EMT: Chapter 30 [abdominal and genitourinary injuries]

evisceration

an open abdominal injury that goes through the skin and muscle layer and through the interior abdominal covering only perform visual assessment of these wounds

An unresponsive trauma patient has a large open abdominal wound with massive external bleeding. You should:

apply direct pressure to the wound

Other than applying a moist, sterile dressing covered with a dry dressing to treat and abdominal evisceration, an alternative form of management may include: Other than applying a moist, sterile dressing covered with a dry dressing to treat and abdominal evisceration, an alternative form of management may include:

applying an occlusive dressing, secured by trauma dressings

Injuries to the external male genitalia _______.

are rarely life-threatening

A 20-year-old male was accidentally shot in the right upper abdominal quadrant with an arrow during an archery contest. Prior to your arrival, the patient removed the arrow. Your assessment reveals that he is conscious and alert with stable vital signs. The entrance wound is bleeding minimally and appears to be superficial. You should:

assume that the arrow injured an internal organ

When documenting a call involving a female patient who was sexually assaulted, the EMT should:

avoid speculation and document only factual data

What is the proper positioning of a seatbelt?

below the anterior superior iliac spines of the pelvis and against the hip joints

melena

black, foul-smelling, tarry stool containing digested blood

hematuria

blood in the urine

A football player was struck by another player in the right flank area just below the posterior rib cage. He complains of severe pain and point tenderness to the area. Your assessment reveals that there is a small amount of blood in his underwear. You should be MOST suspicious for:

blunt injury to the kidney

hollow organ injuries

blunt trauma: hollow organs can "pop" (release fluids or air) penetrating trauma: direct injury via laceration, puncture symptoms: - intense pain out of character for size of injury - signs of peritonitis due to emptying bile/urine/etc. content - signs of free air in cavity due to perforation

urinary bladder

blunt/penetrating injuries may result in rupture, especially if bladder is full (and distended) may result from: - pelvic fracture - penetrating wounds to lower-mid abdomen - sudden deceleration (in men) causing shearing from bladder from urethra - pregnancy in 2nd-3rd trimesters

kidneys

blunt/penetrating injuries to kidneys never in isolation may result from any direct blows high index of suspicion: - abrasion, laceration, contusion in flank - penetrating wound in flank or upper abdomen - lower rib cage fractures - hematoma in flank region

primary assessment

breathing: - keep airway clear of vomitus so that it is not aspirated into the lungs *note nature of vomitus (undigested food, blood, mucus, bile) - realize a distended abdomen/pain may prevent adequate inhalation transport indicated for any patient who.. - has a MOI w/ high index of suspicion - any visible trauma (blunt or penetrating) - abdominal pain with an MOI w/ high index of suspicion

compression injuries

caused by a poorly placed lap belt "clasp-knife injury": injury pattern caused by exaggerated resistance of muscles similar to opening of a clasp knife

assessment of an isolated abdominal injury

caused by bullet, knife, missile-type wounds - always look for entrance AND exit wounds - high-velocity missile = small entrance wound, erupting exit wound

The temporary wound channel caused by high-velocity weapons is called _______.

cavitation

large intestine

cecum, colon, rectum

You are transporting a patient with blunt abdominal trauma. The patient is unstable and is experiencing obvious signs and symptoms of shock. Your estimated time of arrival at the hospital is less than 10 minutes. After treating the patient appropriately, you should:

closely monitor him and reassess him frequently

scene size-up

consider possible injuries from MOI -- if wound is penetrating: - does object have a serrated, smooth or jagged edge? - is it clean or dirty? - how long is it?

