Chapter 30 Abdominal and Genitourinary Injuries

F. Solid organ injuries 1. Solid organs can bleed significantly and cause rapid blood loss.

. Can be hard to identify from a physical exam because the patient is not experiencing significant pain. b. Solid organs can also slowly ooze blood into the peritoneal cavity, causing pain to increase slowly over time.

List the major history of physical findings associated with possible kidney damage

1. An abrasion, laceration, or contusion in the flank 2. A penetrating wound in the flank (the region below the rib cage and above the hip) or the upper abdomen 3. Fractures on either side of the loser rib cage or of the lower thoracic or upper lumbar vertebrae 4. A hematoma in the flank region

B. Scene size-up

1. Assess the scene for hazards and threats to crew safety. a. Assess the impact of hazards on patient care. b. At minimum, gloves and eye protection are required. i. Minimize your direct contact with bodily fluids. ii. Blood can be hidden under thick layers of clothing

B. Closed abdominal injuries

1. Blunt trauma to abdomen without breaking the skin

IV. Patient Assessment of Abdominal Injuries A. Assessment of abdominal injuries is one of the more difficult assessments that you will perform.

1. Causes of injury may be apparent, but resulting tissue damage may not be so apparent. 2. Patient may be overwhelmed with other, more painful injuries. 3. Some abdominal injuries develop and worsen over time, making reassessment critical.

I. Introduction A. The abdomen is the major body cavity, extending from the diaphragm to the pelvis.

1. Contains the organs that make up the digestive, urinary, and genitourinary systems 2. It is important for the EMT to know the anatomy of the abdominal and pelvic cavities and where organs are located. a. Understand the functions of the organs so you can assess an injury's seriousness

B. Significant trauma to the abdomen can occur from blunt trauma, penetrating trauma, or both.

1. Injuries to the abdomen that go unrecognized and are not repaired in surgery are a leading cause of traumatic death. a. 10% of all trauma patients have some form of genitourinary tract injury.

VIII. Patient Assessment of the Genitourinary System A. Potential for patient embarrassment

1. Maintain a professional presence. 2. Provide privacy during assessment. 3. When possible, have an EMT of the same gender perform the assessment. 4. Look for blood on the patient's undergarments, and only inspect the external genitalia when there are complaints of pain or external signs of injury.

E. Secondary assessment

1. May not have time to perform this detailed, comprehensive exam in critically injured patients

E. Hollow organ injuries

1. Often have delayed signs and symptoms

D. Follow appropriate procedures and protocol.

1. Shield the patient from curious onlookers. 2. Document the patient's history, assessment, treatment, and response to treatment for possible court appearances. a. Do not speculate. b. Record only the facts. 3. Follow any crime scene policy of your EMS system. a. Advise the patient not to wash, bathe, shower, douche, urinate, or defecate until after a physical examination. b. If oral penetration occurred, advise the patient not to eat, drink, brush the teeth, or use mouthwash until after a physical examination. c. Handle the patient's clothes as little as possible i. Place articles of clothing or other evidence in paper bags. ii. Do not use plastic bags because mold can grow and destroy evidence. 4. Make sure that the EMT caring for the patient is of the same gender as the patient whenever possible. 5. Treat medical injuries and provide privacy, support, and reassurance.

C. External male genitalia injuries

1. Soft-tissue wounds 2. Painful and of great concern for the patient, but rarely life threatening b. Should not be given priority over more severe wounds unless there is significant bleeding

B. Scene size-up

1. Standard precautions should be taken at the scene; gloves and eye protection should be a minimum. 2. Be sure the scene is safe for you. 3. Call for additional resources early if needed. 4. Mechanism of injury/nature of illness a. Observe the scene for early indicators of the MOI. b. Consider early spinal precautions. c. Consider all of the injuries the MOI could have produced.

B. Hollow and solid organs:

1. The abdomen contains hollow and solid organs.

II. Anatomy and Physiology of the Abdomen A. Abdominal quadrants

1. The abdomen is divided into four quadrants.

B. Often there is little that you can do beyond providing compassion and transport.

1. The patient may have sustained multisystem trauma and need treatment for shock

X. Sexual Assault A. Sexual assault and rape are all too common.

1. Victims are generally women. 2. Sometimes men and children are victims.

Suspect kidney damage if the patient has a history of physical evidence of all of the following

1. an abrasion, laceration, or contusion in the flank 2. a penetrating wound in the region of the lower rib cage or the upper abdomen 3. fractures on either side of the lower rib cage

Suspect a possible injury of the urinary bladder in all of the following findings

1. blood at the urethral opening 2. blood at the tip of the penis or a stain on the patient's underwear 3. physical signs of trauma on the lower abdomen, pelvis, or perineum

You are dispatched to a motor vehicle collision. Your patient is a 42 year old restrained woman. The air bad deployed, and the woman has abrasions on her face. She is complaining of pain to both her chest and abdomen. Her airway is open and respirations are within normal limits. Her pulse is a little rapid but strong and regular. She has distal pulses. In assessing this patient, would be true

1. bowel sounds may help confirm findings 2. palpation is typically performed first with light touch. 3. if you find an entry wound, you should always assess for an exit wound

Signs of injury to the kidney may include the following

1. bruises or lacerations on the overlying skin 2. shock 3. hematuria

List the steps to care for an open abdominal wound with exposed organs

1. cover the wound with sterile dressings moistened with sterile saline solution 2. secure the dressing with a dressing bandage and tape 3. keep the organs moist and warm 4. treat the patient for shock 5. place the patient in a supine position 6. provide high flow oxygen 7. Transport the patient to the highest level trauma center available

