Abdominal Trauma (chapter 43)

Penetrating Trauma

- results from stab wounds, GSW,or impalement major complication: hemorrhage -> form major vessels or solid organs - amount of bleeding is related to vascularity of organ or how many vessels involved • May cause perforation of segment of bowel(ascending, descending, transverse, cecum) • Injuries caused by penetrating trauma do not have as high mortality rate as those caused by blunt trauma - Because injuries from blunt trauma are more difficult to diagnose - Often accompanied by injury to multiple organ systems

Types of questioning

Blunt trauma MOI (MVC) - determine types of vehicles involved (car vs. truck) - speed collision/impact - how the collision occurred, where is damage located, how are the cars positioned after - intrusion - air bags? seat belt Penetrating trauma: - weapon used - edge of weapon - sharp, jagged? - length of weapon - type of gun, number of shots fired? number of times stabbed

Abdominal Anatomical Regions

Know regions and quadrants 9 abdominal regions 4 abdominal quadrants *mesmorize which are in each

Special Consideteration

Younger children and the elderly: - have more flaccid abdominal walls (less muscle and more fat) and increased risk of abdominal injury Obese patients, or patients with increased abdominal wall size: - may have to apply greater pressure on examination to asses for injury - in these patients, have a higher suspicion

treat all abdominal as serious bc it could be

all abdominal organs and vascular structures are susceptible to injury - quick recognition of injury, emergency care, and rapid transport for definitive care can tremendously alter morbidity and mortality

Hollow Organ Injury

hollow organs include: stomach, small intestines, large intestines, bladder • Injuries to hollow organs of abdomen may result in - Sepsis - Wound infection - Abscess formation, particularly if trauma to intestine remains undiagnosed for extended period - With injuries to solid organs, hemorrhage is major cause of symptoms - Injury to hollow organs results in symptoms from spillage of their contents (results in peritonitis)

seat belt bruising

marks of impact on the front seat passenger in a car crash, signs may indicate increased likelihood of intraabdominal injury note child more susceptible bc childs abdominal musculature is not as well developed, so the stomach protrudes more than an adults - the lower border of the liver and spleen extend below the ribs; thus they are less protected than in adults

Solid Organ Injury

solid organs = liver, spleen, kidneys and pancreas - when solid organ is injured the organ bleeds into the peritoneal cavity - may see signs of shock (hypotensive, tachycardia) - normal vitals do not rule out intra abdominal injury Common s/s: - abdominal tenderness/rigidity/rebound tenderness on palpation - abdominal distension NOTE: unexplained tachycardia is almost always a bleed you can't see. tachycardia happens before the patient goes hypotensive SHOCK = supply doesn't meet the demand, global hyperperfusion of the body

Isolated fractures

Direct fratures - a direct blow to the pelvis like fall from a height may lead to fracture of the iliac or the ischium - rest until pain subsides is usually all that is needed

Extravasation of Urine

*condition of interruption of urethra leads to collection of urine in other cavities Applied anatomy (male external genitalia) - rupture of spongy urethra is common in straddle injury that results in extraperiotoneal extravasation of urine within superficial perineal pouch and extending into the scotal, penile, and fatty layer of subcutaneous connective of the lowe anterior abdominal wall areas

Organs in abdomen include

- Intestines (large is retroperitoneal except sigmoid and transverse) - Kidneys (retroperitoneal) - Liver - Gallbladder - Pancreas (retroperitoneal) - Spleen - Stomach - duodenum (retroperitoneal) • Abdomen has many vascular structures - Abdominal aorta - Superior and inferior mesenteric arteries - Renal artery - Splenic artery - Hepatic artery - Iliac arteries - Hepatic portal system - Inferior vena cavae NOTE: splenic rupture = you feel pain in left shoulder bc. there is a specific dermatome their - you got your two planes sagittal plane and transumbillical place McBurney's point = appendicitis, location of rebound tenderness

