CHAPTER 31 Abdominal and Genitourinary Injuries EXAM 6

Blunt trauma causes the organ to

"pop," releasing fluids and air.

Emergency Medical Care of Rectal bleeding

1. Common complaint 2. Possible causes include sexual assault, rectal foreign bodies, hemorrhoids, colitis, and ulcers in the digestive tract. 3. Significant rectal bleeding can occur after hemorrhoid surgery.

§Potential for patient embarrassment

1. Maintain a professional presence. 2. Provide privacy during assessment. 3. When possible, have an EMT of the same gender perform the assessment.

§Closed abdominal injuries

1. Monitor the patient closely and evaluate for progression into shock. 2. The patient may experience nausea and vomiting; have suction available. 3. Administer oxygen to patients who are unconscious or who are in shock. 4. Keep the patient warm. 5. Assist ventilations if necessary. 6. Consider calling ALS for placement of an oral or nasal gastric tube.

§Open abdominal injuries

1. Patients with penetrating injuries a. Generally obvious wounds and external bleeding; however, significant external bleeding is not always present b. Maintain a high index of suspicion for serious, unseen blood loss.

Emergency Medical Care of Female genitalia

1. Treat lacerations, abrasions, and avulsions with moist, sterile compresses. a. Use local pressure to control bleeding. b. Hold dressings in place with a diaper-type bandage. 2. Do not pack dressings into the vagina.

Sexual assault and rape are common

1. Victims are generally women. 2. Sometimes men and children are victims. B. Often there is little that you can do beyond providing compassion and transport. 1. The patient may have sustained multisystem trauma and need treatment for shock

Assessment of an isolated abdominal injury

1. Visually inspect the abdomen for penetrating wounds. 2. If an entrance wound is found, check for a corresponding exit wound. 3. Do not remove an impaled object.

Emergency Medical Care of External male genitalia

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.

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

A. applying an occlusive dressing, secured by trauma dressings. Although the preferred management for an abdominal evisceration includes the application of a moist, sterile dressing covered by a dry dressing, protocols in some EMS systems call for an occlusive dressing, secured by trauma dressings. An occlusive dressing may help prevent the loss of body heat through the abdominal wound.

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

A.Legs drawn up Patients with peritonitis often lie very still and tend to have their legs drawn up into the abdomen. This relieves strain on the abdominal muscles and may provide pain relief.

2.Which of the following organs would be the MOST likely to bleed profusely if severely injured?

A.Liver The liver is a highly vascular solid organ, and contains approximately 40% of the body's total blood volume at any given time. If severely injured, bleeding from the liver would be profuse and rapid. Other solid organs, such as the spleen and kidneys, may also produce severe bleeding if injured, though not as rapid as the liver. The stomach and gallbladder are hollow organs; if lacerated, they would spill their contents into the abdominal cavity, resulting in peritonitis.

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

A.a deformed steering wheel. Airbags save lives when used in conjunction with properly worn seat belts. Unfortunately, however, not all drivers wear their seat belts. If unrestrained, the driver's abdomen may strike the steering wheel, resulting in significant trauma. Suspect this if you lift the airbag and note that the lower part of the steering wheel is deformed.

9.The term "hematuria" is defined as:

A.blood in the urine. Blood in the urine is called hematuria. Following trauma, the presence of hematuria suggests injury to the urinary bladder or kidneys. Bright red blood in the stool is called hematochezia; dark, tarry stools are called melena. Vomiting up blood is called hematemesis.

4.Even when seat belts are worn properly and the airbags deploy, injury may occur to the:

A.iliac crests. Seat belts should be positioned over the iliac crests of the pelvis. If they are positioned higher, significant intra-abdominal injury can occur. Even when seat belts are properly positioned and the airbags deploy, injury to the iliac crests may occur as the locking mechanism of the seat belt engages during a motor vehicle crash that involves rapid deceleration.

1.Peritonitis would MOST likely result following injury to the:

A.stomach. In general, solid organs bleed when injured and hollow organs spill their contents into the abdominal cavity, resulting in peritonitis—inflammation of the intra-abdominal lining. Of the choices listed, the stomach is the only hollow organ.

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

A.use local pressure to control bleeding. Bleeding from the external genitalia should be controlled by applying a dry, sterile dressing and local direct pressure. Never pack anything into the vagina to try to control bleeding; this increases the risk of infection, and anything you place into the vagina will only need to be removed at the hospital. Impaled objects in the genitalia should be carefully stabilized in place, not removed.

Patient Assessment of Abdominal Injuries

Assessment finding in patients with potential abdominal injuries can be challenging to interpret. 1. Some are obvious; however, many are easy to overlook. 2. Patient may be overwhelmed with other more painful injuries. 3. Some abdominal injuries develop and worsen over time.