Late signs of abdominal injury include

1. distention 2. change in mental status 3. pale, cool, moist skin

You are called to a local bar where a fight has taken place. The police department tells you that you have a 36 year old man who has been stabbed twice in the abdomen. On arrival, the patient is alert and oriented. His airway is open. His respirations are at 24 breaths per minute, pulse is rapid, regular, and weak. He has distal pulses, With the penetrating trauma, you should assume that the object has done the following

1. has penetrated the peritoneum 2. has entered the abdominal cavity 3. has possibly injured one or more organs

When performing a history on a patient with abdominal trauma, all of the following questions would be appropriate regarding trauma

1. is there any blood in your stool? 2. does your pain go anywhere? 3. do you have any nausea, vomiting, or diarrhea?

List 3 solid organs of the abdomen

1. liver 2. spleen 3. pancreas

List the steps to care for an open abdominal injury

1. log roll the patient to a supine position on a backboard 2. inspect the patient's back and sides for exit wounds 3. Apply a dry, sterile dressing to all open wounds 4.If the penetrating object is still in place, apply a stabilizing bandage around it to conrol external bleeding and to minimize movement of the object 5. monitor the patient's vital signs for indications of shock 6. administer oxygen, if needed 7. keep the patient warm with blankets 8. provide prompt transport to the emergency department

List the sign and symptoms of an abdominal injury

1. pain 2. guarding 3. distention 4. tenderness 5. bruising and discoloration 6. abrasions 7. tachycardia 8. shock signs 9. Lacerations, 10. bleeding 11.difficulty with movement because of pain

The first signs of peritonitis include

1. severe abdominal pain 2. tenderness 3. muscular spasm

If the seat belt lies too high it can do all of the following

1. squeeze abdominal organs 2. compress the great vessels 3. fracture the lumbar spine

Name 3 hollow organs of the abdomen

1. stomach 2. bladder 3. ureters

List 3 systems that contain organs that make up the contents of the abdominal cavity

1. the digestive system 2. the urinary system 3. the genitourinary system

List 3 of the male genitalia that lie outside the pelvic cavity

1. the urethra 2. the penis 3. the testes

III. Injuries to the Abdomen

A. Abdominal injuries are considered either open or closed and can involve hollow and/or solid organs.

VI. Anatomy of the Genitourinary System

A. The genitourinary system controls reproductive functions and waste discharge.

You are dispatched to a local bar where your patient, a 26 year old man, was involved in an altercation. He has several superficial lacerations to his arms, and a knife, is impaled in his right upper quadrant. He is lying supine on the floor. He is alert. The bar patrons tell you that he did not fall, but they they helped him to the floor. How would you best manage this patient?

Asses the patient's ABCs and apply high flow oxygen or a bag valve mask if needed. Control any bleeding. Stabilize the knife in place with bulky dressing - do not remove it. Keep movement of the patient to the bare minimum so as not to create further injury. Sliding the patient very carefully onto a backboard may help to minimize movement. Monitor vital signs, and provide rapid transport. Keep warm and treat for shock if signs and symptoms present. Bandage minor lacerations en route.

Rectal bleeding

Bleeding from the rectum may present as blood stains or blood soaking through underwear of patients may report blood in the toilet after a a bowel movement. Significant rectal bleeding can occur after hemorrhoid surgery and can lead to significant blood loss and shock.

You are dispatched to a construction site, where a man has fallen onto a piece of rebar. You arrive to find a man sitting on the ground with his legs drawn toward his chest. He tells you that he fell from a ladder onto a piece of rebar. He says, "Something's sticking out of me." As you visualize his abdomen, you can clearly see a portion of his bowel on the outside of his body. How would you best manage this patient?

Cover the abdomen and the portion of the protruding bowel with a moistened, sterile dressing and or an occlusive dressing. Secure these dressings with tape. Allow the patient to dray up his knees as needed for comfort. Apply high flow oxygen, cover the patient to preserve warmth, treat for shock as needed, and promptly transport to the hospital.

Your patient has his penis caught in his zipper. What do you need to do to relieve pressure?

Cut the zipper out of the pants

Kidney injuries

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 prompt transport to the hospital, monitoring the patient's vital signs carefully en route.

Genitalia injuries

Direct pressure with a dry, sterile dressing usually control any external hemorrhage. Lacerations, abrasions, and avulsions should be treated with moist, sterile compresses. Contusions and other blunt injuries all require careful in hospital evaluation. However, the urgency for transport will be determined by associated injuries, the amount of hemorrhage, and the presence of shock.

You are dispatched to assist police with a mentally ill patient who has threatened harm to himself and others. Police officers found the man running around his home with a knife and blood all over his lower body. The man tells you "the voices" told him to cut off his penis. How would you best manage this patient?

Ensure that the scene is safe. Quickly visualize the area to determine how badly he has cut himself and whether he has in fact amputated any portion of his penis. You will need to control bleeding because blood loss in this area can be significant. Use direct pressure and or pressure dressings to control bleeding. If a portion of the penis is amputated, wrap it in a moist, sterile dressing, place it in a plastic bag, and transport it in a cooled container. Do not allow it to come in direct contact with ice. Provide high flow oxygen and prompt transport. Also, request the presence of a police officer during transport because this patient will likely need to be restrained and could be unpredictable during transport.