Abdominal cavity

- lagest cavity in the body: from the diaphragm to the pelvis - at times, difficult for EMS to determine organs involved in traumatic injuries -- digestive sys -- urinary sys -- genitourinary systems - urinary and reproductive/ genital organs - abdominal trauma often goes unrecognized/over looked due to the other fatal injuries *this is why a thorough secondary survey is important

Hip Dislocation

Externally Rotation and Shortening of Limb - Hip fractures are different than dislocation - notice that affected extremity is shortened and externally rotated Hip dislocation following total hip surgery - if the dislocation is posterior, the leg will be in adduction and internal rotation Rare case: open anterior hip dislocation

Blunt trauma

Majority of abdominal trauma invoices Blunt force and may lead to closed abdominal injury CLOSED abdominal injury: soft tissue damage occurs inside the body, but skin is intact 1. Shearing forces - rapid decelerations ex. MVC, falls 2. Crushing forces - abdominal contents crushed btw abdominal wall and spinal column (dashboard, steering column) 3. Compression forces - direct blow or external compression from a fixed object (seat belt, airbags) can deform hollow organs from dramatic changes in pressure causing rupture • May cause abdominal organs to be crushed between solid objects

Stomach

Most often caused by penetrating trauma, rarely blunt force - trauma to stomach often results in spilling of stomach contents (HCI-) into peritoneal space and creates irritation in the abdomen • Patients may show signs of peritonitis rather quickly as result of leakage of acidic gastric contents • Diagnosis of injury to stomach usually is confirmed during surgery or when nasogastric drainage returns blood • Damaged in about 1 percent of cases of blunt abdominal trauma • Damaged in about 10 to 15 percent of cases of penetrating trauma NOTE: biggest thing is the gastric acid HCI

CHRIS NOTES to know

NOTE: for fluid. We give 20cc per kilo. we give maximum of 2000 cc (2 Liters); auscultate every 250 cc, bc you don't want to flood the lungs 3 conditions where you don't give - ROSC (bc it would be backed up) - DKA (diabetic ketoacidosis = sugars are way too high, were worried about the brain not being able to process it, basically water on the brain (hydrocephalysis)) - cardiogenic shock (if the pump is not functioning properly, the extra fluid will go to the lungs) NOTE: pubic arch ECG: pericarditis brought on by blunt trauma or an infection - things that can affect abdomen protruding it can be one of 3 things 1. gas, 2. fluid, including blood and water 3. pulsatile mass (AAA) - epigastric ~ 6inches below (aorta) ALS can use dopamine to the heart = forcibly forces the heart to compress, problem is you can overwork it. - if that does work they can do a pacer that makes the heart pump as well Atrophy = makes the heart beat faster Adenosine = heart do slower

Pelvic Organ Injury

Pelvis supports and protects multiple organ systems - Risk of associated injury is high • Most common associated injuries are those to urinary bladder and urethra • Fractures of pelvis often associated with severe retroperitoneal hemorrhage • Mortality rate for pelvic fractures ranges from 6.4 to 19 percent anterior: - allium - ischium - pubis Posterior: - sacrum - coccyx

Retroperitoneal Organ Injury

SADPUCKER - difficult to diagnose, injuries produce few visible s/s --Grey Turner's Sign = echymossis of the flanks due to retroperitoneal bleeding --Cullen's Sign = ecchymosis around the umbilicus (ectopic pregnancy) these signs are usually delayed several hours or days, and un reliable in pre hospital setting

Open book pelvic fracture

open book - separation of the pubic symphysis, increase in space allows blood to fill pt. will become hypotensive management - fluid therapy - pain meds - warp a sheet or Kravet around the iliac crests/pelvis to decrease the pelvic volume NOTE: with any type of hip fracture be constantly observing blood pressure = because its most likely going to become hypovelemic shock