Your presence is requested by law enforcement to assess a 33-year-old female who was sexually assaulted. The patient is conscious and obviously upset. As you are talking to her, you note an impressive amount of blood on her clothes in the groin area. Her blood pressure is 98/58 mm Hg, her pulse is 130 beats/min, and her respirations are 24 breaths/min. You should:

control any external bleeding, administer O2, and transport at once

A man has a large laceration across his lower abdominal wall and a loop of bowel is protruding from the wound. He is conscious and alert and there is minimal bleeding from the wound. You should:

cover the exposed bowel with a moist sterile dressing and then secure it in place with a dry bandage

Difficulty breathing and a sunken appearance of the anterior abdominal wall is MOST indicative of a ruptured:

diaphragm

You are assessing a patient who reports pain that is tearing and describes it as going from the abdomen posteriorly. What should you suspect?

dissecting abdominal aneurysm

small intestine

duodenum, jejunum, ileum

_______________ takes place in the solid orans.

energy production

reassessment

evisceration: place a sterile moistened (with saline) dressing over wound BVM pts with ruptured diaphragm document: - physical exam results - pertinent negatives (like no blood loss in stool) - if you passed any step of the physical exam inform hospital of your decisions if assault is suspected

female genitalia

external: vulva, clitoris, labia - painful but not life-threatening injuries - apply sterile absorbent napkins to area - do not insert instruments or gloves into vagina - always assume possibility of pregnancy internal: uterus, ovaries, fallopian tubes - rarely damaged due to internal location risk of internal damage increases with pregnancy - uterus enlarges and rises out of pelvis - damage to uterus can cause massive internal bleeding (due to blood supply) - contractions may begin - ask about delivery date *lie pt on left side so uterus doesn't obstruct vena cava (supine hypotensive syndrome)

What is the most common mechanism of injury in geriatric patients?

falls

A 40-year-old male presents with severe abdominal pain following blunt trauma. He is diaphoretic, intensely thirsty, and has a weak and rapid pulse. Appropriate treatment for this patient includes all of the following, EXCEPT:

giving him small sips of plain water

When a patient stiffens the muscles of the abdomen, it is known as _______.

guarding

A 66-year-old male presents with dark red rectal bleeding and abdominal pain. He is conscious and alert; however, his skin is cool and clammy and his pulse is rapid. Further assessment reveals that his blood pressure is 112/60 mm Hg. Which of the following questions would be MOST pertinent to ask him?

have you experienced recent abdominal trauma?

A sign of kidney damage following blunt trauma is:

hematuria

Which of the following signs would indicate that an injury to the kidney has occurred?

hematuria

Damage to solid organs typically leads to _______.

hemorrhage

Placing a pregnant patient in a supine position during the third trimester of pregnancy:

may decrease the amount of blood that returns to the heart

late signs of peritonitis may include:

nausea

the first signs of peritonitis include all of the following EXCEPT:

nausea

When should you visually inspect the external genitalia on your patient?

only when there is a complaint of severe pain or other injury

Which of the following is an indication of a spleen injury?

referred left shoulder pain

What is the major cause of death following injury to a hollow organ in the abdomen?

sepsis

emergency medical care of open abdominal injuries

signs: - protrusion of bowel, fat, etc. - nausea, vomiting stabilize any penetrating objects never replace an organ protruding from an abdominal laceration - cover with moist sterile dressings - occlusive dressing may be used - keep area warm

Peritonitis will most likely result following injury to the:

stomach

hollow organs

stomach, large and small intestines, ureters, bladder spill contents into peritoneal cavity when ruptured *stomach and intestines spill acid-like substances

left upper quadrant (LUQ)

stomach, spleen, part of pancreas

any air in the peritoneal cavity seeks the most _________ space or void; thus, the location of the air can change with positioning of the patient.

superior

a very common early sign of a significant abdominal injury is:

tachycardia

Which of the following statements regarding intra-abdominal bleeding is false?

the absence of pain and tenderness rules out intra-abdominal bleeding

Which of the following statements is true?

the higher the velocity of a projectile, the larger the cavity it produces

What is the purpose of wrapping a sexual assault victim in a burn sheet?

to preserve potential evidence

seat belt injuries

too high: belt can squeeze abdominal organs or great vessels against spine pregnant patients: more susceptible to bladder injuries due to anterior displacement by uterus

Most of the ________ system lies behind the digestive tract.

urinary

Which of the following organs is at MOST risk for injury as the result of a pelvic fracture?

urinary bladder

When caring for a female trauma to the external genitalia, the EMT should:

use local pressure to control bleeding

Which of the following statements regarding trauma during pregnancy is correct?