Sexual assault

Follow local protocol for crime scene management and evidence preservation. If available, and E.M.T. of the same gender as the patient should perform the assessment and treatment. Advise the patient not to change clothes, shower, drink, or eat. Maintain patient privacy at all times. On some occasions, patients will have sustained multiple system trauma and will also need treatment for shock. D not examine the genitalia unless obvious bleeding must be managed.

List the solid organs of the abdomen and urinary system

Liver, spleen pancreas, adrenal glands, ovaries, and kidneys

Blunt abdominal injuries

Log roll the patient to a supine position on a backboard. If the patient vomits, turn him to one side and clear the mouth and throat of vomitus. Monitor the patient's vital signs for any indication of shock. If signs of shock are present, administer high flow supplemental oxygen via a nonrebreathing mask, or a bag valve mask if needed, and treat for shock. Keep the patient warm. Provide rapid transport to the emergency department.

Abdominal evisceration

Never attempt to replace protruding organs. Cover the exposes organs with a moist, sterile dressing. If local protocol allows, cover the sterile dressing with an occlusive dressing. Maintain body temperature, treat for shock, and transport to the highest level trauma center available.

Penetrating abdominal injuries

Patients with penetrating injuries generally have obvious wounds and external bleeding; however, significant external bleeding is not always present. As an E.M.T., you should have a high index of suspicion that the patient has serious unseen blood loss occurring inside the body. Inspect the patient's back and side for exit wounds, and 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 to minimize movement of the object.

Urinary bladder injuries

Suspect a possible injury of the urinary bladder if you see blood at the urethral opening or physical signs of trauma on the lower abdomen, pelvis, or perineum. There may be blood at the tip of the penis or a stain on the patient's underwear. The presence of associated injuries or of shock will dictate the urgency of transport. In most instances, provide prompt transport, and monitor the patient's vital signs en route.

VII. Injuries of the Genitourinary System A. Kidney injuries 1. Not unusual and rarely occur in isolation

a. A forceful blow or penetrating injury is often involved. b. Less significant injuries can result from an indirect blow or even a football tackle.

6. Transport decision

a. Abdominal injuries generally indicate a quick transport to the hospital. i. A delay in medical evaluation may result in an unnecessary and dangerous progression of shock. b. Patients with abdominal injuries should be evaluated at the highest level of trauma center available.

D. Open abdominal injuries 1. Injuries in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside

a. Also called penetrating injuries b. Stab wounds and gunshot wounds are examples. c. Open wounds can be deceiving; therefore, you should maintain a high index of suspicion for unseen injuries, internal damage to organs, and potential life-threatening injuries.

D. History taking 1. Clarify the chief complaint and MOI.

a. Also identify associated signs and symptoms and pertinent negatives. i. Note the position in which the patient is lying. b. Movement of the body or the abdominal organs irritates the inflamed peritoneum, causing additional pain. i. To minimize this pain, patients will lie still, usually with their knees drawn up. ii. Breathing will be rapid and shallow.

2. Suspect kidney damage if the patient has a history or physical evidence of any of the following:

a. An abrasion, laceration, or contusion on the flank b. A penetrating wound in the region of the lower rib cage and above the hip (flank) or the upper abdomen c. Fractures on either side of the lower rib cage or of the lower thoracic or upper lumbar vertebrae d. A hematoma in the flank region

5. Transport decision

a. Any injury to the genitourinary system can be life altering. i. Often requires medical specialist for specialized care

8. Direct blows to the scrotum can result in the rupture of a testicle or significant accumulation of blood around the testes.

a. Apply an ice pack to the scrotal area during transport.

E. Rectal bleeding 1. Common complaint

a. Bleeding from the rectum may present as blood in or soaking through undergarments, or may be passed into the toilet with a bowel movement.

B. Urinary bladder 1. Suspect a urinary bladder injury if you see:

a. Blood at urethral opening b. Signs of trauma to the lower abdomen, pelvis, or perineum

3. Both blunt and penetrating trauma can cause hollow organ injuries.

a. Blunt trauma causes the organ to "pop," releasing fluids and air. b. Penetrating trauma causes direct injury, such as lacerations and punctures.

3. The spleen and pancreas are also very vascular.

a. Both are prone to heavy bleeding when fractured, lacerated, or punctured. b. The spleen is often injured from: i. Motor vehicle collisions, especially in cases of improperly placed seatbelts ii. Steering wheel trauma iii. Falls from heights or onto sharp objects iv. Bicycle and motorcycle accidents where the patient hits the handlebars on impact.

5. The kidneys can also be impacted or penetrated by trauma.

a. Can cause significant amounts of blood loss b. Common finding is blood in the urine (hematuria) c. Blood visible on inspection of the urinary meatus indicates significant trauma to the genitourinary system.

3. Significant rectal bleeding can occur after hemorrhoid surgery.

a. Can lead to significant blood loss and shock

D. History taking 1. Investigate chief complaint.

a. Common associated complaints with genitourinary injuries are: i. Nausea and vomiting ii. Diarrhea iii. Blood in urine (hematuria) iv. Vomiting blood (hematemesis) v. Abnormal bowel and bladder habits

3. Communication and documentation

a. Communicate all relevant information to staff at the receiving hospital. b. Document the results of the physical examination and any pertinent negatives. c. It is imperative that you be able to describe the scene in enough detail to give the trauma team a clear idea of the circumstances. d. Be cautious and diligent when dealing with patients who refuse transport after sustaining an injury to the abdomen or genitourinary system. i. These patients are at high risk for complications.

