Chapter 30: Abdominal & Genital Injuries

peritoneal cavity

(the abdominal cavity), causing an intense inflammatory reaction and possible infection. The lining of the peritoneal cavity, the peritoneum, may become inflamed and painful—a condition known as peritonitis. The intestines and stomach contain acid- like substances that aid in the digestive process. When these substances spill or leak into the peritoneal cavity, they cause pain and irritate the peritoneum. The first signs of peritonitis are severe abdominal pain, tenderness, and muscular spasm. Later, bowel sounds diminish or disappear as the bowel stops functioning. A patient may feel nauseous and may vomit; the abdomen may become distended and firm to touch; and infection may occur. Peritonitis is serious and may become life threatening.

Blunt Abdominal Injuries

A patient with a blunt abdominal injury may have one or more of the following injuries: ▪ Severe bruising of the abdominal wall▪ Laceration of the liver and spleen▪ Rupture of the intestine▪ Tears in the mesentery, the membranous folds that attach the intestines to the walls of the body, and injury to blood vessels within them▪ Rupture of the kidneys or avulsion of the kidneys from their arteries and veins▪ Rupture of the urinary bladder, especially in a patient who had a full and distended bladder at the time of the injury ▪ Severe intra-abdominal hemorrhage▪ Peritoneal irritation and inflammation in response to the rupture of hollow organs A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard. Ensure you protect the spine while you roll him or her. If the patient vomits, turn him or her to one side and clear the mouth and throat of vomitus. Monitor the patient's vital signs for any indication of shock such as pallor; cold sweat; rapid, thready pulse; or low blood pressure. If you see any of these signs, administer high-flow supplemental oxygen via a nonrebreathing mask, or a BVM if needed, and take all the appropriate measures to treat for shock. Patients with dyspnea due to a diaphragmatic rupture may require assistance with a BVM. Keep the patient warm with blankets, and provide rapid transport to the ED.

scene Size up: Genital injuries

As you arrive at the scene, observe it for hazards and threats to the safety of the crew, bystanders, and the patient. Assess the impact the hazards have on patient care and address those hazards. Assess the potential for violence and assess for environmental hazards. Ensure that you and your crew have taken standard precautions—a minimum of gloves and eye protection. Control of blood and bloody contaminants can be difficult unless you are careful about what you touch and where. Apply standard precautions before you approach the scene to minimize your direct exposure to body fluids. Because of the color of blood and how well it soaks through clothing, you can often identify patients with an open injury as you approach the scene. However, blood can be hidden under thick clothing such as denim and leather. Eye protection is required when managing open injuries. Determine the number of patients and consider if you need additional or specialized resources on the scene. As you observe the scene, look for indicators of the MOI. Consider information from dispatch, your observations of the scene, and the MOI to help develop your list of expected injuries. Be aware that the patient may avoid discussing the injury to avoid undergoing a physical examination. Also, the patient may provide an MOI that seems "less embarrassing" than the actual MOI. By maintaining a professional demeanor, respecting the patient's privacy, and maintaining the patient's dignity, you will earn the patient's trust. If the patient trusts you, you are more likely to discover the true facts behind the injury.

blunt and penetrating trauma and hollow organs

Blunt trauma causes the organ to "pop," thus releasing fluids or air. Penetrating trauma causes direct injury such as laceration and punctures. In open wounds, patients typically report an intense pain that can be out of character for the size of the injury. Patients may also report intense pain with open wounds of the stomach or small bowel. The gallbladder and the urinary bladder, which are filled with bile and urine, are two additional hollow organs whose contents are potentially irritating and damaging to the tissues of the abdomen if ruptured by injury. These fluids move via gravity into the loose spaces and voids in the peritoneal cavity, eventually leading to infection. Free air in the peritoneal cavity is abnormal and usually indicates that a hollow organ or loop of bowel has perforated. Perforation with free air is usually very painful. If the site of perforation is not rapidly identified and repaired, severe infection and septic shock may develop. Any air in the peritoneal cavity seeks the most superior space or void; thus the location of the air can change with positioning of the patient.

damage to kidneys

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. However, you will see signs of shock if the injury is associated with significant blood loss. Because one of the functions of the kidneys is the formation of urine, another sign of kidney damage is blood in the urine (hematuria). Treat shock and associated injuries in the appropriate manner. Provide rapid transport to the hospital, carefully monitoring the patient's vital signs en route.

primary assessment: genital injuries

During the primary assessment, you must quickly scan the patient to identify and treat potential life threats and determine the priority of patient care and transport. The genitourinary system is very vascular, and injuries to it can produce a significant volume of blood loss. Do not avoid this area during the primary assessment. In fact, life-threatening hemorrhage must be addressed immediately, even before airway or breathing concerns. Look externally at the patient's undergarments for signs of bleeding and injury. If bleeding is present, maintain privacy for the patient and inspect the exterior genitals for visible injury. As you approach the trauma patient, important indicators will alert you to the seriousness of the patient's condition. Is the patient awake and interacting with his or her surroundings, or lying still, not making sounds? Does the patient have any apparent life threats? What color is the patient's skin? Is he or she appropriately or inappropriately responding to you? Your general impression will help you develop an index of suspicion for serious injuries and determine how urgently your patient needs care. As stated, the genitourinary system is very vascular and can be a significant source of bleeding. If visible significant bleeding is seen, you must begin the steps necessary to control bleeding. Significant bleeding is an immediate life threat and must be controlled quickly using appropriate methods. In dark environments, bleeding can be hard to see because of its color. Thick clothing may also hide bleeding. After you consider the MOI and form suspicions as to where bleeding may occur, expose that part of the body. Ensure the patient has a clear and patent airway. Because trauma was involved, protect the patient from further spinal injury as you manage the airway. If the patient is unresponsive or has a significant altered level of consciousness, consider inserting an oropharyngeal airway or nasopharyngeal airway. Quickly assess the patient for adequate breathing. Provide assisted ventilations using a BVM as needed, depending on the level of consciousness and if your patient is breathing inadequately. Quickly assess the patient's pulse rate and quality; determine the skin condition, color, and temperature; and check the capillary refill time. These assessments will help you determine the presence of circulatory conditions or shock. Closed injuries do not always have visible signs of bleeding. Because the bleeding is occurring inside the body, shock may be present. Your assessment of the pulse and skin will indicate to you how aggressively you need to treat your patient for shock. A patient with a genitourinary system injury should be taken to a trauma center for evaluation and treatment. Any injury to this system can prove to be life altering and often requires specialized care from a medical specialist. When possible and protocols allow, transport the patient to a facility capable of treating this subset of injuries.