uterine trauma is likely to cause shock in the pregnant patient

open abdominal injuries

when a foreign object enters the abdomen and opens the peritoneal cavity

deceleration injuries

when a person or vehicle a person is in strikes an immovable mass

guarding

when patient either consciously or unintentionally stiffens the muscles of the surface of the abdomen in response to abdominal pain

peritonitis

when peritoneum becomes inflamed and painful first signs: - severe abdominal pain - tenderness - muscular spasm later signs: - nausea and vomiting - distended abdomen

closed abdominal injuries

where blunt force trauma results in injury to the abdomen without breaking the skin possible MOIs: - striking the handlebar of a bicycle, steering wheel of a car - being struck by a board/bat - motorcycle crashes - falls - blast injuries - pedestrian injuries - compression - deceleration

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

maintaining the airway

signs of an open injury

1. tachycardia (early sign) 2. signs of shock (decreased BP, changes in patient's mental status, pale/cool/moist skin) 3. trauma to abdomen

signs of abdominal bleeding

**rigidity** - bruising around the belly button - ecchymosis

sexual assault and rape

- do not examine genitalia - document everything - shield scene from onlookers - advise patient not to wash, bathe, shower, etc. until physician has examined them - wrap in sterile burn sheet to preserve any fluids/hairs from offender - place articles of clothing in paper bags - have pt urinate in sterile urine container (can be used for evidence) - same gender EMT

secondary assessment

- do not remove clothes if evisceration present - allow patient to remain in position of comfort (ex. with legs pulled toward abdomen) - examine for entrance wounds @ posterior, anterior, lateral surfaces (remember under armpits) DCAP-BTLS: - inspect/palpate abdomen for deformity - look for contusions and abrasions (point of impact) - do not overlook puncture wounds/penetrating injuries - manage burns - palpate for tenderness; localize to a specific quadrant (start @ furthest quadrant from signs of pain) - apply dressings to lacerations - inspect and palpate flank region (tenderness, bruising, swelling, etc.) - listen to bowel sounds and signs of guarding for hollow organ injuries - palpate back upon logrolling of pt onto their side (*avoid logrolling pts with evisceration to avoid excess protrusion)

signs of abdominal pain

- guarding - abdominal distention between xiphoid process and groin - tenderness - bruising, discoloration - lower rib fractures

DCAP-BTLS of genitourinary injuries

- inspect/visualize region, look for deformities that reveal presence of multiple rib fractures - identify contusions or abrasions - identify penetrating injuries - note presence of burns - palpate for tenderness - look for lacerations and local swelling

complaints associated w/ genitourinary injuries

- nausea and/or vomiting - diarrhea - hematuria - hematemesis - abnormal bowel/bladder habits *ask about presence of these symptoms in history taking

signs of a blunt injury

1. bruises in RUQ, LUQ or flank could be liver, spleen, kidney injuries 2. umbilical bruises

three velocity levels of injury

1. low-velocity: caused by hand-held, hand-powered weapons 2. medium-velocity: caused by smaller caliber handguns, shotguns 3. caused by high-powered rifles or higher-powered handguns high and medium: wound channels caused by cavitation (pressure wave from projectile transferred to tissues) - more cavitation based on higher velocity

history taking

SAMPLE - ask if patient has experienced any nausea, vomiting, diarrhea - ask about appearance and frequency of bowl movements - ask about melena

While inspecting the interior of a wrecked automobile, you should be most suspicious that the driver experienced an abdominal injury if you find:

a deformed steering wheel

You should suspect a kidney injury anytime the patient presents with _______.

a hematoma in the flank region

suspect kidney damage if the patient has a history or physical evidence of all of the following EXCEPT:

a hematoma in the umbilical region

Compression injuries to the abdomen that occur during a motor vehicle crash are typically the result of:

a poorly placed lap belt

Even when seatbelts are worn properly and the airbags deployed, injury may occur to the:

iliac crests

late signs of abdominal injury include all of the following EXCEPT:

increased BP

signs of injury to the kidney may include any of the following EXCEPT:

increased urgency of urination

Which of the following is true regarding injury to the kidneys?

injury to the kidneys usually indicates injury to other organs

You are transporting a 42-year-old male who experienced blunt abdominal trauma. He is receiving oxygen at 12 L/min via a nonrebreathing mask and full spinal precautions have been applied. During your reassessment, you note his level of consciousness has decreased and his respirations have become shallow. You should:

insert an airway adjunct if he will tolerate it and begin assisting his ventilations with a BVM