3. Communication and documentation

a. Communicate your concerns to the hospital staff. b. Describe all injuries and treatment given. c. Documentation should be complete and thorough.

4. Airway and breathing

a. Ensure that the patient has a clear and patent airway. b. If a spinal injury is suspected, prevent the patient from moving. c. Clear the airway of vomitus so it is not aspirated into the lungs. i. Note the nature of the vomitus. d. A distended abdomen may prevent adequate inhalation. i. Providing supplemental oxygen will help improve oxygenation

3. Airway and breathing

a. Ensure that the patient has a clear and patent airway. i. Protect the patient from further spinal injury if trauma was involved. b. If patient is unresponsive or has a significant altered level of consciousness, consider inserting an oropharyngeal airway or nasopharyngeal airway.

B. Open abdominal injuries 1. Patients with penetrating injuries

a. Generally obvious wounds and external bleeding; however, significant external bleeding is not always present b. Maintain a high index of suspicion for serious, unseen blood loss. i. Only a surgeon can accurately assess the damage. ii. You should assume the object has penetrated the peritoneum and possibly injured organs. c. Follow the general procedures described previously for care of a blunt abdominal injury, as well as: i. Inspect the patient's back and sides for an exit wound. ii. Apply a dry, sterile dressing to all open wounds. iii. If the penetrating object is still in place, apply a stabilizing bandage around it to control external bleeding and to minimize movement of the object. d. Severe lacerations of the abdominal wall may result in evisceration. i. Internal organs or fat protrude through the wound ii. Never try to replace a protruding organ. (a) Keep the organs moist and warm. (b) Cover the wound with moistened, sterile dressings. (c) Secure the dressing with a bandage. (d) Secure the bandage with tape.

4. Circulation

a. Genitourinary system can be a significant source of bleeding. i. Assess pulse rate and quality. ii. Determine skin condition, color, and temperature. iii. Check capillary refill time. b. Closed injuries do not have visible signs of bleeding. i. Shock may be present. ii. Assessment of pulse and skin will indicate how aggressively to treat for shock. c. Control bleeding if visible bleeding is seen. i. Significant bleeding is a life threat and must be controlled quickly.

E. Secondary assessment 1. Physical examinations

a. Genitourinary system injuries can be awkward to assess and treat. i. Privacy is a genuine concern. b. When the patient has an isolated injury, focus on that and the body region affected. c. Look for DCAP-BTLS. d. Identify wounds and control bleeding. e. For significant trauma, start with a full-body scan to see if there is trauma affecting multiple systems. i. Presence of penetrating injury indicates possible internal injury that should be managed accordingly. ii. Presence of burns must be noted and managed immediately. iii. Palpate for tenderness to localize the injury and presence of fractures. iv. Look for lacerations and local swelling.

C. Primary assessment 1. Quickly scan the patient to identify and treat life threats.

a. Genitourinary system is very vascular. i. Injuries can produce a significant volume of blood. b. Do not avoid this area in the rapid scan. i. Life-threatening hemorrhage must be addressed immediately. ii. If bleeding is present, maintain privacy for the patient and inspect exterior genitals for visible injury.

IX. Emergency Medical Care of Genitourinary Injuries A. Kidneys 1. Damage may not be obvious upon inspection.

a. However, you will see: i. Signs of shock ii. Blood in the urine (hematuria)

2. Form a general impression.

a. Important indicators will alert you to the seriousness of the patient's condition. b. Trauma patients with closed abdominal injuries may have what appear to be minor injuries. You should not be distracted from looking for more serious hidden injuries. c. Check for responsiveness using the AVPU scale. i. Provide high-flow oxygen via nonrebreathing mask to all patients whose level of consciousness is less than alert and oriented. ii. Unresponsiveness may indicate a life-threatening condition.

4. Injuries are painful but generally not life threatening

a. In-hospital evaluation required b. Transport urgency is determined by associated injuries, the amount of hemorrhage, and the presence of shock.

2. External female genitalia

a. Includes the vulva, clitoris, and the major and minor labia at the entrance of the vagina b. Very rich nerve supply, so injuries are very painful c. Vaginal bleeding may occur because of penetrating or blunt trauma. d. Consider sexual assault and pregnancy. i. Ask patient about last known menstrual period. ii. Ask about sexual history. iii. Assume all women of childbearing age are possibly pregnant. (a) This information is relevant because some medications and tests are harmful for a fetus. e. In cases of external bleeding and trauma, a sterile absorbent sanitary napkin or pad may be applied to the labia. f. Do not insert instruments, gloved fingers, or a tampon into the vagina. i. Can cause further damage

2. Hollow organs commonly spill contents into the abdomen.

a. Infection develops, which can take hours or days. b. Stomach and intestines can leak highly toxic and acidic digestive liquids into the peritoneal cavity.

C. External male genitalia 1. A few general rules for the treatment of injuries to the external male genitalia:

a. Injuries are painful; make the patient comfortable. b. Use sterile, moist compresses to cover areas stripped of skin. c. Apply direct pressure with dry, sterile gauze dressings to control bleeding. d. Never move or manipulate foreign objects in the urethra. e. Identify and take avulsed parts to the hospital with patient. i. If patient has an avulsion of skin on the penis: (a) Wrap the penis in a soft, sterile dressing moistened with sterile saline. (b) Transport promptly. (c) Use direct pressure to control any bleeding. (d) Try to save and preserve the avulsed skin.