Assessment of an Isolated Abdominal Injury

If the MOI suggests an isolated injury to the abdomen, focus your physical examination only on the injured area. Inspect the skin of the abdomen for wounds through which bullets, knives, or other missile-type foreign bodies may have passed. Keep in mind that the size of the wound does not necessarily indicate the extent of the underlying injuries. If you find an entry wound, you must always check for a corresponding exit wound in the patient's back or sides. If the injury was caused by a very high-velocity missile from a rifle, you may see a small, harmless-looking entrance wound with a large, gaping exit wound. Do not attempt to remove a knife or other object that is impaled in the patient. Instead, stabilize the object with supportive bandaging. Bruises or other visible marks are important clues to the cause and severity of any blunt injury. Steering wheels and seat belts produce characteristic patterns of bruising on the abdomen or chest.

Damage to Diaphragm

If the diaphragm is penetrated or ruptured, loops of bowel may herniate into the thoracic cavity. Because the bowel will now be displacing lung tissue and vital capacity, patients will exhibit dyspnea or feel short of breath. Patients with a ruptured diaphragm after a motor vehicle crash may become very anxious and short of breath if placed in the supine position on a backboard. Change in position from upright to supine results in more abdominal contents spilling into the thoracic cavity and compressing the lungs, prohibiting the lungs from fully expanding.

tearing to genitalia male

If you encounter a patient with an avulsion (tearing away) of skin of the penis, wrap the penis in a soft, sterile dressing moistened with sterile saline solution, and rapidly transport the patient. Use direct pressure to control any bleeding. You should try to save and preserve the avulsed skin, but do not delay treatment or transport for more than a few minutes to do so. Managing blood loss is your top priority in amputation of the penile shaft, whether partial or complete. You should use local pressure with a sterile dressing on the remaining stump. Never apply a constricting device to the penis to control bleeding. Surgical reconstruction of even a completely amputated penis is possible if you can locate the amputated part. 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. If the connective tissue surrounding the erectile tissue in the penis is severely damaged, the shaft of the penis can be fractured or severely angled, sometimes requiring surgical repair. The injury may occur during particularly active sexual intercourse. It is associated with intense pain, bleeding into the tissues, and fear. Provide rapid transport to the ED. Accidental laceration of the skin about the head of the penis usually occurs when the penis is erect and is associated with heavy bleeding. Local pressure with a sterile dressing is usually sufficient to stop the hemorrhage. It is not uncommon for the skin of the shaft of the penis or the foreskin to get caught in the zipper of pants. If a small segment of the zipper is involved (one or two teeth), you can try to unzip the pants. If a longer segment is involved or the patient is agitated, use heavy scissors to cut the zipper out of the pants to make the patient more comfortable during transport. Explain to the patient how you are going to use the scissors before you begin cutting. Be particularly careful not to cause injury to the scrotum while cutting the zipper away from the penis.

Secondary Assessment: Abdominal & Genital Injuries

In some instances, such as with a critically injured patient or a short transport time, you may not have time to conduct a secondary assessment. Usually, you will perform the physical examination on all patients with abdominal injuries in the same manner, as follows: ▪ Remove or loosen clothes to expose the injured regions of the body. Inspect the patient for bleeding before removing clothing to prevent damaging any exposed tissues, such as in the case of an evisceration. ▪ Provide privacy as needed or wait until you are in the back of the ambulance.▪ The patient without suspected spinal injury should be allowed to stay in the position of comfort—with the legs pulled up toward the abdomen. This position will relieve some of the tension on the abdomen and thus provide pain relief.▪ For a patient with spinal injury, place padding such as blankets or pillows under the his or her knees to help alleviate tension on the abdominal wall. Keep in mind that you can worsen the spinal injury if you are too aggressive when placing these items. The patient without suspected spinal injury should not be forced to lie flat for the physical examination or transport. The fetal position may provide the patient with the most comfort during the physical examination or transport.Examine the entire abdomen including all posterior, anterior, and lateral surfaces. This is a critical step when patients have an injury with an entrance wound. Examine the axillae (armpits) for entrance wounds. Use DCAP-BTLS to help identify specific signs and symptoms of injury. Inspect and palpate the abdomen for the presence of deformity, which may be subtle in abdominal injuries. Look for the presence of contusions and abrasions, which can help localize focal points of impact and may indicate significant internal injury. Puncture wounds and other penetrating injuries must not be overlooked because the intra-abdominal extent of these injuries may be life threatening. The presence of burns, as in the case of flash burns or scalding fluids spilled onto the abdomen, must be noted and managed appropriately. Palpate for tenderness and attempt to localize to a specific quadrant of the abdomen. Identify and treat any lacerations with appropriate dressings. Swelling may involve the entire abdomen and indicates significant intra-abdominal injury. Remember to palpate the abdomen when examining the region. Palpation is typically performed first with a light touch, progressing to applying gentle increasing pressure deeper into the tissues to draw out a pain response for injuries. The object is not to cause the patient further pain but to identify the location of the pain. Start by palpating the quadrant farthest away from the quadrant that is exhibiting signs and symptoms of injury and pain. This technique allows you to investigate the possibility of radiation and extension of the pain into other quadrants without causing the patient to guard the rest of the abdomen. If a light touch causes pain, deep palpation is not required or recommended. If the patient has been subjected to a significant MOI, an exam of the entire body will help you quickly identify any injuries your patient may have, not just abdominal injuries. Begin with the head and finish with the lower extremities, moving in a systematic manner. Your goal is not to identify the extent of all the injuries but to determine whether other injuries are present. This requires you to work quickly but thoroughly. If you find a life-threatening injury, stop and treat it immediately; otherwise move on. The injuries you find will guide your decisions in packaging your patient for transport. Assess the patient's need for spinal immobilization and apply per local protocol. In some EMS systems, full spinal immobilization of the patient with penetrating trauma is not performed in the interest of rapid transport for surgical intervention. Up to this point in the patient assessment process you may have been stabilizing the patient's spine by simply holding the head still and asking the patient not to move. If a cervical collar has not been applied, place one on the patient now before you log roll the patient to inspect the posterior part of the body and place the patient on a backboard. The kidneys are located in the flank region of the back. Inspect and palpate this area for tenderness, bruising, swelling, or other signs of trauma. Remember, you may not be able to trigger pain from the specific organ, but the tissues around it may exhibit symptoms of pain. Hollow organs will spill their contents into the peritoneal cavity and will typically produce a significant peritonitis, which may be seen as diffuse pain with guarding and reaction to sudden jarring movements. Bowel sounds may help confirm these findings, but you should not depend on these sounds to rule out a specific injury. Quickly obtain the patient's vital signs. Many abdominal emergencies, in addition to injuries or illnesses that result in severe bleeding, can cause a rapid pulse and low blood pressure. Record vital signs as early as possible and periodically thereafter (every 5 minutes in the patient whom you suspect has a serious injury). This will help you identify changes in the patient's condition and be alert to signs of decompensation from blood loss. If the patient is experiencing external or internal hemorrhaging, as in the case of a stab wound or a direct blow to the abdomen, closely monitor the vital signs with a degree of suspicion and pay close attention to changes in the vital signs. Use pulse oximetry and noninvasive blood pressure devices when these monitoring devices are available. It is recommended you always assess the patient's first blood pressure manually with a sphygmomanometer (blood pressure cuff) and stethoscope.