Abdominal rigidity and periumbilical bruising are signs of _______.

internal bleeding

male genitalia

internal: prostrate gland, seminal vesicles external injuries: - soft-tissue wounds - painful but rarely life-threatening - pain from an injury to the testicles to refer to lower abdomen

Which of the following statements regarding rebound tenderness is correct?

it is often discovered when the patient is jarred or moved suddenly

Management of evisceration injuries includes _______.

keeping the injury moist and warm

A 16-year-old boy was playing football and was struck in the left flank during a tackle. His vital signs are stable however he is in severe pain. You should be most concerned that he has injured his:

kidney

emergency medical care of genitourinary injuries

kidneys - possible bruises/lacerations - signs of shock - hematuria urinary bladder - blood at urethral opening, physical sides of trauma - blood at tip of penis, stain in underwear external male genitalia - cover wounds with sterile, moist dressing - wrap wounds on penis in soft, sterile dressing - never apply a tourniquet to penis due to amputation; always look for missing piece - always save voided urine for later examination - wrap avulsed skin on scrotum with moist, sterile dressing and apply ice in the case of direct blows rectum - blood stains, blood after bowel movement/attempted bowel movement - can be caused by sexual assault, foreign bodies, hemorrhoids (hemorrhoid surgery), colitis, digestive track ulcers

retroperitoneal region

kidneys, ureters, urinary bladder great vessels (abdominal aorta, inferior vena cava)

right lower quadrant (RLQ)

large and small intestines (i.e. ascending colon), appendix

left lower quadrant (LLQ)

large and small intestines (i.e. descending colon)

In pediatric patients, the liver and spleen are _______.

larger in proportion to the abdomen

You are dispatched to a residence for a young female who was kicked in the abdomen. While en route to the scene, you should ask the dispatcher if:

law enforcement is at the scene

You are transporting a patient with possible peritonitis following trauma to the abdomen. Which position will he most likely prefer to assume?

legs drawn up

While assessing a 21-year-old female who struck a tree head-on with her small passenger car, you note that her air bag deployed. You should:

lift the air bag and look for deformity to the steering wheel

Bruising over the right upper quadrant could indicate injury to which of the following?

liver

Where is abdominal injury most likely to occur in young children?

liver

Which of the following organs would MOST likely bleed profusely when injured?

liver

You should have an index of suspicion that a patient with pain referred to the right shoulder has an injury to which organ?

liver

right upper quadrant (RUQ)

liver, gallbladder, small intestine duodenum, part of pancreas

solid organs

liver, spleen, pancreas, kidneys

closed injury signs

liver/spleen: pain referred to shoulder abdominal aneurysm: tearing pain traveling from abdomen posteriorly kidney/ureter: pain from lateral hip to groin midline appendix: RLQ only gallbladder: under the margin of ribs on right side, between shoulder blades peritonitis: jarring motion to affected area causing pain (rebound tenderness)

solid organ injuries

liver: very vascular, can contribute to hypoperfusion if injured by fractured lower right rib or penetrating trauma - pain to right shoulder spleen (and pancreas): also vascular and injured in MVCs where improper restraint, falls from heights, crashes with handlebars - pain to left shoulder ruptured diaphragm: abdominal contents may herniate into thoracic cavity -> SOB, dyspnea (*look for sunken anterior wall of abdomen) kidneys: can be sheared, crushed or fractured - hematuria

In the abdomen, why can pain often be deceiving?

pain may be referred from the site of injury to another location in the body

Which of the following are considered solid organs?

pancreas and spleen

When a hollow organ is punctured during a penetrating injury to the abdomen: When a hollow organ is punctured during a penetrating injury to the abdomen:

peritonitis may not develop for several hours

emergency medical care of closed abdominal injuries

possible injuries: - abdominal wall bruising - liver/spleen laceration - intestinal rupture - tears in mesentery - kidney rupture of avulsion of kidneys from their vessels - bladder rupture - intra-abdominal hemorrhaging - peritoneal irritation backboard, turn to vomit, watch for signs of shock, BVM if diaphragmatic rupture