CH 30: ABDOMINAL AND GENITOURINARY INJURIES

The kidneys The urinary bladder The external male genitalia The internal female genitalia The external female genitalia

-Injuries to the kidneys are not unusual and rarely occur in isolation. A penetrating wound that reaches the kidneys almost always involves other organs. A blow that is forceful enough to cause significant kidney damage often results in damage to other intra-abdominal organs. Less-significant injuries to the kidneys may result from a direct blow or even from a tackle in football. Suspect kidney damage if the patient has a history or physical evidence of any of the following: An abrasion, laceration, or contusion in the flank A penetrating wound in the flank (the region below the rib cage and above the hip) or the upper abdomen Fractures on either side of the lower rib cage or of the lower thoracic or upper lumbar vertebrae A hematoma in the flank region. Damage to the kidneys may not be obvious on inspection of the patient. You may or may not see bruises or lacerations on the overlying skin. You will see signs of shock if the injury is associated with significant blood loss. Another sign of kidney damage is blood in the urine (hematuria). Treat shock and associated injuries in the appropriate manner. Provide rapid transport to the hospital, carefully monitoring the patient's vital signs en route -Injury to the urinary bladder, either blunt or penetrating, may result in its rupture. Urine spills into the surrounding tissues, and any urine that passes through the urethra is likely to be bloody. Blunt injuries of the lower abdomen or pelvis often cause rupture of the urinary bladder, particularly when the bladder is full and distended. Sharp, bony fragments from a fracture of the pelvis often perforate the urinary bladder. Penetrating wounds of the lower mid-abdomen or the perineum (the pelvic floor and associated structures that occupy the pelvic outlet) can directly involve the urinary bladder. In men, sudden deceleration from a motor vehicle or motorcycle crash can literally shear the bladder from the urethra. In the second and third trimesters of pregnancy, the incidence of injury to the urinary bladder is increased by displacement of the uterus. -Injuries of the external male genitalia include all types of soft-tissue wounds. Although these injuries are uniformly painful and generally a source of great concern to the patient, they are rarely considered life threatening and should not be given priority over other, more severe wounds, unless the rich blood supply causes significant bleeding. Pain from an injury to the testicles or another cause, such as infection or cancer, may be referred to the lower abdomen. When assessing men with lower abdominal pain, you should also consider injury or other causes of pain to the testicles. -The uterus, ovaries, and fallopian tubes are rarely damaged because they are small, deep in the pelvis, and well protected by the pelvic bones. They are usually not injured as a result of a pelvic fracture. An exception is the pregnant uterus. As pregnancy progresses, the uterus enlarges substantially and rises out of the pelvis, becoming vulnerable to both penetrating and blunt injuries. These injuries can be particularly severe because the uterus has a rich blood supply. You can expect to see the signs and symptoms of shock with these patients. Note also that contractions may begin. Ask the patient when she is due to deliver, and report this information to the hospital staff. In the third trimester, the uterus is large and may obstruct the vena cava, leading to a decrease in the amount of blood returning to the heart if the patient is placed in a supine position (supine hypotensive syndrome). As a result, blood pressure may decrease. Place the patient on her left side so that the uterus will not lie on the vena cava. If the patient is secured to a backboard, tilt the board to the left. -

Emergency Medical Care of Open Abdominal Injuries A large wound may have protrusions of bowel, fat, or other structures. In addition to pain, patients often report nausea and vomiting. Patients with peritonitis generally prefer to lie very still with their legs drawn up because it hurts to move or straighten their legs. In caring for a patient with a penetrating wound to the abdomen, follow the general procedures described for care of a blunt abdominal injury as well as the specific steps for the penetrating wound. Inspect the patient's back and sides for exit wounds. Apply a dry, sterile dressing to all open wounds. If the penetrating object is still in place, apply a stabilizing bandage around it to control external bleeding and minimize movement of the object.

Emergency Medical Care of Abdominal Evisceration Never try to replace an organ that is protruding from an abdominal laceration. Cover it with sterile dressings moistened with sterile saline solution and secure with a bandage and tape. Protocols in some EMS systems call for an occlusive dressing over the dressings. Because the open abdomen radiates body heat, and because exposed organs lose fluid rapidly, keep the organs moist and warm. Do not use any material that is adherent or loses its substance when wet (eg, toilet paper, facial tissue, paper towels, or absorbent cotton). Treat the patient for shock by keeping the patient warm and placing the patient in the supine position. Provide high-flow oxygen and transport according to local protocols and destination policy. Transport the patient to the highest level trauma center available.