Injuries of the External Male Genitalia

Injuries of the external male genitalia include all types of soft-tissue wounds. Although these injuries are uniformly painful and generally a source of great concern to the patient, they are rarely considered life threatening. They should not be given priority over other, more severe wounds, unless the rich blood supply causes significant bleeding. It is important to know that pain from an injury to the testicles or another cause, such as infection or cancer, may be referred to the lower abdomen. As a result, when assessing men with lower abdominal pain you should also consider injury or other causes of pain to the testicles.

Injuries of the Kidneys

Injuries of the kidneys are not unusual and rarely occur in isolation. This is because the kidneys lie in such a well-protected area of the body. A penetrating wound that reaches the kidneys almost always involves other organs. The same is true with blunt injuries. A blow that is forceful enough to cause significant kidney damage often results in damage to other intra- abdominal organs. Less significant injuries to the kidneys may result from a direct blow or even from a tackle in football Figure 30-16 . Suspect kidney damage if the patient has a history or physical evidence of any of the following: ▪ An abrasion, laceration, or contusion in the flank▪ A penetrating wound in the flank (the region below the rib cage and above the hip) or the upper abdomen ▪ Fractures on either side of the lower rib cage or of the lower thoracic or upper lumbar vertebrae▪ A hematoma in the flank region

Hollow Organ Injuries

Injuries that involve the hollow organs often have delayed signs and symptoms. The hollow organs commonly spill their contents into the abdomen and then an infection develops, which can take a few hours to days to develop. When the stomach and the intestines are injured, they can spill gastrointestinal contents such as food, waste, and digestive liquids that are highly toxic and acidic. These substances cause significant tissue damage to the entire peritoneum.

Injuries to the Urinary Bladder

Injury to the urinary bladder, either blunt or penetrating, may result in its rupture. When this happens, urine spills into the surrounding tissues, and any urine that passes through the urethra is likely to be bloody. Blunt injuries of the lower abdomen or pelvis often cause rupture of the urinary bladder, particularly when the bladder is full and distended. Sharp, bony fragments from a fracture of the pelvis often perforate the urinary bladder Figure 30-17 . Penetrating wounds of the lower midabdomen or the perineum (the pelvic floor and associated structures that occupy the pelvic outlet) can directly involve the urinary bladder. In men, sudden deceleration from a motor vehicle or motorcycle crash can literally shear the bladder from the urethra. Remember, in the second and third trimesters of pregnancy, the incidence of injury to the urinary bladder is increased by displacement of the uterus.

female genitalia

Lacerations, abrasions, and avulsions should be treated with moist, sterile compresses. Use local pressure to control bleeding and a diaper-type bandage to hold dressings in place. Under no circumstances should you pack or place dressings into the vagina. Leave any foreign bodies in place after you stabilize them with bandages. In general, although these injuries are painful, they are not life threatening. Bleeding may be heavy, but it can usually be controlled by local compression. 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.

History taking: abdominal & genital injuries

Once you have identified and treated life threats, you can then gather a history from the patient. You should clarify the chief complaint and MOI, as well as any associated symptoms. You can quickly assess the patient's chief complaint with a simple inspection, noting the position in which he or she is lying. Movement of the body or the abdominal organs irritates the inflamed peritoneum, causing additional pain. To minimize this pain, patients will lie still, usually with their knees drawn up, and their breathing will be rapid and shallow. For the same reason, they will contract their abdominal muscles, a sign called guarding. Ask about previous injuries associated with a chief complaint of abdominal pain. Next, obtain a SAMPLE history from your patient. Using OPQRST to help explain an abdominal injury may provide some helpful information such as the description of the pain and if the pain is radiating. Take this time to confirm that you have all the necessary history to inform the hospital staff. If the patient is not responsive, attempt to obtain the SAMPLE history from friends or family members. Be sure to ask the patient if he or she has experienced any nausea, vomiting, or diarrhea when you are investigating the details of the current injury. If the patient has experienced any of these symptoms, ask how many times and over what time period. Ask about the appearance of any bowel movements and urinary output to determine if there was any blood in the urine or black tarry stools (melena). This can help determine if the patient has gastrointestinal bleeding and if there is bleeding in the lower intestinal tract.

Signs and Symptoms of a Closed Injury

Pain in the abdomen can often be deceiving because it is often diffuse in nature and may be referred from the site of injury to another location in the body. Most injured organs irritate the surrounding tissues. This commonly predictable radiation pattern can help you determine the source of the pain and possibly the site of the injury. In patients with liver and spleen injuries, and bleeding into the peritoneal space, pain is referred to the shoulder. For example, bleeding from an injury to the spleen can result in referred pain to the tip of the left shoulder. However, shoulder pain can be misleading, and injury to the liver or spleen could possibly be overlooked if the shoulder is also injured or if the MOI suggests that an impact or injury may have occurred in the shoulder girdle.