3.Which of the following statements regarding intra-abdominal bleeding is FALSE? A.Intra-abdominal bleeding often causes abdominal distention. B.Intra-abdominal bleeding is common following blunt force trauma. C.The absence of pain and tenderness rules out intra-abdominal bleeding. D.Bruising may not occur immediately following blunt abdominal trauma.

C. The absence of pain and tenderness rules out intra-abdominal bleeding. Intra-abdominal bleeding is common following blunt trauma to the abdomen. Signs include abdominal distention, rigidity, bruising (may not occur immediately), and in some cases, pain to palpation. However, unlike gastric juices and bacteria, blood within the abdominal cavity does not provoke an inflammatory response; therefore, the absence of pain and tenderness does not rule out internal bleeding.

Low-velocity injuries

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

§High-velocity injuries

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

Anatomy of the Genitourinary System

Controls reproductive functions and waste discharge

Emergency Medical Care of Kidney injuries

Damage may not be obvious upon inspection. a. You may see signs of shock and/or blood in the urine 2. Treat for shock, transport promptly, and monitor vital signs en route to the hospital.

LLQ

Descending colon, left transverse colon

§High- and medium-velocity injuries

Have temporary wound channels

Emergency Medical Care of

Identify and take avulsed parts to the hospital with patient. i. If patient has an avulsion of skin on the penis: (a) Wrap the penis in a soft, sterile dressing moistened with sterile saline. (b) Transport promptly. (c) Use direct pressure to control any bleeding. (d) Try to save and preserve the avulsed skin.

RLQ

Large and small intestine, appendix

Emergency Medical Care of Female genitalia (cont'd)

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.

RUQ

Liver, gallbladder, duodenum, pancreas

§Kidney injuries

Not uncommon 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 such as a football tackle.

§External male genitalia injuries

Soft-tissue wounds Painful and of great concern for the patient, but rarely life-threatening a. Rarely life-threatening b. Should not be given priority over more severe wounds unless there is significant bleeding c. Pain may be referred to as the lower abdomen

LUQ

Stomach and spleen

Emergency Medical Care of Urinary bladder injury

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.

Injuries to the abdomen that go unrecognized or are not repaired in surgery are

a leading cause of traumatic death.

§Follow 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.

§Suspect kidney damage if patient has 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.

§Female genitalia injuries (cont'd)

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. 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. d. In cases of external bleeding and trauma, a sterile absorbent sanitary napkin or pad may be applied to the labia. e. Do not insert instruments, gloved fingers, or a tampon into the vagina.

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.

§Female genitalia injuries

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.

Evisceration can be

a. 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.

Organs of the genitourinary system are located in the

abdomen a. Kidneys are solid organs. b. Ureters, bladder, and urethra are hollow organs. 2. The male genitalia lie outside the pelvic cavity, except for the prostate gland and seminal vesicles. 3.The female genitalia are contained entirely within the pelvis, except the vulva, clitoris, and labia

§Low-velocity injuries

also have the capacity to damage underlying organs. i. Internal injury may not be apparent during physical examination. ii. Any time a patient has an injury at or below the xiphoid process, it should be assumed that the thoracic and peritoneal cavities have been violated.

The proper position for a seat belt is

below the anterior superior iliac spines of the pelvis and against the hip joints, as shown in diagram

In later trimesters of pregnancy

bladder injuries increase from displacement of the uterus.

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.

Patients with injuries to the mesentery can

bleed significantly into the peritoneal cavity. Signs of this include abdominal rigidity and periumbilical bruising.

Hollow Organ Injuries caused by

blunt and penetrating trauma

Evisceration

bowel protrudes from peritoneum

§High- and medium-velocity injuries caused by

cavitation

The solid organs are solid masses of tissue that do much of the

chemical work in the body and receive a large, rich supply of blood.

The abdomen extends from the

diaphragm to the pelvis and contains the organs that make up the digestive, urinary, and genitourinary systems

Penetrating trauma causes

direct injury, such as lacerations and punctures

The gallbladder and the urinary bladder are

hollow organs whose contents are potentially irritating and damaging if ruptured. a. These fluids move into loose spaces and voids in the peritoneal cavity, eventually leading to infection.

Liver, spleen, pancreas, kidneys perform chemical work of the body like:

i. Enzyme production ii. Blood cleansing iii. Endocrine function iv. Energy production Because of their rich blood supply, hemorrhage of solid organs can be severe

Follow the general procedures described previously for the 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.

MALE---Urethral injuries are not uncommon---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.

The appendix is a source of

infection if it ruptures.

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

kidney The flanks are located laterally in the back and overlie the kidneys. During football, spearing injuries occur when a player is struck in the flank by another player's helmet. This can result in injury to the kidney ranging from bruising to severe bleeding. Injury to the liver, spleen, and bladder would more likely occur following blunt trauma to the anterior abdomen.