The genitourinary system controls: Reproductive functions The waste discharge system

Male Genitalia The male genitalia, except for the prostate gland and the seminal vesicles, lie outside the pelvic cavity.' Female Genitalia The female genitalia, except for the vulva, clitoris, and labia, are contained entirely within the pelvis.

Closed abdominal injuries are those in which blunt force trauma results in injury to the abdomen without breaking the skin. MOIs include: Striking the handlebar of a bicycle or the steering wheel of a car Being struck by a wooden board or baseball bat Motorcycle crashes Falls Blast injuries Pedestrian injuries Compression Deceleration Compression injuries are typically caused by a poorly placed lap belt. This creates an injury pattern called a clasp-knife injury, an exaggerated resistance of muscles that resembles the opening of a penknife or clasp knife. A compression injury can also be caused when a person is run over or rolled over by a vehicle or object. Deceleration injuries commonly occur when a person or the vehicle the person is traveling inside strikes a large, immovable mass.

Signs and Symptoms of a Closed Injury In patients with liver and spleen injuries, and/or with bleeding into the peritoneal space, pain is referred to the shoulder. Shoulder pain can be misleading, and injury to the liver or spleen could possibly be overlooked if the shoulder is also injured. Symptoms of an abdominal aneurysm that is dissecting include pain that is described as tearing going from the abdomen posteriorly. Pain that is following the angle from the lateral hip to the midline of the groin can be the result of damage to the kidneys or the ureters. Pain primarily located in the right lower quadrant can indicate an inflamed or ruptured appendix. Pain from the gallbladder due to direct injury or inflammation can be found just under the margin of the ribs on the right side or between the shoulder blades. As blood and fluid from damaged organs flow into the peritoneal cavity, the common response is acute pain in the entire abdomen, which spreads as the blood or contaminant seeks out the voids in the peritoneal cavity. The resulting peritonitis can produce pain if the affected area is exposed to any jarring motion, commonly referred to as rebound tenderness. As an EMT, you do not need to produce rebound tenderness intentionally when examining the patient. It is often discovered when you are moving the patient onto the stretcher or into the ambulance. In guarding, the patient either consciously or unintentionally stiffens the muscles of the surface of the abdomen. Most often it is the rectus abdominis muscles that are held tight, and the tightness can be mistaken for abdominal rigidity. This stiffening is a natural response to abdominal pain; the body is attempting to splint the area to prevent unnecessary movement and to avoid further pain. Abdominal distention or swelling that occurs between the xiphoid process and the groin is often the result of free fluid, blood, or organ contents spilling into the peritoneal cavity. Swelling can also be the result of air in the form of gases from the bowel or from infection. Other signs and symptoms include: Tenderness Bruising and discoloration Another likely injury is lower rib fractures—a trauma that was forceful enough to break the ribs may also have damaged internal organs.

flank The region below the rib cage and above the hip.

Signs and Symptoms of an Open Injury A very common early sign of a significant abdominal injury is tachycardia because the heart is increasing its pumping action to compensate for blood loss. Later signs include Evidence of shock (such as decreased blood pressure and pale, cool, moist skin) or changes in the patient's mental status Trauma to the abdomen In some cases, the abdomen may become distended from the accumulation of blood and fluid. Blunt injuries include bruises (often indicated by red areas of skin at this early stage) or other visible marks, whose location should guide your attention to underlying structures. For example: Bruises in the right upper quadrant, left upper quadrant, or flank might suggest an injury to the liver, spleen, or kidney, respectively. Bruises around the umbilicus can predict significant internal abdominal bleeding.

