Chapter 30 Abdominal & GENITOURINARY INJURIES

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.

Emergency Medical Care of 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. Treat for shock, transport promptly, and monitor vital signs en route to the hospital.

Secondary assessment

1. May not have time to perform this detailed, comprehensive exam in critically injured patients 2. Physical examinations 3. Obtain vital signs 4. If the MOI suggests an isolated injury to the abdomen, focus your physical examination on the injured area only.

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. In males, sudden deceleration from a motor vehicle or motorcycle crash can shear the bladder from the urethra. 3. In later trimesters of pregnancy, bladder injuries increase from displacement of the uterus.

Reassessment

1. Repeat the primary assessment and vital signs. a. Reassess the interventions and treatment you have provided. 2. Interventions 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.

Sexual assault and rape 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.

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

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

Emergency Medical Care of 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 2. If shock or associated injuries are present, transport promptly and monitor vital signs en route.

Female genitalia treatment

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. 2. Do not pack dressings into the vagina. 3. Leave any foreign bodies in place after stabilizing with bandages. 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.

Low-velocity injuries

Caused by handheld or hand-powered objects, such as knives and other edged weapons 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.

High-velocity injuries

Caused by larger weapons, such as high-powered rifles and higher-powered handguns

Medium-velocity injuries

Caused by smaller caliber handguns and shotguns

Female genitalia injuries

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.

guarding

Involuntary muscle contractions (spasm) of the abdominal wall to minimize the pain of movement and protect the inflamed abdomen; a sign of peritonitis.

Kidney injuries

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.

Sexual assault and rape

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 C. Do not examine the genitalia unless obvious bleeding requires application of a dressing.

Closed abdominal injuries care

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.

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.

History taking 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.

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

kidneys

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

Primary assessment 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.

Primary assessment 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.

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

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.

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.

Reassessment 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.

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.

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.

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.

Signs and symptoms of a closed abdominal 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. 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

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.

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.

Secondary assessment 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. 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. c. Examine the entire abdomen, including all posterior, anterior, and lateral surfaces. i. Critical step for patients with an entrance wound 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. 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. 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. 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.

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

Closed abdominal injuries 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

Primary assessment 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.

evisceration

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

History taking 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.

Primary assessment 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.

seatbelts Can cause what injuries to pregnant patients who adjust the lap belt for comfort

bladder injuries

Solid organ injuries

can bleed significantly and cause rapid blood loss. a. 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.

hollow 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.

The female genitalia are contained

entirely within the pelvis, except the vulva, clitoris, and labia.

There are three levels of velocity that are common in open abdominal traumatic injuries:

high, low, medium

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.

Open abdominal injuries 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.

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

Right lower quadrant (RLQ)

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

Right Upper Quadrant (RUQ)

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

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.

Left upper quadrant (LUQ)

i. Stomach ii. Spleen

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.

Left lower quadrant (LLQ)

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

Accidental laceration of the head of the penis

is associated with heavy bleeding. a.Local pressure with a sterile dressing usually stops the hemorrhage

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.

liver

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.

The solid organs of the abdomen include

liver, spleen, pancreas, and kidneys 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.

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.

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).

Abdominal distention or swelling between the xiphoid process and the groin is often the result of

of free fluid, blood, or organ contents spilling into the peritoneal cavity. e. Additional signs of abdominal injury are bruising and discoloration. f. Closed abdominal injuries may initially appear as abrasions.

The male genitalia lie

outside the pelvic cavity, except for the prostate gland and seminal vesicles.

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

spleen and pancreas

pancreas are also very vascular. a. Both are prone to heavy bleeding when fractured, lacerated, or punctured.

Rectal bleeding causes include

sexual assault, rectal foreign bodies, hemorrhoids, colitis, and ulcers in the digestive tract. Significant rectal bleeding can occur after hemorrhoid surgery

The hollow organs of the abdomen include

stomach, intestines, ureters, and bladder.

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.

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.

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

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

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.