Signs and Symptoms of an Open Injury

Patients with any type of abdominal injury generally have one concern: pain. But other significant distracting injuries may at first mask the pain, and some patients may not be able to tell you about pain because they are unconscious or unresponsive, such as after a head injury or a drug or alcohol overdose. A very common early sign of a significant abdominal injury is tachycardia because the heart is increasing its pumping action to compensate for blood loss. Later signs include evidence of shock, such as decreased blood pressure and pale, cool, moist skin, or changes in the patient's mental status, combined with trauma to the abdomen. In some cases, the abdomen may become distended from the accumulation of blood and fluid. As an EMT, you must look for other signs and symptoms of potential trauma and injuries to the abdomen. A patient may have both closed and open injuries. Blunt injuries include bruises (often indicated by red areas of skin at this early stage) or other visible marks, whose location should guide your attention to underlying structures Figure 30-7 . For example, bruises in the right upper quadrant, left upper quadrant, or flank (the region below the rib cage and above the hip) might suggest an injury to the liver, spleen, or kidney, respectively Figure 30-8 . Bruises around the umbilicus can predict significant internal abdominal bleeding

Penetrating Abdominal Injuries

Patients with penetrating injuries generally have obvious wounds and external bleeding Figure 30-10A ; however, significant external bleeding is not always present. As an EMT, you should have a high index of suspicion that the patient has serious unseen blood loss occurring inside the body. A large wound may have protrusions of bowel, fat, or other structures. In addition to pain, these patients often report nausea and vomiting. Patients with peritonitis generally prefer to lie very still with their legs drawn up because it hurts to move or straighten their legs. They may express grief or pain after every bump in the road during transport. In caring for a patient with a penetrating wound to the abdomen, follow the general procedures previously described for care of a blunt abdominal injury as well as following the specific steps for the penetrating wound. Inspect the patient's back and sides 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

Rectal bleeding

Rectal bleeding is a common complaint and something that you may hear as a chief complaint or secondary to abdominal or pelvic complaints. Bleeding from the rectum may present as blood stains or blood soaking through underwear or patients may report blood in the toilet after a bowel movement or attempted bowel movement. Rectal bleeding can be caused by a sexual assault, rectal foreign bodies, hemorrhoids, colitis, or ulcers of the digestive track. Significant rectal bleeding can occur after hemorrhoid surgery and can lead to significant blood loss and shock.

Reassessment: Adominal & Genital Injuries

Repeat the patient's primary assessment and vital signs. Reassess the interventions and treatment you have provided to the patient. Identify trends in pain, vital signs, and the progress of treatments to determine whether the patient's condition is improving or getting worse. Adjustments in care can be based on these objective findings. Manage airway and breathing conditions based on signs and symptoms found during the primary assessment. Provide spinal immobilization to the patient with suspected spinal injuries. If the patient has signs of hypoperfusion, provide aggressive treatment of shock and rapid transport to the appropriate hospital. If an evisceration is discovered, place a sterile dressing moistened with normal saline over the wound, apply a bandage, and transport. Never attempt to push eviscerated tissue or organs back into the abdominal cavity. A patient who has a ruptured diaphragm may have an abdomen with a sunken anterior wall and difficulty breathing because of bowel contents in the chest cavity. These patients should receive positive-pressure ventilation with a BVM, which may be more difficult to perform without a patent diaphragm and with bowel contents impairing lung expansion. Do not delay transport of the seriously injured trauma patient to complete nonlifesaving treatments such as splinting extremity fractures. Instead, complete these types of treatments en route to the hospital. Communicate to the hospital the MOI and injuries found during your assessment. It is important to use appropriate medical and anatomic terminology; however, when in doubt just describe what you see. The content of your radio report will depend on your local protocols. The information you provide helps the hospital staff prepare for the patient. Documentation of your assessment and trends in vital signs is a tremendous help to physicians in evaluating the problem when the patient arrives in the ED. Document the results of the physical examination and any pertinent negatives such as no blood loss noted in bowel movements. Also document if you passed over any step of the physical examination such as with a patient with acute abdominal pain in whom you opted to not perform palpation. Continuity of care is maintained when the ED has an accurate record of your findings at the scene as well as the treatments you have provided. It is imperative that you be able to describe the scene in enough detail so the trauma team has a clear idea of the circumstances. Some services and departments now carry digital or other instant cameras to be able to show the trauma team the MOI that the patient was exposed to. Remember, your written report is also a legal record of your care. If assault is suspected, you may have a legal requirement to inform the hospital staff of your suspicions; however, this information can wait until you have transported the patient to the hospital and had a chance to discuss it privately with appropriate hospital personnel. Be cautious and diligent when dealing with patients who refuse transport to the hospital after sustaining an injury to the abdomen or genitourinary system. These patients are at high risk for complications; therefore, that information should be explained to them in great detail. Contacting medical control for assistance to convince the patient of the need for transport can be very useful. Always document in detail the information you provide to the patient and, if the patient continues to refuse transport, have the patient sign a document of refusal or an "against medical advice" form.

reassessment: genital injuries

Repeat the patient's primary assessment and vital signs. Reassess the interventions and treatment you have provided to the patient. Identify trends in pain, vital signs, and the progress of treatments to determine whether the patient's condition is improving or getting worse. Adjustments in care should be based on these objective findings. When treating patients with trauma to the genitourinary system, the concerns are similar to those for other injuries to other body systems. Provide oxygen if there are signs of dyspnea or shock and maintain a patent airway. Attempt to control bleeding and treat for shock. Place the patient in a position of comfort and transport to the appropriate facility. Communicate your suspicions and concerns early with the receiving facility staff so they can be adequately prepared and, if required, have a specialist en route to evaluate and treat the patient. Your documentation should be complete and thorough. Describe all injuries and the treatment given. Remember, your documentation is your legal record of what happened.