4. If the MOI suggests an isolated injury to the abdomen, focus your physical examination on the injured area only.

a. Inspect the skin of the abdomen for wounds through which bullets, knives, or other missile-type foreign bodies may have passed. i. If you find an entry wound, you must always check for a corresponding exit wound. b. Do not attempt to remove a knife or other impaled object. i. Instead, stabilize the object with supportive bandaging.

1. Organs of the genitourinary system are located in the abdomen

a. Kidneys are solid organs. b. Ureters, bladder, and urethra are hollow organs.

6. Urethral injuries in the male are not uncommon.

a. Lacerations of the urethra can result from: i. Straddle injuries ii. Pelvic fractures iii. Penetrating wounds of the perineum b. It is important to know if the patient can urinate and if there is blood in the urine. i. Save any urination for later examination at the hospital. c. Any foreign bodies protruding from the urethra will have to be surgically removed.

4. Accidental laceration of the head of the penis is associated with heavy bleeding

a. Local pressure with a sterile dressing usually stops the hemorrhage.

2. Mechanism of injury/nature of illness

a. Look for indicators of the MOI. i. Consider information from dispatch, your observations of the scene, and the MOI to help develop your list of expected injuries. ii. Patient may avoid the discussion to avoid undergoing a physical examination. iii. Patient may also provide an MOI that seems "less embarrassing" than the actual MOI.

2. The velocity of the object can help predict the amount of damage to tissue

a. Low-velocity injuries i. Caused by handheld or hand-powered objects, such as knives and other edged weapons b. Medium-velocity injuries i. Caused by smaller caliber handguns and shotguns c. High-velocity injuries i. Caused by larger weapons, such as high-powered rifles and higher-powered handguns d. High- and medium-velocity injuries have temporary wound channels in addition to exit and entrance wounds. i. Caused by cavitation (a) A cavity forms as the pressure wave from the projectile is transferred to the tissues. (b) Causes microscopic tears to the blood vessels and nerves (c) Can produce a large amount of bleeding ii. The higher the velocity of the projectile, the larger the cavity it produces. e. Low-velocity penetrations also have the capacity to damage underlying organs. i. Internal injury may not be apparent during physical examination. (a) Bleeding may hide the fact that the object went farther and deeper into the peritoneal cavity and injured other organs and tissues. ii. Any time a patient has an injury at or below the xiphoid process, it should be assumed that the thoracic and peritoneal cavities have been violated.

2. Interventions

a. Manage airway and breathing problems based on signs and symptoms found during the primary assessment. b. Provide complete spinal immobilization to the patient with suspected spinal injuries. c. If the patient has signs of hypoperfusion, provide aggressive treatment for shock and rapid transport. d. If an evisceration is found, place a saline-moistened dressing over the wound and transport. i. Never attempt to push eviscerated tissue or organs back into the abdominal cavity. e. A patient with a ruptured diaphragm may have an abdomen with a sunken anterior wall. i. These patients should receive positive-pressure ventilations with a bag-valve mask.

2. Amputation of penile shaft

a. Managing blood loss is the top priority. i. Use local pressure with a sterile dressing on the remaining stump. b. Never apply a constricting device. c. Surgical reconstruction is possible if you can locate the amputated part. i. Wrap it in a moist, sterile dressing. ii. Place it in a bag. iii. Transport it in a cooled container without it directly touching ice.

3. Obtain vital signs

a. Many abdominal emergencies can cause a rapid pulse and low blood pressure. b. Your record of vital signs will help you identify changes in the patient's condition. c. Use appropriate monitoring devices when available. i. Pulse oximetry ii. Noninvasive blood pressure devices iii. It is recommended that you always assess the patient's first blood pressure manually with a sphygmomanometer and stethoscope.

2. The hollow organs of the abdomen include the stomach, intestines, ureters, and bladder.

a. Most of these organs contain food that is in the process of being digested, urine that is being passed to the bladder for release, or bile. i. When ruptured or lacerated, the contents spill into the peritoneal cavity. (a) Can cause an intense inflammatory reaction and possible infection (b) Peritonitis is an inflammation of this type. (1) Serious and may become life threatening (2) Signs include severe abdominal pain, tenderness, and muscular spasm. b. Intestinal blood supply comes from the mesentery (fold of tissue that connects the small intestine to the abdominal wall). i. Patients with injuries to the mesentery can bleed significantly into the peritoneal cavity. ii. Signs of this include abdominal rigidity and periumbilical bruising.

5. Skin of shaft or foreskin can get caught in the zipper of pants.

a. Not uncommon event b. If small segment of the zipper is involved, you can try to unzip the pants. c. If a longer segment is involved, use heavy scissors to cut the zipper out of the pants to make the patient more comfortable. i. Explain what you are going to be cutting. ii. Be careful not to injure the scrotum while cutting.

2. Vital signs

a. Obtain the patient's vital signs. i. It is important to reassess vital signs to identify how quickly the patient's condition is changing. ii. Signs such as tachycardia; tachypnea; low blood pressure; weak pulse; and cool, moist, and pale skin indicate hypoperfusion. (a) Evaluate the need for rapid transport. b. Use pulse oximetry and noninvasive blood pressure devices when available

4. If the diaphragm is penetrated or ruptured, loops of bowels may herniate into the thoracic cavity.

a. Patients may exhibit dyspnea (feel short of breath).

