Chapter 36- abdominal and Genitourinary trauma

female genitalia

Blunt trauma may result from: a. Motor vehicle crashes with high-energy impact b. Saddle type injuries 2. Lacerations to the vaginal wall, uterine rupture, or ovarian contusion may occur. 3. Trauma to the external genitalia may produce contusions to the vulva or labia. 4. Penetrating trauma may result from stabbings to the lower pelvis or gunshot wounds. a. Injuries to the abdomen or upper legs may have damaged reproductive organs

hollow organs are more resilient to blunt trauma

Hollow organs are more resilient to blunt trauma. a. They are less likely to be injured unless they are full. b. When full, they are likely to be injured and burst. i. Substances can be released into the abdominal cavity. c. Spillage of hollow organs can cause peritonitis. i. Inflammation of the lining of the abdomen (peritoneum)

intestines

Injuries to the small and large intestines i. These injuries most commonly occur from penetrating trauma. ii. Rupture causes contents (fecal matter and bacteria) to spill into the peritoneal or retroperitoneal cavities. (a) Results in peritonitis iii. Blunt trauma to the abdominal wall commonly causes injury to the duodenum. (a) Presents as back pain iv. Penetrating trauma causes injury to the small bowel, stomach, and large intestine. (a) Common cause is the seat belt (b) Symptoms caused by contents rather than blood loss v. Small-bowel and colon injury may present with only generalized pain.

The abdominal cavity is the largest cavity in the body, extending from the diaphragm to the pelvis.

The abdominal cavity contains several vital organ systems. a. These organ systems are vulnerable to trauma because of: i. Location ii. Lack of protective structures from the skeletal system b. Trauma may be caused by blunt or penetrating force. i. Ranges from minor single-system injuries to complicated multisystem injuries

anatomic regions

The abdominal cavity extends from the diaphragm to the pelvic brim. a. The pelvic brim stretches at an angle from the intervertebral disk between L5 and S1 to the pubic symphysis

the male reproductive system

The male reproductive system: i. Penis: male reproductive organ ii. Testes (testicles) (a) Produce sperm and secrete male hormones (b) Held outside the body in the scrotal sac (c) Can be retracted by the cremaster muscles

pancreas- solid

The pancreas is located in the retroperitoneal space under the liver and behind the stomach. i. Produces and secretes digestive enzymes and the hormone insulin.

spleen-solid

The spleen is a highly vascular organ. i. Lies in the left upper quadrant ii. Shaped like a catcher's mitt

stomach-hollow

The stomach is an intraperitoneal organ. i. Lies in the upper left quadrant and epigastric region ii. Primarily serves as the storage area for ingested food and liquid

urinary bladder

The urinary bladder is a hollow, muscular sac situated in the pelvis. i. Stores urine until excreted c. The ureters carry urine from the kidneys to the urinary bladder.

Solid organs

can easily be crushed by blunt trauma to the abdomen. a. Spleen (most common) b. Liver (second most common) i. Most frequently injured with penetrating trauma

abdominal wall contusion

can indicate that significant blunt force trauma has been applied to the underlying structures i. Can act as a valuable clue to possible hemorrhagic shock

Frequently, blunt renal trauma presents as

flank pain and hematuria (blood in the urine). a. Suspicion should be high if the patient has obvious hematomas or ecchymoses over the: i. Upper abdomen ii. Lateral aspects of the middle back iii. Lower rib cage b. Fractures of the lower rib cage should also raise suspicion

Penetrating abdominal trauma most often results ...

from stab wounds and gunshot wounds

five patters of impact in a motor vehicle crash

frontal (head on) impact lateral, side-impact, or t-bone collision rotational forces rear-impact collision rollover impact

Pancreatic injuries

have subtle or absent signs. a. Suspect pancreatic injury in rapid deceleration. b. Injury should be suspected after a localized blow to the midabdomen. c. Patients report vague upper and midabdomenal pain radiating to the back. d. Peritoneal signs may develop hours after injury.

The major cause of morbidity and mortality in abdominal trauma is

hemorrhagic shock.