Injuries from Seat Belts and Air Bags

Seat belts have prevented many thousands of injuries and saved many lives, including those of people who otherwise would have been ejected during a motor vehicle crash. However, seat belts occasionally cause blunt injuries of the abdominal organs. When worn properly, a seat belt lies below the anterior superior iliac spines of the pelvis and against the hip joints. If the seat belt lies too high, it can squeeze abdominal organs or great vessels against the spine when the vehicle suddenly decelerates or stops Figure 30-5 . Occasionally, fractures of the lumbar spine have been reported. If you are called to the scene of such a crash, keep in mind that the use of seat belts in many cases turns what could have been a fatal injury into a manageable one. In later stages of pregnancy the gravid uterus displaces the urinary bladder to the anterior. This anatomic change allows the normally protected bladder to become more susceptible to injuries from impacts and the seat belt. Pregnant patients who adjust the lap belt portion for comfort as opposed to functionality can sustain further injuries. In all current-model vehicles, the lap and diagonal (shoulder) safety belts are combined into one so that they may not be used independently. Of course, people can still place the diagonal portion of the belt behind their back, significantly reducing the effectiveness of this design. Remember to inspect beneath the air bag for signs of damage to the steering column.

Abdominal Evisceration

Severe lacerations of the abdominal wall may result in an evisceration, in which internal organs or fat protrude through the wound Figure 30-11 . Never try to replace an organ that is protruding from an abdominal laceration, whether it is a small fold of peritoneum or nearly all of the intestines. Instead, cover it with sterile dressings moistened with sterile saline solution and secure with a bandage and tape. (Protocols in some EMS systems call for an occlusive dressing over the dressings.) Because the open abdomen radiates body heat very effectively, and because exposed organs lose fluid rapidly, you must keep the organs moist and warm Figure 30-12 . Do not use any material that is adherent or loses its substance when wet, such as toilet paper, facial tissue, paper towels, or absorbent cotton. Treat the patient for shock by keeping the patient warm and placing the patient in the supine position. Provide high-flow oxygen and transport according to local protocols and destination policy. Transport the patient to the highest level trauma center available.

Solid Organ Injuries

Solid organs (liver, spleen, diaphragm, kidneys, and pancreas) can bleed significantly and cause rapid blood loss that can be hard to identify from a physical examination because the patient is not experiencing significant pain. Conversely, solid organs can slowly ooze blood into the peritoneal cavity, causing pain to increase slowly over time and increasing the chance for toxicity to develop. Blood in the peritoneal cavity irritates tissue and fills any voids or spaces, which can make it difficult for you to determine the exact source of the bleeding. Because of the structures in the retroperitoneal space and the spaces in the abdominal cavity, the peritoneal cavity can hold a large volume of blood following traumatic injuries of solid organs and major blood vessels.

Urinary Bladder damages

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 rapid transport, and monitor the patient's vital signs en route.

External Female Genitalia

The external female genitalia include the vulva, the clitoris, and the major and minor labia (lips) at the entrance of the vagina. Injuries of the external female genitalia can include all types of soft-tissue injuries. Because these genital parts have a rich nerve supply, injuries are very painful. Vaginal bleeding may occur because of penetrating or blunt trauma. These injuries can be accidental, as in the case of straddle injuries from bicycles or motorcycles; or they can be intentional as in the case of assaults. Determining the MOI will assist you in deciding if you need to call for additional resources, as in the case of sexual assault. In any case of trauma, it is important to determine the possibility of pregnancy. Ask the patient for the date of her last known menstrual period or if she has been sexually active. Assume all women of childbearing age are possibly pregnant. This information is medically relevant because there are medications and tests that are harmful for a fetus and there is the potential for another source of blood loss in the gravid uterus. In cases of external bleeding and trauma, a sterile absorbent sanitary napkin or pad may be applied to the labia. Do not insert instruments, gloved fingers, or a tampon into the vagina because this can cause further damage.

Anatomy of the Genitourinary System

The genitourinary system controls both the reproductive functions and the waste discharge system, which are generally considered together. The organs of the genitourinary system, such as the kidneys and urinary bladder, are located in the abdomen. The urinary system controls the discharge of certain waste materials filtered from the blood by the kidneys. In the urinary system, the kidneys are solid organs; the ureters, urinary bladder, and urethra are hollow organs The genital system is also important to the reproductive processes. The male genitalia, except for the prostate gland and the seminal vesicles, lie outside the pelvic cavity Figure 30-14 . The female genitalia, except for the vulva, clitoris, and labia, are contained entirely within the pelvis Figure 30-15 . The male and female reproductive organs have certain similarities and, of course, basic differences. They allow for the production of sperm and egg cells and appropriate hormones, the act of sexual intercourse, and, ultimately, reproduction.

damage to the liver

The liver is the largest organ in the abdomen. It is very vascular; therefore, it can contribute to hypoperfusion if it is injured. It is often injured by a fractured lower right rib or a penetrating trauma, such as a stab wound. A common finding during assessment of patients with an injured liver is referred pain to the right shoulder. Like the liver, the pancreas and spleen are organs responsible for filtering blood and are therefore very vascular. Both organs are prone to heavy bleeding when fractured by blunt force or lacerated or punctured by penetrating injury. The spleen is often injured during motor vehicle crashes, especially in the cases of improperly placed seat belts or impact from the steering wheel, falls from heights or onto sharp objects, and bicycle and motorcycle crashes where the patient hits the handlebars on impact. Referred left shoulder pain also occurs in some cases of splenic injury.

secondary assessment: Genital Injuries

The secondary assessment is a more detailed, comprehensive examination of the patient that is used to uncover injuries that may have been missed during the primary assessment. In some instances, such as with a critically injured patient or a short transport time, you may not have time to conduct a secondary assessment. Genitourinary system injuries can be awkward to evaluate and can be even more awkward to treat. Privacy is a genuine concern. When examining the patient, expose only what is needed. If an area must be exposed, cover it after it has been examined. Being professional helps reduce anxiety for both you and your patient. If possible, a provider who is the same gender as the patient should perform direct assessment of the genitalia. However, never delay treatment of any reason if hemorrhage is significant and potentially life threatening. When your patient has an isolated injury to the genitourinary system with a limited MOI, focus your assessment on the isolated injury, the patient's concern, and the body region affected. Look for DCAPBTLS. Ensure that wounds are identified and the bleeding is controlled. Note the location and extent of the injury. If there is significant trauma (such as a blunt trauma) likely affecting multiple systems, start with an exam of the entire body looking for DCAP-BTLS to determine the nature and extent of genitourinary injury. This examination will help determine all the injuries and the extent of those injuries. Inspect or visualize the region looking for deformities that may reveal the presence of multiple rib fractures (that could injure the kidneys). Identify small areas of contusions or abrasions that may pinpoint a specific point of impact. The presence of penetrating injuries indicates a possible internal injury that should be managed accordingly. The presence of burns must be noted and managed appropriately. Palpate for tenderness to localize the injury and the presence of fractures. Look for lacerations and local swelling. Applying this systematic approach to patient assessment minimizes the chance of missing a significant injury. With genitourinary injuries, it is important to not focus only on one area of the body. With significant trauma, you should quickly assess the entire patient from head to toe. Obtain the patient's vital signs. Patients who have hidden injuries may have internal bleeding and their condition may rapidly become unstable. It is important to reassess the vital signs to identify how quickly the patient's condition is changing. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and cool, moist, and pale skin indicate hypoperfusion and imply the need for rapid treatment at the hospital. The reassessment of your patient's vital signs will give you a good understanding of how well or how poorly your patient is tolerating the injury.