4. Signs and symptoms of an open injury

a. Patients with abdominal injury complain of pain. b. Common sign of significant abdominal injury is tachycardia i. The heart is increasing its pumping action to compensate for blood loss. c. Later signs include: i. Evidence of shock, such as decreased blood pressure and pale, cool, moist skin ii. Changes in patient's mental status iii. Abdomen may become distended from accumulation of blood and fluid. d. A patient may have both closed and open injuries. i. Blunt injuries should guide your attention to underlying structures. ii. Bruises in the RUQ may suggest injury to the liver. iii. Bruises in the LUQ may suggest injury to the spleen. iv. Bruises to the flank may suggest injury to the kidney. v. Bruises around the umbilicus, called Cullen's sign, are predictive of significant internal abdominal bleeding.

7. Avulsion of the skin of the scrotum may damage the scrotal contents.

a. Preserve the avulsed skin in a moist sterile dressing for possible use in reconstruction. b. Wrap the scrotal contents or the perineal area with a sterile moist compress, and use a local pressure dressing to control bleeding.

3. A patient with a blunt abdominal injury should be log rolled to a supine position on a backboard.

a. Protect the spine. b. Monitor the patient's vital signs for any indication of shock and treat appropriately

2. Interventions

a. Provide oxygen if there are signs of dyspnea or shock and maintain a patent airway. b. Attempt to control bleeding and treat for shock. c. Place patient in position of comfort and transport.

F. Reassessment 1. Repeat the primary assessment and vital signs.

a. Reassess the interventions and treatment you have provided.

2. Physical examinations

a. Remove or loosen clothes to expose injured regions of the body. i. Inspect the patient for bleeding before removing the clothing to prevent damaging exposed tissues. ii. Provide privacy or perform in the back of the ambulance.

2. A patient with blunt abdominal wounds may have:

a. Severe bruising of abdominal wall b. Liver and spleen laceration c. Rupture of intestine d. Tears in mesentery e. Rupture of kidneys or avulsion of kidneys from their arteries and veins f. Rupture of urinary bladder g. Severe intra-abdominal hemorrhage h. Peritoneal irritation and inflammation

3. If the connective tissue surrounding the erectile tissue is severely damaged, the shaft can be fractured or severely angled.

a. Sometimes requires surgical repair b. Injury may occur during particularly active sexual intercourse. c. Associated with intense pain, bleeding into the tissues, and fear.

2. Some MOI examples:

a. Steering wheel b. Bicycle handlebars c. Motorcycle collisions d. Falls e. Blast injuries f. Pedestrian injuries g. Compression i. Typically caused by a poorly placed lap belt ii. Creates an injury pattern called a clasp-knife injury iii. Can also be caused when a person is run or rolled over by vehicles or objects h. Deceleration i. Person or the vehicle that he or she is traveling in strikes a large, immovable mass such as a larger vehicle, a bridge abutment, or the ground

5. Circulation

a. Superficial abdominal injuries usually do not produce significant external bleeding. i. Internal bleeding can be profound. ii. Trauma to the liver, kidneys, and spleen can cause significant internal bleeding. b. Evaluate pulse, skin color, temperature, and condition to determine the stage of shock. c. Treat aggressively if the patient is in shock.

2. The genital system controls reproductive processes.

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

V. Emergency Medical Care of Abdominal Injuries A. Closed abdominal injuries 1. The EMT's biggest concern is not knowing the true extent of the closed abdominal injury.

a. The patient requires rapid transport to the nearest and highest level of care, primarily to a trauma center with a surgeon b. Position the patient for comfort. c. Apply high-flow oxygen if the patient has signs of hypoxia or shock. d. Treat for shock.

D. Female genitalia injuries 1. Internal female genitalia

a. The uterus, ovaries, and fallopian tubes are rarely damaged. i. Small, deep in the pelvis, and well protected b. Exception is the pregnant uterus i. Uterus enlarges substantially and rises out of the pelvis. ii. Injuries can be serious because the uterus has a rich blood supply during pregnancy. iii. Also keep the fetus in mind. iv. In last trimester of pregnancy, the uterus is large and may obstruct the vena cava. (a) Blood pressure may decrease. (b) Patient should be placed on her left side so the uterus will not lie on the vena cava.

4. The gallbladder and the urinary bladder are hollow organs whose contents (bile and urine) are potentially irritating and damaging if ruptured.

a. These fluids move into loose spaces and voids in the peritoneal cavity, eventually leading to infection.

3. The solid organs of the abdomen include the liver, spleen, pancreas, and kidneys

a. These organs perform the chemical work of the body. i. Enzyme production ii. Blood cleansing iii. Energy production b. Because of their rich blood supply, hemorrhage of solid organs can be severe.

3. In evisceration, bowel protrudes from the peritoneum.

a. This can be extremely painful and is also visually shocking. b. Do not push down on the patient's abdomen. c. Only perform a visual assessment when there is any suspicion of this type of injury. d. Cut clothing close to the wound. e. Never pull on any clothing stuck to or in the wound channel.

B. Urinary bladder injuries 1. May result in rupture

a. Urine spills into surrounding tissues. b. Blunt injuries to lower abdomen or pelvis can cause rupture to the urinary bladder, particularly when the bladder is full and distended. c. Penetrating wounds of the lower mid-abdomen or the perineum can directly involve the urinary bladder.

