air Transport Nurse

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Urinary System

Kidney

UreterUrinary Bladder

Urethra

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Kidney Trauma 50% of all GU trauma

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Kidney Trauma Penetrating

– GSW– Stab wound– Blast injuries similar to other solid organs

Rare, usually associated with trauma to other abdominal organs

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Kidney Trauma Blunt

– Direct blow to back, flank, upper abdomen

Suspect with fractures of 10th - 12th ribs or T12, L1, L2

– Acceleration/Deceleration Shearing of renal artery/vein

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Kidney Trauma Signs and Symptoms

– Gross Hematuria 80% of cases Absence does NOT exclude renal injury

– Localized flank/abdominal pain– Palpable mass

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Kidney Trauma

Signs and Symptoms– Tenderness: Lower ribs, upper L-spine,

flank– Pain: groin, shoulder, back, flank

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Ureter Trauma

Less than 2% of GU trauma Usually secondary to penetrating

trauma Indicator

– Wound to lower back with urine escaping

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Urinary Bladder Trauma Mechanisms

– Blunt injury to lower abdomen– Seat belts– Pelvic fracture– Penetrating trauma to lower abdomen or

perineum (pelvic floor)– Can display hollow or solid organ blast

injuries dependant upon urine in bladder

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Extraperitoneal Bladder Rupture

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

Dysuria Hematuria Suprapubic tenderness Swelling, redness secondary to tissue

damage from urine

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Intraperitoneal Bladder Rupture

Urgency to void Inability to void Shock Abdominal distension

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Urethral Trauma Mechanisms

– Sudden decelerations (bladder shears off urethra)

– Straddle injuries

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Urethral Trauma Signs and Symptoms

– Blood at external meatus– Perineal bruising (butterfly bruise)– Scrotal hematoma

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Questions?

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References Elsayed, N. (1997) Toxicology of

overpressure. Mayorga, M. (1997) The pathology of

primary blast overpressure injury. Phillips, Y.Y. and Zajtuk, J.T. (1991) The

management of primary blast injury. Browner, B.D. (2002) Emergency care and

treatment of the sick and injured.