Mechanisms of Abdominal Injury

• Abdominal injury may result from blunt or penetrating trauma - Regardless of organ injured, management usually is limited to • Securing airway with spinal precautions • Providing ventilatory support • Providing wound management • Managing shock with fluid replacement • Be aware of kinematics and mechanism of injury when evaluating patient with abdominal trauma Examples - In motor vehicle collision, note • Extent of damage to car • Patient's location within car • Whether patient struck steering wheel or dash • Whether personal restraints were used properly Note; you can't stop abdominal bleeding, if pregnant ask how pregnant, look for bruising

Abdominal Trauma Management

• Emergency care - Usually limited to two scourses of action 1. Stabilizing patient's condition 2. Rapidly transporting patient to a hospital for physician evaluation and surgical repair of injury • Most important components of on‐scene care - Thorough scene survey to identify forces involved in abdominal trauma - Rapid evaluation of patient and mechanism of injury - Airway maintenance with spinal precautions - Administration of high‐concentration O2 (≥92 percent) - Ventilatory support as needed - Reduction of hemorrhage by application of pressure - Cardiac monitoring - Fluid replacement with IV ad saline • O2 saturation should be maintained at or above 90 percent - Goal of fluid resuscitation for patient with abdominal injury and hypotension is to maintain systolic BP between 80 and 90 mm Hg (mean arterial pressure of 60 to 65 mm Hg) - Aggressive fluid replacement can reinitiate bleeding in abdomen from sites that had stopped bleeding from blood clots and hypotension • Strive to balance perfusion to vital organs without restoring BP to normal limits • On route to hospital, full physical examination and ongoing assessment can be performed - Vital sign assessment (and reassessment) - Inspection, percussion, palpation of abdomen - Auscultation of abdomen for presence of bowel sounds can establish baseline measurement for hospital personnel - Assessment is difficult and time‐consuming in prehospital setting and should never delay patient transport: detailed abdominal assessment can be done on-route to hospital

Urinary Bladder

• Hollow organ That may be ruptured by • Blunt trauma • Penetrating trauma • Pelvic fracture Rupture more likely if bladder is distended at time of injury - With rupture, integrity of peritoneum may be disrupted - Urine may enter peritoneal cavity - Bladder injury should be suspected in inebriated patients that suffer trauma to lower abdomen S/S: • Gross hematuria (blood in urine) may be present • Patient may complain of being unable to void • Urinary bladder and surrounding structures are damaged in about 6 percent of cases of abdominal trauma NOTE: if there is trauma to pelvic region, probably damage to abdomen

Ureters

• Hollow organs that are rarely injured by blunt trauma - Flexible structure - When injury occurs, usually is result of penetrating abdominal or flank - can be then due to deceleration forces in an MVI especially if the patients bladder is full

Vascular Structure Injuries

• Injuries to arterial and venous vessels in abdomen can be life‐threatening because of their potential for massive hemorrhage - Usually are caused by penetrating trauma - May also be result of compression or deceleration forces on abdomen - Injury usually marked by hypovolemia - In some cases, vascular injuries are associated with palpable abdominal mass • Injuries to arterial and venous vessels in abdomen can be life‐threatening because of their potential for massive hemorrhage - Major vessels most often injured • Aorta • Inferior vena cava • Renal, mesenteric, iliac arteries and veins - Injury to major vessels in abdomen has high mortality rate - Immediate surgical repair often required

Liver

• Largest organ in abdominal cavity - Because of its location, often is injured by trauma to 8th to 12th ribs on right side of body - Also is often injured by trauma to upper central part of abdomen - Injury should be suspected in any patient with • Steering wheel injury • Lap belt injury • History of epigastric trauma • After injury to liver, blood and bile escape into peritoneal cavity - Results in signs and symptoms of shock and peritoneal irritation • Abdominal pain • Tenderness • Rigidity • Second most commonly injured intra‐abdominal organ (spleen is first) - Damaged in about 15 to 20 percent of blunt abdominal trauma - Damaged in about 37 percent of cases of penetrating trauma - Mortality rate for liver injury is 10 percent

