Chapter 30: abdominal and genitourinary injuries

What are common associated complaints with genitourinary injuries?

- nausea/vomiting - diarrhea - hematuria - hematemesis - abnormal bowel and bladder habits (such as increase in frequency or absence of the need to void) be sure to determine if there is blood in the urine gain info about intake of fluid and food to predict what is contained in the genitourinary system

what typically causes rectal bleeding?

- sexual assault - rectal foreign bodies - hemorrhoids - colitis - ulcers of the digestive tract ** sig rectal bleeding may occur after hemorrhoidal surgery and may lead to significant blood loss and shock

which organs are commonly found in the left upper quadrant?

- stomach - spleen - some of pancreas super sleep

general rules when applying treatment to injuries of external male genitalia:

- they're very painful. make pt as comfortable as possible - use sterile, moist compresses to cover areas stripped of skin - apply direct pressure with dry, sterile gauze dressings to control bleeding - never move or manipulate impaled instruments or foreign bodies in the urethra - identify and take avulsed parts to hospital w pt and put name on bag

A 54-year-old male experienced an avulsion to his penis when his foreskin got caught in the zipper of his pants. He was able to unzip his pants and remove the foreskin prior to your arrival. Your assessment reveals that he is in severe pain and that the avulsion is bleeding moderately. The MOST appropriate treatment for this patient includes:

B. applying direct pressure with a dry, sterile dressing.

which male genitalia lie outside the pelvic cavity?

all except prostate gland and seminal vesicles

which female genitalia lie inside the pelvis?

all except the vulva, clitoris and labia

Injuries to the external male genitalia _______.

are rarely life-threatening

What should you always be sure to do when treating a pregnant patient?

ask pt when she is due to deliver and report to hospital staff

Where do the lines separating the four quadrants intersect?

at the umbilicus

Your documentation on a sexual assault victim should _______.

be objective and factual

where does seatbelt lay when worn properly?

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

where does abdominal distention or swelling occur as a result of organ contents spilling into peritoneal cavity?

between the xiphoid process and the groin

Closed abdominal injury

blunt trauma to abdomen without breaking skin

what causes hollow organ injuries?

blunt trauma: pop and rleasing of fluids or air - penetrating trauma: lacerations or punctures

open abdominal injury

break in the surface of skin or mucous membrane, exposing deeper tissue to potential contamination

what do high and medium velocity injuries have that low velocity injuries (like a stabbing) do not?

cavity that forms as the pressure wave from the projectile is transferred to the tissues (in addition to the exit and entrance wounds)

what are the components of the 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 frequently

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 oxygen, and transport at once.

emergency medical care of abdominal evisceration

cover with sterile dressings moistened with sterile saline solution & secure with bandage and tape to keep fluids and heat in treat patient for shock and provide high low oxygen

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

diaphragm

Sexual assault and rape

do not examine genitalia unless obvious bleeding requires shield pt's privacy document in detail pt history, assessment, treatment and response to treatment bc you may need it in court 2-3 years later advise pt not to shower, bathe, douche, urinate, or defecate until after physician has examined - if needs to urinate, do so in a container if oral penetration occurred, advise them not to put anything in mouth until examined wrap pt in burn sheet to keep offenders hair fluid or fibers on pt handle pt clothes as little as possible EMT should be same gender if possible treat medical injuries while providing privacy, support and reassurance

What should you do in the case of evisceration?

do not push down on the patient's abdomen 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 on any clothing stuck to or inside the wound channel

what are the components of the small intestine?

duodenum, jejunum, ileum

later signs of open abdominal injury

evidence of shock or changes in mental status trauma to the abdomen

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

guarding

what are the overall signs and symptoms of closed abdominal injury?

guarding, tenderness, bruising and discoloration

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

hematoma in the flank region

rupture of the solid organ, the kidney, would lead to what?

hematuria

when should you expect kidney damage?