Internal Female Genitalia

The uterus, ovaries, and fallopian tubes are subject to the same kinds of injuries as any other internal organ. However, they are rarely damaged because they are small, deep in the pelvis, and well protected by the pelvic bones. Unlike the urinary bladder, which lies adjacent to the bony pelvis, they are usually not injured as a result of a pelvic fracture. An exception is the pregnant uterus. As pregnancy progresses, the uterus enlarges substantially and rises out of the pelvis, becoming vulnerable to both penetrating and blunt injuries. These injuries can be particularly severe because the uterus has a rich blood supply during pregnancy. You must also keep in mind that the fetus is at risk. You can expect to see the signs and symptoms of shock with these patients; be prepared to provide all necessary support and prompt transport. Note also that contractions may begin. If possible, ask the patient when she is due to deliver, and report this information to the hospital staff. In the third trimester of pregnancy, the uterus is large and may obstruct the vena cava, leading to a decrease in the amount of blood returning to the heart if the patient is placed in a supine position (supine hypotensive syndrome). As a result, blood pressure may decrease. The patient should be carefully placed on her left side so that the uterus will not lie on the vena cava. If the patient is secured to a backboard, tilt the board to the left

abdominal quadrants

These areas are the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ). Remember, right and left refer to the patient's right and left, not yours.

When a patient reports pain that is tearing and describes it as going from the abdomen posteriorly.........

When a patient reports pain that is tearing and describes it as going from the abdomen posteriorly, he or she is often describing symptoms of an abdominal aneurysm that is dissecting. Pain that is following the angle from the lateral hip to the midline of the groin can be the result of damage to the kidneys or the ureters. Pain primarily located in the right lower quadrant can indicate an inflamed or ruptured appendix. Pain from the gallbladder due to direct injury or inflammation can be found just under the margin of the ribs on the right side or between the shoulder blades. As blood and fluid from damaged organs flow into the peritoneal cavity, the common response is acute pain in the entire abdomen, which spreads as the blood or contaminant seeks out the voids in the peritoneal cavity. The resulting peritonitis or inflammation of the peritoneum can produce pain if the affected area is exposed to any jarring motion. This is commonly referred to as rebound tenderness. As an EMT, you do not need to produce rebound tenderness intentionally when examining the patient. It is often discovered when you are moving the patient onto the stretcher or into the ambulance.

history taking: Genital injuries

When determining the chief complaint, you are seeking the primary reason that the patient called for assistance. Begin your interview by establishing why the patient called 9-1-1. Ask about associated complaints, but be cautious not to put words in the patient's mouth, such as when describing pain. This can be avoided by asking, "What else is wrong?" or "Is anything else bothering you?" Common associated complaints with genitourinary injuries are nausea, vomiting, diarrhea, blood in urine (hematuria), vomiting blood (hematemesis), or abnormal bowel and bladder habits such as an increase in frequency or the absence of the need to void. You can use the SAMPLE history to further gather more facts and specifics about the chief complaint.Use the SAMPLE mnemonic device to help determine the patient's baseline. Establish the signs and symptoms of the injury. Use OPQRST to learn more about any pain the patient reports. Ask the patient about output from the genitourinary system, specifically the presence of blood in the urine. This may or may not be visible, and the simple lack of it does not preclude your patient from having internal genitourinary injuries. Ask your patient about any allergies to medications or environmental triggers. Medications mask the signs and symptoms of injuries or make them more severe, so it is important to determine what your patient is prescribed and what over-the-counter or herbal remedies the patient may have taken. The importance of past medical history cannot be overstated. Incidence of repeated or previous injury or illness involving the genitourinary system can help determine the extent of the current injury and possibly the MOI. The last intake of both food and fluids is important because it can predict what is contained in the genitourinary system and if the symptoms are related to the ingestion of those foods and fluids. Finally, addressing the events that led to the injury help determine the MOI and help you draw conclusions and develop an index of suspicion.