Duodenum

• Lies across lumbar spine - Seldom injured due to location in retroperitoneal area, near pancreas - When great force from blunt trauma or penetrating injury occurs, may be crushed or lacerated • Injury usually associated with concurrent pancreatic trauma • Confirmed through surgery - spilling of contents into retroperitoneum, leads to contamination and irritation/abdominal pain - high suspicion of abdominal trauma with s/s of nausea and vomiting

Spleen

• Lies in upper left quadrant of abdomen - Slightly protected by organs that surround it medially and anteriorly - Protected by lower portion of rib cage - Injury to spleen often associated with other intra‐abdominal injuries - Splenic injury should be suspected in motor vehicle crashes and in falls or sports injuries involving an impact to lower left chest or flank or to upper left abdomen • About 40 percent of patients with spleenic injures have no symptoms - May complain of pain in left shoulder - Kehr sign (acute shoulder tip pain due to presence of blood in peritoneal cavity) -- aggravated when pt. laying down and legs elevated -- left shoulder tip pain is a classic sign of ruptures/abscessed spleen

Specific Abdominal Injuries

• May be classified as - Solid organ - Hollow organ - Retroperitoneal organ - Pelvic organ - Vascular injury KNOW diff b/w hollow and solid

Colon and small intestine

• More likely caused by penetrating trauma: - Large and small bowel also may be injured by compression forces in high‐speed motor vehicle crashes - May sustain deceleration injuries associated with wearing of personal restraints • Considerable force is required to cause injury to colon or small intestine - Other injuries usually are present - Peritoneal contamination with bacteria is common problem - With blunt abdominal trauma, colon is damaged in about 2 to 5 percent of cases and small intestine in about 5 to 15 percent of cases - With gunshot wounds, colon is damaged in about 25 percent of cases and 5 percent of stab wounds - Small intestine is damaged in about 26 percent of cases NOTE: mesentery bleeding

Assessment of Abdominal Trauma

• Most significant sign is unexplained shock - Mechanism of injury and classic presentation of hypovolemia are important indicators - attempt to palpate the non painful area of abdomen first, then palpate the injured or painful site - Other signs and symptoms that should alert to possibility of severe abdominal trauma are abdominal wall injuries and • Obvious bleeding • Pain and abdominal tenderness or guarding • Abdominal rigidity and distention • Evisceration • Rib fractures • Pelvic fractures • Absence of signs and symptoms does not rule out an abdominal injury - Maintain high degree of suspicion based on mechanism of injury

Focused History

• Should be obtained from patient or reliable source • Historical facts that may be important: SAMPLE - Events prior to injury - Alcohol or other drug use - Underlying medical problems • Diabetes • Cardiovascular disease • Respiratory disease • Seizure disorder - Medication use - Drug allergies

Pancreas

• Solid organ that lies within retroperitoneal space - Injury is rare - When it occurs, usually caused by compressive or penetrating forces on upper left quadrant • Steering wheel and bicycle handlebar impalement - More often is injured by penetrating trauma (particularly firearms) than by blunt trauma NOTE: if pancreatic gets ruptures it leaks gastric acid, and it will disrupt blood sugar (bc. insulin)

Kidneys

• Solid organs that lie in retroperitoneal space - May be injured by abdominal trauma - Trauma may cause contusion as well as lacerations and fractures to organ - Can result in hemorrhage, extravasation of urine, or both - Contusions usually are self‐limiting • Usually heal with bed rest and forced fluids - Organ fractures and lacerations are more severe • May require surgical repair, depending on which part of kidney is damaged Note; good question do you have blood when you urinate? A. minor renal laceration B. renal contusion - laceration into collecting sys will be where you pee blood

Urethra

• Tear in urethra occurs more often in men than in women - Usually occurs as result of blunt trauma associated with pelvic fracture - Patient may complain of abdominal pain and of being unable to urinate - Blood at meatus indicates urethral injury - Passage of indwelling urinary catheter is contraindicated