history or physical evidence of... - abrasion, laceration or contusion in the flank - penetrating wound in the flank (region below rib cage and above the hip) - fractures on either side of lower rib cage or of the lower throacic or lumbar vertebrae - a hematoma in the flank region

what does free air in the peritoneal cavity indicate?

hollow organ or loop of bowel has perforated bc free air is abnormal the location of this air can vary depending on patient position

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

why is it important to always determine possibility of pregnancy in trauma?

medications and tests may be harmful for a fetus and there is potential for another source of blood loss in the gravid (pregnant) uterus

What is the peritoneum

membrane lining the abdominal cavity

hollow organ injuries

often have delayed signs and symptoms typically leads to infection. the contents are typically irritating and damage the tissues of the abdomen if ruptured

which stages of pregnancy is the urinary bladder most susceptible to injury?

second and third trimesters because of displacement of the uterus

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

sepsis

what are the first signs of peritonitis?

severe abdominal pain, tenderness and muscular spasm

what can cavitation lead to?

significant bleeding depending on speed or velocity of penetrating object

what does bruising around the umbilicus indicate?

significant internal abdominal bleeding

All of the following are hollow abdominal organs, EXCEPT the:

spleen

In what order should you palpate the amdomen?

start with the quadrant farthest away from the quadrant that is exhibiting signs and symptoms of injury and pain... palpate lightly and then harder this allows you to investigate possibility of radiation and extension of the pain into the other quadrants without causing the patient to guard the rest of the abdomen

which abdominal organs are hollow?

stomach, intestines, ureters, urinary bladder

Early sign of open abdominal injury

tachycardia bc heart is increasing pumping action to compensate for blood loss

why is swelling common in the right lower quadrant?

the appendix is a common source of intra abdominal infection

where does the intestinal blood supply come from?

the mesentary: injuries to the mesentary can bleed significantly into the peritoneal cavity

Which of the following statements regarding abdominal eviscerations is correct?

the protruding organs should be kept warm and moist

what happens in later stages of pregnancy to the uterus and urinary bladder placement?

the uterus displaces the urinary bladder to the anterior so the normally protected bladder becomes more susceptible to injuries from impacts and the seatbelt

why? injuries of the external female genitalia can include all types of soft-tissue injuries

these genital parts have. rich nerve supply therefore they are very painful if injured

always be aware that the patient may avoid discussing the injury to avoid undergoing a physical exam

they may provide an moi that seems less embarrassing than the actual moi

what happens when hollow abdominal organs are ruptured or lacerated?

they spill their contents into the peritoneal cavity causing intense inflammatory reaction and possibly infection

in which trimester may the uterus obstruct the vena cava?

third trimester... leads to a decrease in amount of blood returning to the heart if pt is in supine position

why does the body guard?

to create a natural splint

T/F: A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard.

true

T/F: The higher the velocity of a projectile, the larger the cavity it produces.

true

T/F: You should allow patients with peritonitis to lie still with their legs drawn up.

true

T/F: a penetrating wound to the kidney almost always involves other organs

true

T/F: never allow penis to come in direct contact with ice when preserving?

true. keep it cool but not on direct ice

what change in position when the diaphragm is ruptured is dangerous? Why?

upright to supine because abdominal contents spill into the thoracic cavity and compress the lungs

What is the risk of damage to the urinary bladder?

urine spills into surrounding tissues urine is bloody

supine hypotensive syndrome:

uterus is large and obstructs vena cava, leading to less blood returning to the heart - bp decreases

internal female genitalia injury

uterus, ovaries, and fallopian tubes rarely damaged because they lie deep in the pelvis. exception: pregnancy... uterus enlarges substantially and rises out of the pelvis making it vulnerable to blunt and penetrating injuries. uterus has a rich blood supply

how do patients with peritonitis prefer to lay?

very still with their legs drawn up. tends to hurt when legs move or are straightened.

peritonitis

when the peritoneum becomes inflamed and painful

how should you treat soft tissue injuries of the female external genitalia?

with moist, sterile compresses use local pressure to control bleeding never pack or place dressings into vagina & leave foreign bodies in place after stabilizing

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

MOI of closed abdominal injuries

- handlebar of bicycle or steering wheel of car - being stuck by wooden board or baseball bat - motorcycle crashes - falls - blast injury - pedestrian injury - compression - deceleration

which organs commonly occupy the right lower quadrant?