Signs and symptoms of a diaphragmatic rupture can include:

i. Abdominal pain ii. Acute respiratory distress iii. Decreased breath sounds iv. Abdominal sounds in the chest v. Subcutaneous emphysema vi. Sunken abdomen or an abdomen that appears empty

Consider immediate transport to a trauma center for:

i. Adults who have experienced falls greater than 20 ft (6 m). ii. Children who have experienced falls greater than 10 ft (3 m) or two or three times the height of the child.

Duodenal injuries

i. Duodenum can rupture in cases of high-speed deceleration injuries. (a) Contents spill into the retroperitoneum. (b) Contamination causes abdominal pain or fever. (c) Symptoms may not appear for hours or days. (1) Abdominal pain (2) Nausea and vomiting (d) Maintain a high degree of suspicion in any abdominal trauma. (e) Close proximity to other organs means it is unlikely to be injured by itself. (f) Suspect injury in children who have been thrown from a bicycle and strike the handlebars.

In active hemorrhage, presentation includes:

i. Hypotension ii. Tachycardia iii. Shock

Palpation may reveal localized or generalized tenderness, rigidity, and rebound tenderness.

i. Suggest peritoneal injury

The forces of sudden deceleration can be dissipated by the:

i. Surface the person has fallen onto ii. Degree to which that surface can deform (plasticity) under the force

In a gunshot case, determine:

i. Type of gun ii. Number of shots iii. Estimated distance between the victim and assailant (if any)

If a patient has stab wounds, determine:

i. Type of knife ii. Angle of entry iii. Number of stab wounds

female reproductive system

i. Uterus ii. Ovaries b. Can be injured from crushing and compression forces and shearing injuries

Increased hypovolemia

results in initial agitation and confusion. a. The heart compensates by increasing the heart rate and stroke volume. b. Increased hypoperfusion prevents the arteries from being able to meet the increased demands. i. Leads to ischemia and heart failure

The area around the umbilicus is referred to as ...

the periumbilical area.

Evisceration

visceration is externalization of abdominal organs through a wound in the abdominal wall. a. The protrusion may be small or large. b. Little pain is associated with this injury. Apply a saline-soaked sterile dressing over the top of the evisceration. a. Cover the injured area to keep it warm

Hemoperitoneum

(a collection of blood in the abdominal cavity) may not immediately be apparent on abdominal examination alone.

Upper peritoneal cavity:

(a) Diaphragm (b) Liver (c) Spleen (d) Stomach (e) Gallbladder (f) Transverse colon

Lower peritoneal cavity:

(a) Small bowel (b) Sigmoid colon (c) Parts of ascending and descending colon (d) Internal reproductive organs (in women)

An abdominal injury is most often the result of blunt trauma.

mortality rates of 10% to 30%. can cause compression and crushing injuries. i. Can deform solid organs and cause hollow organs to rupture Blunt trauma results from compression or deceleration forces, leading to a closed abdominal injury. i. Soft-tissue damage occurs inside the body, but the skin remains intact.

If a patient has unexplained symptoms of shock....

suspect abdominal trauma

kidneys

The kidneys are located in the retroperitoneal space. i. Filter blood ii. Excrete body wastes in the form of urine

bright red urine

Bright red suggests bleeding in the lower portion of the tract.

dark brown urine

Dark brown suggests bleeding in the upper urinary tract.

Damage can be decreased by factors such as:

i. An empty bladder ii. Toned abdominal muscles

the diaphragm

A dome-shaped muscle that separates the thoracic cavity from the abdominal cavity a. Curves from its point of attachment in the flanks b. Peaks in the center at the fourth intercostal space

liver- solid

The liver lies in the right upper quadrant i. Superior and anterior to the gallbladder and the hepatic and cystic ducts ii. Superior to the stomach iii. Has a significant blood supply provided by the hepatic artery and the hepatic-portal vein

hematuria

(blood in the urine). a. This is a sign of renal and urinary tract injuries.

motorcycles

Helmets transmit any impact to the cervical spine, offering no protection for severe cervical injury. Consider transport to a trauma center with: a. Crashes at speeds greater than 20 mph b. Separation of the rider from the motorcycle

The wall of the corpora cavernosa is torn in penile fracture.