Diaphragm when penetrated or ruptured

loops of bowels may herniate into the thoracic cavity. a. Patients may exhibit dyspnea b. 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.

Intestinal blood supply comes from

mesentery (fold of tissue that connects the small intestine to the abdominal wall).

Fracture of the pelvis can result in

perforation of the bladder by the bony fragments. Urine then leaks into the pelvis.

Hollow Organ Injuries---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.

Retroperitoneal space is in the

posterior aspect of the abdomen and behind the peritoneum. Contains the kidneys, ureters, urinary bladder, and the majority of the pancreas.

Cavitation occurs as the

pressure wave from the projectile is transferred to the tissues. The higher the velocity of the projectile, the larger the cavity it produces.

In males, sudden deceleration from a motor vehicle or motorcycle crash can

shear the bladder from the urethra.

Solid organs can also

slowly ooze blood into the peritoneal cavity, causing pain to increase slowly over time.

Referred left shoulder pain also occurs in

some cases of splenic injury.

The hollow organs of the abdomen include the

stomach, intestines, ureters, and bladder.

When hollow organs of the abdomen are ruptured or lacerated

the contents spill into the peritoneal cavity causing inflammation and possible infection (peritonitis) Severe abdominal pain, tenderness, and muscular spasm.

Liver is the

the largest organ in the abdomen. a. Very vascular and can contribute to hypoperfusion if injured b. Often injured by a fractured lower right rib or a penetrating trauma c. A common assessment finding is referred pain in the right shoulder.

The hollow organs in the abdominal cavity are structures through

which materials pass.

§Laceration of head of penis

§Associated with heavy bleeding §Apply local pressure with sterile dressing.

Closed Abdominal Injuries S&S

§Blood in the peritoneal cavity produces acute pain in the entire abdomen. §Abdominal distention is often the result of free fluid, blood, or organ contents spilling into the peritoneal cavity. §Abdominal bruising and discoloration

Open Abdominal Injuries

§Foreign object enters the abdomen and opens the peritoneal cavity to the outside.

§Skin of shaft or foreskin caught in zipper

§If small segment of zipper is involved, try to unzip. §If long segment of zipper is involved, cut the zipper out of the pants with heavy scissors.

Sexual Assault 2

§Make sure EMT caring for patient is same gender as patient whenever possible. §Treat medical injuries and provide privacy, support, and reassurance.

Seat belts

§May cause blunt injuries of abdominal organs §Particularly when the belt lies too high §Can cause bladder injuries to pregnant patients §Remember to inspect beneath the airbag for signs of damage to the steering column.

Blunt trauma to the abdomen MOIs capable of causing closed injuries:

§Motor vehicle crashes §Motorcycle crashes §Falls §Blast injuries §Pedestrian versus bicycle §Rapid deceleration §Compression

§Common associated complaints with genitourinary injuries are:

§Nausea and vomiting §Diarrhea §Blood in urine §Vomiting blood §Abnormal bowel and bladder habits

Emergency Medical Care of Evisceration

§Never try to replace a protruding organ. §Keep the organs moist and warm. §Cover with moistened, sterile dressings. §Secure dressing with bandage. §Secure bandage with tape.

Hollow Organ Injuries

§Often have delayed signs and symptoms §Spill contents into the abdomen §Infection develops, which can take hours or days. §Stomach and intestines can leak highly toxic and acidic liquids into the peritoneal cavity.

§Medium-velocity injuries

§Smaller caliber handguns and shotguns

Spleen and pancreas

§Vascular and prone to heavy bleeding §Spleen is often injured. §Motor vehicle collisions §Steering wheel trauma §Falls from heights §Bicycle and motorcycle accidents involving handlebars

When an erect penis is

§bent sharply, the shaft can be severely damaged. §Sometimes requires surgical repair §Associated with intense pain, bleeding, and fear

Significant trauma to the abdomen can occur from

§blunt trauma, penetrating trauma, or both.

External male genitalia---Direct blows to scrotum

§can result in the rupture of a testicle or accumulation of blood around the testes. Apply ice to the scrotal area.

Do not examine

§genitalia unless obvious bleeding requires the application of the dressing. §Follow appropriate procedures and protocol. §Shield patients from curious onlookers. §Document the patient's history, assessment, treatment, and response to treatment.

Urinary bladder injuries May result in

§rupture §Urine spills into surrounding tissues. §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.

External male genitalia---Avulsion of the skin of the

§scrotum may damage scrotal contents. §Preserve avulsed skin in a moist sterile dressing. §Wrap scrotal contents or perineal area with a sterile moist compress.

RLQ is a common location for

§swelling and inflammation.