- large intestine - small intestine - ascending colon - right half of transverse colon - appendix

which organs commonly occupy the left lower quadrant?

- large intestine - small intestine - descending colon - left half of the transverse colon

what are later signs of peritonitis?

- limited bowel functions and sounds - nausea, vomiting - abdomen becomes distended and firm to the touch - infection may occur

Which organs are commonly found int he right upper quadrant?

- liver - gallbladder - duodenum - pancreas (small portion) LGDN let go dont nag

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

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

What are the four abdominal quadrants?

RUQ: right upper quadrant LUQ: left upper quadrant LLQ: left lower quadrant RLQ: right lower quadrant

T/F: A very common early sign of a significant abdominal injury is tachycardia.

True

T/F: Free air in the peritoneal cavity is abnormal and indicates that a hollow organ or loop of bowel has perforated.

True

what is rigidity, and what does it indicate in the abdomen?

a boardlike feeling to the abdomen that indicates bleeding

solid organ injuries to the liver, spleen and pancreas would lead to what?

a lot of bleeding!

what are compression injuries typically caused by?

a poor placed lap belt

where should you take a pt with a genitourinary injury for evaluation and treatment?

a trauma center

Compression injury is most likely due to which of the following?

improperly placed lap belt

where are most of the solid organs located?

in the retropineal region

Abdominal pain, vomiting, and fever are most likely due to _______.

infection

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.

guarding

involuntary muscle contractions (spasm) of the abdominal wall to minimize pain of movement and protect the inflamed abdomen it is a sign of peritonitis

In pediatric patients, the liver and spleen are _______.

larger in proportion to the abdomen

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

liver

What are the solid organs of the abdomen?

liver, spleen, pancreas, kidneys

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

liver. In pediatric patients, the liver and spleen are very large in proportion to the size of the abdominal cavity and are more easily injured. The soft, flexible ribs of infants and young children do not protect these two organs very well and may allow injury to underlying organs, even without fracturing the ribs.

why should you not log roll a pt with evisceration? which position should you keep them in?

logrolling may cause the abdominal organs to protrude from the wound keep in supine and allow them to flex knees to relieve tension on the abdomen

what occurs if the diaphragm is penetrated or ruptured?

loops of bowel may herniate into the thoracic cavity and lead to dyspnea

evisceration

open abdominal injury that goes through the skin and muscle layer and through the fascia or interior covering of the abdomen. leads to displacement of organs outside the body

what signs/symptoms are associated with abdominal aneurysm that is dissecting?

pain described as tearing going from abdomen posteriorly

what signs/symptoms are associated with damage to kidneys or urters?

pain following angle from the lateral hip to the midline of the groin

What signs/symptoms are associated with liver and spleen injury?

pain in the shoulder

what signs/symptoms are associated with inflamed/ruptured appendix?

pain located in right lower quadrant

what signs/symptoms are associated with damage to inflammation or injury to the gallbladder?

pain under the margin of the ribs on the right side or between the shoulder blades

what is important to do during a secondary assessment of a patient with suspected abdomen injury?

palpate for tenderness to attempt to localize specific quadrant of abdomen.

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

peritonitis may not develop for several hours.

how should you treat supine hypotensive syndrome? (when woman is in the third trimester of pregnancy)

place pt on her left side so that uterus will not lie on the vena cava. if secured to backboard, tilt board to left

Because the depth of an open abdominal wound is often difficult to determine:

prompt transport to the hospital is essential