Primary Assessment: Abdominal & Genital Injuries

Your goal in the primary assessment is to evaluate the patient's ABCs and then immediately care for any life threats. First perform a primary assessment. The general impression, including an evaluation of the level of consciousness, will help you establish the seriousness of the patient's condition. Some abdominal injuries will be obvious and graphic; however, most will be very subtle and may go unnoticed. Considering the MOI together with the general impression will help you focus on the immediate problem. Remember, in some cases of trauma or blows to the abdomen, the injury may have occurred hours or even days earlier and the pain has now reached a point where it is severe enough for the patient to seek help. As you approach the trauma patient with a suspected closed abdominal injury, important indicators will alert you to the seriousness of the patient's condition. Is the patient awake and interacting with his or her surroundings, or is he or she lying still, not making sounds? Does the patient have any apparent life threats? What color is the patient's skin? Is he or she appropriately or inappropriately responding to you? Your general impression will help you develop an index of suspicion for serious injuries and determine how urgently your patient needs care. Trauma patients with closed abdominal injuries may have what appear to be minor injuries; however, you must not be distracted from looking for more serious hidden injuries. For example, an abrasion to the abdomen may appear to be a superficial injury when in actuality it may be the only outward clue that abdominal organs are injured. Check for responsiveness using the AVPU scale. Ask the alert patient about his or her chief complaint. Unresponsiveness may indicate a life-threatening condition. You should administer high-flow oxygen via a nonrebreathing mask to trauma patients whose level of consciousness is less than alert and oriented and provide rapid transport to the emergency department (ED). Trauma patients with open injuries may have obvious significant injuries that indicate a serious condition. However, other injuries may not be as obvious but may still indicate a very serious condition. Your general impression of how the patient is doing is based on information as simple as the MOI and the patient's level of consciousness. Observations such as bleeding from open injuries, skin color and condition, and gasping respirations also contribute to your general impression and help you determine your treatment priorities and the urgency of care needed. A good question to ask yourself is, "How sick is my patient based on what I know right now?" In trauma patients, life-threatening external hemorrhage must be addressed before airway or breathing concerns. Next, ensure the patient has a clear and patent airway. If a spinal injury is suspected, prevent the patient from moving by having a team member hold the patient's head still and verbally remind the patient not to move. Patients may report feeling nauseous, and they may vomit. Remember to keep the airway clear of vomitus so that it is not aspirated into the lungs, especially in a patient who is unconscious or has an altered level of consciousness. Turn the patient on one side, stabilizing the spine if necessary, and try to clear any material from the throat and mouth. Note the nature of the vomitus: undigested food, blood, mucus, or bile. You must also quickly assess the patient for adequate breathing. A distended abdomen or pain may prevent adequate inhalation. When these guarded respirations decrease the effectiveness of the patient's breathing, providing supplemental oxygen with a nonrebreathing mask will help improve oxygenation. If the patient's level of consciousness is decreased and respirations are shallow, consider supplementing respirations with a bag-valve mask (BVM). Use airway adjuncts as necessary to ensure a patent airway and assist with breathing.Superficial abdominal injuries usually do not produce significant external bleeding. However, internal bleeding from open or closed abdominal injuries can be profound. Trauma to the kidneys, liver, and spleen can cause significant internal bleeding. If you suspect shock, evaluate the patient's pulse and skin color, temperature, and condition to determine the stage of shock. Treat the patient aggressively by providing oxygen, positioning the patient supine, and keeping the patient warm. Wounds should be covered and bleeding should be controlled as quickly as possible. Because of the nature of abdominal injuries, a short on-scene time and rapid transport to the hospital are generally indicated. Abdominal pain together with an MOI that suggests injury to the abdomen or flank is a good indication for rapid transport. In the prehospital environment, it is difficult to determine whether the liver, spleen, or kidney has been injured. Hollow organs that have ruptured are also difficult to identify without more advanced diagnostic equipment. A delay in medical evaluation may result in an unnecessary and dangerous progression to shock. Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable. Treatment should be directed at quickly addressing life threats and providing rapid transport to the nearest appropriate hospital. Patients with abdominal injuries should be evaluated at the highest level trauma center available because of the hidden or occult nature of most abdominal injuries. Transport to a trauma center is indicated for any patient who has an MOI that produces a high index of suspicion and who has any visible significant trauma, blunt or penetrating. Follow local protocols when considering a lower level care center such as acute care sites and clinics. Only the lowest levels of MOI should be considered eligible for these types of facilities.

Scene Size Up: Abdominal & Genital Injuries

Your scene size-up begins with the information reported from dispatch. This information may be vague or incomplete, but can still provide information to consider as you prepare to respond. For example, is the patient injured or ill? Could one have led to the other? What equipment might you need to assess and treat the patient? Standard precautions should be taken prior to arrival at the scene; gloves and eye protection should be a minimum. When you arrive at the scene, you will continue to gather information that will help manage the incident. Observe the scene for hazards and threats to your safety. Make sure the scene is safe and that law enforcement personnel have controlled the scene if necessary. If additional resources are needed, call for them early, and consider early ALS intercept for patients who may become unstable. As you observe the scene, look for indicators of the MOI, and consider early spinal stabilization. This helps you develop an early index of suspicion for underlying injuries in the patient who has sustained a significant MOI. As you put together information from dispatch and your observations of the scene, consider the possible injuries the MOI could have produced. Patient Assessment of Abdominal Injuries As you inspect a vehicle, look at the damage. Could this damage result in an abdominal injury? In the case of an assault, think about how many times the patient was struck, where the patient was struck, and with what object. If the wound is penetrating, inspect the object of penetration if possible. Does the object have a serrated, smooth, or jagged edge? Is it clean or dirty? How long is it? The MOI may also provide indications of potential safety threats. For example, a stab wound may indicate the presence of a violent individual. Weapons can provide useful information for hospital staff; however, do not spend too much time searching for a weapon, and be careful not to contaminate evidence in the process.

Low-velocity penetrations

also have the capacity to damage underlying organs. This internal injury may not be apparent during the physical examination. The bleeding entrance wound may hide the fact that the object went farther and deeper into the peritoneal cavity and injured other organs and tissues. This is especially important information to remember when an injury occurs in the region where the thoracic cavity and the peritoneal cavity are separated by the diaphragm. Any time your patient has an injury at or below the xiphoid process, it should be assumed that both cavities have been violated.

open abdominal injuries

are those in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside; these are also known as penetrating injuries Figure 30-6 . Stab wounds and gunshot wounds are examples of open injuries, or penetrating trauma. Open wounds may not be deeper than the muscular wall of the abdomen; however, this cannot be determined in the prehospital setting. Therefore, you should maintain a high index of suspicion for unseen injuries, internal damage to organs, and potential life-threatening injuries and provide rapid transport. Patients with open abdominal injuries must be assessed and evaluated at the hospital.

closed abdominal injuries

are those in which blunt force trauma, some type of impact to the body, results in injury to the abdomen without breaking the skin. Such a blow might come from the patient striking the handlebar of a bicycle or the steering wheel of a car, or when the patient is struck by a wooden board or baseball bat during a fight or assault

compression injuries

are typically caused by a poorly placed lap belt. This creates an injury pattern called a clasp-knife injury, an exaggerated resistance of muscles, resembling the opening of a penknife or clasp knife. A compression injury can also be caused when a person is run over or rolled over by a vehicle or object. Deceleration injuries commonly occur when a person or the vehicle the person is traveling inside strikes a large immovable mass, such as a larger vehicle, a bridge abutment, or the ground.

solid organs

as their name suggests, are solid masses of tissue. They include the liver, spleen, pancreas, and kidneys. It is here that much of the chemical work of the body—enzyme production, blood cleansing, and energy production—takes place. Solid organs have a rich blood supply, so injury can cause severe and unseen hemorrhage. The same is true of the aorta or inferior vena cava, whether the injury is open or closed. Blood may irritate the peritoneal cavity and cause the patient to report abdominal pain; however, this may not always occur. Therefore, the absence of pain and tenderness does not necessarily mean the absence of major bleeding in the abdomen. Many solid organs, in addition to the great vessels, the abdominal aorta, and the inferior vena cava, are found in the retroperitoneal region (behind the peritoneum). This area also houses the kidneys, ureters, and urinary bladder. The majority of the pancreas is located in this region, which is why the pancreas is referred to as a retroperitoneal organ. The last portion of a hollow organ, the colon, occupies the lowest portion of the retroperitoneal space.