Hollow Organ Injuries When the stomach and the intestines are injured, they can spill gastrointestinal contents such as food, waste, and digestive liquids that are highly toxic and acidic. These substances cause significant tissue damage to the entire peritoneum. Blunt trauma causes the hollow organs to "pop," releasing fluids or air. Penetrating trauma causes direct injury such as laceration and punctures. In open wounds, patients typically report an intense pain that can be out of character for the size of the injury. Patients may also report intense pain with open wounds of the stomach or small bowel. The contents of the gallbladder and the urinary bladder, bile and urine, are potentially irritating and damaging to the tissues of the abdomen if ruptured. These fluids move via gravity into the loose spaces and voids in the peritoneal cavity, eventually leading to infection. Free air in the peritoneal cavity is abnormal and indicates that a hollow organ or loop of bowel has perforated. Perforation with free air is usually very painful. If the site of perforation is not rapidly identified and repaired, severe infection and septic shock may develop. Any air in the peritoneal cavity seeks the most superior space or void; thus, the location of the air can change with positioning of the patient.

Solid Organ Injuries Because of the structures in the retroperitoneal space and the spaces in the abdominal cavity, the peritoneal cavity can hold a large volume of blood following traumatic injuries of solid organs and major blood vessels. The liver, the largest organ in the abdomen, is very vascular and can contribute to hypoperfusion if it is injured. It is often injured by a fractured lower right rib or a penetrating trauma, such as a stab wound. A common finding during assessment of patients with an injured liver is referred pain to the right shoulder. The pancreas and spleen are responsible for filtering blood and are, therefore, vascular. Both organs are prone to heavy bleeding when fractured by blunt force or lacerated or punctured by penetrating injury. The spleen is often injured during motor vehicle crashes, especially in the cases of improperly placed seat belts or impact from the steering wheel; falls from heights or onto sharp objects; and bicycle and motorcycle crashes where the patient hits the handlebars on impact. Referred left-shoulder pain also occurs in some cases of splenic injury. If the diaphragm is penetrated or ruptured, loops of bowel may herniate into the thoracic cavity. Because the bowel will displace lung tissue and vital capacity, patients will exhibit dyspnea or feel short of breath. Change in position from upright to supine results in more abdominal contents spilling into the thoracic cavity and compressing the lungs, prohibiting the lungs from fully expanding. The kidneys can be sheared from their base, crushed, or fractured, causing significant blood loss. If the kidney is injured, a common finding is hematuria. Blood visible on inspection of the urinary meatus (opening of the urethra situated on the glans penis in men and in the vulva in women) indicates significant trauma to the genitourinary system. If blood is not present, do not take this as a sign that the patient is free from injury; the blood may not be visible yet.

Injuries from Seat Belts and Air Bags When worn properly, a seat belt lies below the anterior superior iliac spines of the pelvis and against the hip joints. If the seat belt lies too high, it can squeeze abdominal organs or great vessels against the spine when the vehicle suddenly decelerates or stops. Occasionally, fractures of the lumbar spine have been reported. In later stages of pregnancy, the gravid uterus displaces the urinary bladder to the anterior. This allows the normally protected bladder to become more susceptible to injuries from impacts and the seat belt. Pregnant patients who adjust the lap belt portion for comfort as opposed to functionality can sustain further injuries.

open Abdominal Injuries Open abdominal injuries are those in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside; these are also known as penetrating injuries. There are three levels of velocity that are common in traumatic injuries: Low-velocity injuries: Caused by hand-held or hand-powered objects such as knives and other edged weapons Medium-velocity penetrating wounds: Caused by smaller caliber handguns and shotguns High-velocity injuries: Caused by larger weapons such as high-powered rifles and the higher-powered handguns High- and medium-velocity injuries have temporary wound channels caused by cavitation in addition to the exit and entrance wounds. A cavity forms as the pressure wave from the projectile is transferred to the tissues, causing microscopic tears to the blood vessels and nerves and expanding the width and length of the wound beyond what you can see during physical examination. Cavitation can produce significant bleeding depending on the speed, or velocity, of the penetrating object. The higher the velocity of the projectile, the larger the cavity it produces, typically resulting in a larger amount of tissue damage. An open abdominal injury that goes through the skin and muscle layer and through the fascia or the interior covering of the abdomen is an evisceration. Do not push down on the patient's abdomen, and perform only a visual assessment when there is any suspicion of this type of injury. If there is clothing close to the wound, carefully cut the clothing around the wound, leaving a border of intact cloth outside the injured area. Never pull, even gently, on any clothing stuck to or inside the wound channel because this may remove even more of the abdominal contents.