2. SAMPLE history

a. Use OPQRST to help explain an abdominal injury. b. Ask if the patient has experienced any nausea, vomiting, or diarrhea. i. How many times and over what period c. Ask about the appearance of any bowel movements and urinary output. i. Determine if there was any blood in the urine or black, tarry stools (melena). ii. This will help determine if the patient has gastrointestinal bleeding and if there is bleeding in the lower intestinal tract.

2. SAMPLE history

a. Use OPQRST to learn about the patient's pain. b. Ask patient about output from the genitourinary system. i. Especially blood in the urine c. Ask about allergies to medications or environmental triggers. d. The importance of past medical history cannot be overstated. i. Repeated or previous injuries or illness can help determine the extent of the current injury or illness. e. Last intake of food and fluids is important because it can predict the genitourinary system's contents. f. Address the events leading up to the injury.

D. Female genitalia 1. Treat lacerations, abrasions, and avulsions with moist, sterile compresses.

a. Use local pressure to control bleeding. b. Hold dressings in place with diaper-type bandage.

5. Free air in the peritoneal cavity produces pain.

a. Usually indicates that a hollow organ or loop of bowel has perforated b. If not rapidly identified and repaired, severe infection and septic shock may develop

2. The liver is the largest organ in the abdomen.

a. Very vascular and can contribute to hypoperfusion if injured b. Often injured by a fractured lower right rib or a penetrating trauma c. A common finding during assessment of patients with an injured liver is referred pain to the right shoulder.

C. Injuries from seatbelts and air bags 1. Seatbelts have prevented many injuries and saved many lives, but they occasionally cause blunt injuries to the abdominal organs.

a. When worn properly, a seatbelt lies below the anterior superior iliac spines of the pelvis and against the hip joints. i. If belt lies to high, it can squeeze abdominal organs or great vessels against the spine when the car decelerates or stops. b. Can cause bladder injuries to pregnant patients who adjust the lap belt for comfort. c. In all current-model vehicles, lap and diagonal belts are combined so they cannot be used independently. i. People can still put the shoulder belt behind their backs.

C. Primary assessment 1. First perform a rapid scan.

a. Will help establish the seriousness of the patient's condition b. Some abdominal injuries will be obvious and graphic, but most will be very subtle and will go unnoticed. c. Remember that in some cases of abdominal injuries, the injury may have occurred hours or days earlier.

peritoneal cavity

abdomimal cavity

Blood may irritate the peritoneal cavity and cause the patient to report

abdominal pain

f. Closed abdominal injuries may initially appear as

abrasions.

3. In trauma patients, life-threatening external hemorrhage must be addressed before

airway or breathing concerns.

Whenever possible, you should always provide the sexual assault patient with

an attendant of the same gender

e. The RLQ is a common location for swelling

and inflammation

hematuria

blood in the urine

Closed abdominal injuries are also known as

blunt injuries

guarding

contracting stomach muscles to minimize pain

When treating a patient with an amputation of the penile shaft, your top priority is

controlling bleeding

When treating a patient with an evisceration, you should

cover the protruding contents with moist, sterile gauze compresses

e. Additional signs of abdominal injury are bruising and

discoloration.

evisceration

displacement of organs outside the body

Patients with peritonitis will want to lie still with their legs

drawn up

You have a male patient who has no immediate life threat but does have bleeding genitalia. You should bandage with a

dry dressing

One of the most common signs of a significant abdominal injury is an

elevated pulse rate

An open wound that allows internal organs or fat to protrude through the wound is called

evisceration

The displacement of organs outside the body

evisceration

The urinary system is responsible for

filtering waste

The posterior region below the margin of the lower rib cage

flank

The region below the rib cage and above the hip is called the

flank

Contracting the stomach muscles to minimize the pain of abdominal movement

guarding

Structures through which materials pass, such as the stomach, small intestines, large intestines, ureters, and bladder

hallow organs

The spleen is often injured during motor vehicle collisions, especially in the case 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

Because solid organs have a rich supply of blood, any injury can result in major

hemorrhaging

2. Treat for shock, transport promptly, and monitor vital signs en route to the

hospital.

f. Perform a full-body scan to identify injuries other than abdominal injuries

i. Begin with the head and finish with the lower extremities, moving in a systematic manner. (a) Goal is to identify the presence of other injuries, not the extent of those injuries ii. If you find a life-threatening issue, stop and treat it immediately. iii. Assess the patient's need for spinal immobilization and apply per local protocol.

c. Determining the location of the pain or referred pain can be difficult when the patient has voluntary or involuntary guarding

i. Conscious or unintentional stiffening of the muscles of the surface of the abdomen to avoid further pain ii. May be mistaken for abdominal rigidity

c. Examine the entire abdomen, including all posterior, anterior, and lateral surfaces.

i. Critical step for patients with an entrance wound

g. Inspect and palpate the kidney area for tenderness, bruising, swelling, or other signs of trauma.

i. Hollow organs will spill their contents into the peritoneal cavity. ii. These injuries will typically present as diffuse pain with guarding and reaction to sudden jarring movements.

d. Use DCAP-BTLS to help identify specific signs and symptoms of injury.

i. Inspect and palpate the abdomen for the presence of deformities. ii. Look for the presence of contusions and abrasions. iii. Puncture wounds and other penetrating injuries cannot be overlooked; the intra-abdominal extent of these injuries may be life threatening. iv. Note the presence of burns. v. Palpate for tenderness and attempt to localize to a specific quadrant of the abdomen. vi. Treat lacerations with appropriate dressings. vii. Swelling may involve the abdomen globally and indicate significant intra-abdominal injury.