High- and medium-velocity injuries

have temporary wound channels in addition to the exit and entrance wounds. These temporary channels are caused by cavitation. A cavity forms as the pressure wave from the projectile is transferred to the tissues. This causes microscopic tears to the blood vessels and nerves, expanding the width and length of the wound beyond what you can see during physical examination. Cavitation can produce significant bleeding depending on the speed or velocity of the penetrating object. The higher the velocity of the projectile, the larger the cavity it produces, typically resulting in a larger amount of tissue damage

Urethral injuries

in men are not uncommon. Lacerations of the urethra can result from straddle injuries, pelvic fractures, or penetrating wounds of the perineum. These injuries may bleed profusely, although bleeding may not be evident externally. Direct pressure with a dry, sterile dressing usually controls any external hemorrhage. Because the urethra is the channel for urine, it is very important to know whether the patient can urinate and whether hematuria is present. For this reason, you should save any voided urine for later examination at the hospital. Any foreign bodies that may be protruding from the urethra will have to be removed in a surgical setting. Avulsion of the skin of the scrotum may damage the scrotal contents. If possible, preserve the avulsed skin in a moist, sterile dressing for possible use in reconstruction. Wrap the scrotal contents or the perineal area with a sterile, moist compress, and use a local pressure dressing to control bleeding. Promptly transport the patient to the ED. Direct blows to the scrotum can result in the rupture of a testicle or significant accumulation of blood around the testes. In either case, you should apply an ice pack to the scrotal area while transporting the patient.

hollow organs

including the stomach, large and small intestines, ureters, and urinary bladder, are actually structures through which materials pass Figure 30-2 . Most of these organs will contain food that is in the process of being digested, urine that is being passed to the urinary bladder for release, or bile.

small intestine

is composed of the duodenum, the jejunum, and the ileum. The large intestine includes the cecum, the colon, and the rectum. The intestinal blood supply comes from the mesentery. The term mesentery refers to any fold of tissue that attaches an organ to the body wall. However, the majority of time the term is used in reference to the intestinal mesentery: a fold of tissue that contains a web of vessels, both arteries and veins, as well as nerves and lymphatic tissues. It connects the small intestine to the posterior of the abdominal wall. Both blunt and penetrating abdominal injuries affect this vasculature, and patients with injuries to the mesentery can bleed significantly into the peritoneal cavity. A common sign of bleeding in the abdomen is rigidity, with an almost boardlike feeling to the abdomen. Occasionally you will find bruising around the belly button (periumbilical bruising) or ecchymosis.

abdominal distention

or swelling that occurs between the xiphoid process and the groin is often the result of free fluid, blood, or organ contents spilling into the peritoneal cavity. Swelling can also be the result of air in the form of gases from the bowel or from infection. Tenderness is another sign of a closed abdominal injury. Additional signs of abdominal injury are bruising and discoloration. Another likely injury is lower rib fractures—a trauma that was forceful enough to break the ribs may also have damaged internal organs. Closed abdominal injuries may initially appear as abrasions to the surface of the skin depending on the MOI, such as a physical assault or a pedestrian struck by a motor vehicle. In some circumstances, depending on how deep in the abdomen the injury occurs, it may take several minutes to hours for the contusion or hematoma to become present on the surface. Therefore, it is not prudent for you to rule out injury simply on the basis of absence of these findings.

damage to kidney

the kidneys can be impacted or penetrated by trauma. The kidneys are filtration organs; therefore, they are supplied with large quantities of blood. They can be sheared from their base, crushed, or fractured— causing significant blood loss. If the kidney is injured, a common finding is hematuria, or blood in the urine. This may be obvious to the naked eye or impossible to detect in the field. You may find drops of blood or blood-tinged urine on the patient's underwear, leading you to inspect the exterior of the genitals. Blood visible on inspection of the urinary meatus (opening of the urethra situated on the glans penis in men and in the vulva in women) indicates significant trauma to the genitourinary system. If blood is not present, do not take this as a sign that the patient is free from injury; the blood may not be visible yet.

An open abdominal injury that goes through.....

the skin and muscle layer and through the fascia or the interior covering of the abdomen, such that organs now protrude from the peritoneum, is an evisceration. This visually shocking injury can be extremely painful. Do not push down on the patient's abdomen, and perform only a visual assessment when there is any suspicion of this type of injury. If there is clothing close to the wound, carefully cut the clothing around the wound, leaving a border of intact cloth outside the injured area. Never pull, even gently, on any clothing stuck to or inside the wound channel because this may remove even more of the abdominal contents.

Determining the location of the pain or referred pain can be more difficult when the patient has

voluntary or involuntary guarding. In guarding, the patient either consciously or unintentionally stiffens the muscles of the surface of the abdomen. Most often it is the rectus abdominis muscles that are held tight, and the tightness can be mistaken for abdominal rigidity. This stiffening is a natural response to abdominal pain; the body is attempting to splint the area to prevent unnecessary movement and to avoid further pain.

There are three levels of velocity that are commonly discussed in traumatic injuries.

▪ Low-velocity injuries. Caused by hand-held or handpowered objects such as knives and other edged weapons▪ Medium-velocity penetrating wounds. Caused by smaller caliber handguns and shotguns▪ High-velocity injuries. Caused by larger weapons such as high-powered rifles and the higher-powered handguns

Other mechanisms of injury include the following:

▪ Motorcycle crashes ▪ Falls▪ Blast injuries▪ Pedestrian injuries ▪ Compression ▪ Deceleration

External Male Genitalia damages

▪ These injuries are very painful. Make the patient as comfortable as possible.▪ Use sterile, moist compresses to cover areas that have been 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.▪ If possible, always identify and take avulsed parts to the hospital with the patient. Label the bag with the patient's name.