d. Organs found in the RLQ:

i. Large and small intestines ii. The ascending colon and the right half of the transverse colon iii. The appendix

a. Organs commonly found in the RUQ:

i. Liver ii. Gallbladder iii. Duodenum of the intestines iv. Small portion of the pancreas

3. Signs and symptoms of a closed injury a. Pain can be deceiving.

i. Often diffuse in nature ii. May be referred to another body location (a) Liver and spleen injuries refer pain to the shoulder. iii. Tearing pain from the abdomen posteriorly may be dissected aneurysm. iv. Pain 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. v. Pain located in the RLQ can indicate an inflamed or ruptured appendix. vi. Pain under the margin of the ribs on the right side or between the shoulder blades can indicate an injury to the gallbladder.

b. Blood or fluid in the peritoneal cavity produces acute pain in the entire abdomen

i. Pain spreads as the blood or contaminant seeks out the voids in the peritoneal cavity. ii. Often a jarring motion (rebound tenderness or Blumberg sign) will alert the patient to the peritonitis or inflammation of the peritoneum

e. Palpate the abdomen when examining the region.

i. Palpate the quadrant farthest away from the quadrant that is exhibiting signs and symptoms of injury and pain. ii. This technique allows you to investigate the possibility of radiation and extension of the pain into other quadrants.

b. Organs found in the LUQ:

i. Stomach ii. Spleen

c. Organs found in the LLQ:

i. The descending colon ii. The left half of the transverse colon

b. Patient should be able to stay in a position of comfort unless spinal injury is suspected.

i. Will relieve some of the tension ii. Place padding under the knees of a patient with a suspected spine injury. (a) Can worsen pain if you are too aggressive iii. Fetal position may be the position of most comfort for a patient without spinal injury.

2. Form a general

impression.

open abdonimal injury

injury in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside

Swelling may involve the entire abdomen and indicates significant

intra abdominal injury

In any case of trauma to a female patient, you should always determine if the patient

is pregnant

You respond to an 18 year old high school football player who was hit in the right flank with a helmet several hours ago. He is complaining of pain in the area. He is alert and oriented. His airway is open, and his respirations are within normal limits. His pulse is rapid and regular. He has a radial pulse. He tells you that he is noticing blood in his urine. Based on this information, the patient is likely to have an injury to the

kidney

The solid organs of the urinary system include the

kidneys

The largest organ in the abdomen is the

liver

solid organs

liver, pancreas, spleen

Your primary concern when dealing with an unresponsive patient with an open abdominal injury is

maintaining the airway

black, tarry stools

melena

If you are treating a patient with an abdominal evisceration, you should use a

moist, sterile dressing

2. If shock or associated injuries are present, transport promptly and

monitor vital signs en route.

Late signs of peritonitis may include

nausea

Peritoneal irritation is in response to hollow

organ injury

A penetrating wound that reaches the kidneys almost always involves

other organs

Patients with open abdominal injuries often complain of

pain

The major complaint of patients with abdominal injury is

pain

Open abdominal injuries are also known as

penetrating injuries

d. Abdominal distention or swelling between the xiphoid process and the groin is often the result of free fluid, blood, or organ contents spilling into the

peritoneal cavity

the abdominal cavity is known as the

peritoneal cavity

Peritonitis is an inflammation of the

peritoneum

When ruptured, the organs of the abdominal cavity can spill their contents into the peritoneal cavity, causing an intense inflammatory reaction called

peritonitis

You have a patient with suspected kidney injury but no spinal injury. How should he be positioned?

position of comfort

Any air in the peritoneal cavity seeks the most superior space or void; thus, the location of the hair can change with

positioning of the patient

flank

posterior region below the margin of the lower rib cage

In a closed abdominal injury, there is a break in the surface of the skin or mucous membrane, exposing deeper tissue to

potential contamination

The abdomen is divided into four

quadrants

C. Do not examine the genitalia unless obvious bleeding

requires application of a dressing.

kidneys are located in the

retroperitoneal space

f. The appendix is a source of infection, and can cause severe infection or septic shock if it

ruptures.

Blunt abdominal injuries may result from

seat belts

In a closed abdominal injury, there is soft tissue damage inside the body, but the

skin remains intact

closed abdominal injury

soft tissue damage inside the body, but the skin remains intact

Energy production takes place in the

solid organs

Severe bleeding may occur with injury to

solid organs

Solid masses of tissue where much of the chemical work of the body takes place

solid organs

3. Leave any foreign bodies in place after

stabilizing with bandages.

List the hollow organs of the abdomen and urinary system

stomach, intestines, ureters, bladder, gallbladder, bile duct, appendix, uterus, fallopian tubes, and rectum

hollow organs

stomach, small intestine, ureters

A very common early sign of a significant abdominal injury is

tachycardia

3. In later trimesters of pregnancy, bladder injuries increase from displacement of

the uterus.

2. The quadrant location of bruising or pain can delineate which organs are possibly involved in a

traumatic injury.

2. Possible causes include sexual assault, rectal foreign bodies, hemorrhoids, colitis, and

ulcers in the digestive tract.

2. In males, sudden deceleration from a motor vehicle or motorcycle crash can shear the bladder from the

urethra.

In cases of sexual assault, advise the patient not to wash,

urinate, or defecate

2. Do not pack dressings into the

vagina.