Presentation includes pain and a large hematoma

Kehr sign

The patient presents with referred pain to the left shoulder

evisceration

displacement of an organ outside the body

Trauma to the genitourinary system can be a result of blunt or penetrating trauma.

1. Most injuries involve the kidneys. 2. Consider trauma to the genitourinary system when injuries involve: a. Lower rib cage b. Abdomen c. Pelvis d. Upper legs

Injuries to the testicle or scrotal sac

Blunt trauma can be a result of motor vehicle crashes, physical assaults, or sports injuries. i. May result in contusions, rupture, and torsion ii. Ruptures often caused from sports iii. Frequently present following trauma to the thighs, buttocks, penis, lower abdomen, and pelvis c. Penetrating trauma is caused by stab wounds, gunshot wounds, blast wounds, or animal bites. i. Have a high suspicion for other associated injuries

pain meds

Pain medication may mask symptoms and often is contraindicated due to hypotension. Consult with medical direction en route to the hospital. i. May order an analgesic such as fentanyl

gallbladder-hollow

The gallbladder is a saclike organ on the lower surface of the liver. i. Acts as a reservoir for bile

Rotational forces

a. Often result in cervical spine and abdominal visceral injuries

Retroperitoneal space

i. Area posterior to the peritoneal lining of the abdomen (a) The abdomen contains many vital vessels.

The main causes of death resulting from abdominal trauma are:

i. Hemorrhage ii. Systemic infection

blast

2. Can generate fragments traveling at velocities of 4,500 fps (1,372 m/s) a. This is nearly double the velocity of a projectile from a high-speed rifle. b. Energy transmitted from a fragment will cause extensive and disruptive tissue damage.

peritonitis

(a) Chemical peritonitis may have a sudden onset. (b) Bacterial peritonitis may develop slowly over several hours. iii. Can also be classified as primary or secondary (a) Primary peritonitis occurs when infection travels from the blood or lymph nodes into the peritoneum. (b) Secondary peritonitis occurs when infection travels from the gastrointestinal or biliary tract into the peritoneum. (1) More common

female genitelia

1. Signs of trauma may include: a. Hematomas and ecchymoses in the lower pelvic area and on the external female genitalia b. Bleeding from the vagina c. Tenderness on palpation of the lower pelvis 2. Assessment may reveal clues of sexual assault.

impaled objects

1. Stabilize the object and transport the patient in the position in which he or she was found. a. Do not attempt to remove or manipulate the object. 2. In unusual situations, it may be necessary to shorten a portion of the object while it is still within the abdominal cavity. a. Enables transport 3. Make every attempt to move the object as little as possible in these situations. a. Minimizes tissue damage

female genitalia management

1. Use compression to stem external hemorrhage. 2. Administer replacement fluids to treat hypotensive patients. a. Use pain medication with extreme caution. 3. Do not attempt to remove any object that is stuck in the vaginal canal. a. Transport the patient to the hospital. b. Remember emotional considerations. c. Be familiar with reporting requirements for assault.

spleen injurie

Falls and motor vehicle crashes can injure the spleen, as can less obvious injury patterns, such as sports. ii. Ruptured spleens have been reported in cases where contact was minor. (a) Especially prone if the spleen is enlarged from mononucleosis or disease iii. About 5% of circulating blood filters through the spleen every minute. (a) If the spleen is ruptured, blood spills into the peritoneum, causing shock and death. (b) The spleen can bleed profusely. iv. Penetrating trauma is not much of a threat of shock unless a major blood vessel supplying the organ is lacerated. v. Suspect spleen lacerations if: (a) The 9th through 10th ribs are fractured. (b) The patient presents with left upper quadrant tenderness. (c) The patient presents with signs of peritoneal irritation. (d) The patient presents with referred pain to the left shoulder (Kehr sign). (e) The patient presents with hypotension. (f) There are signs of hypovolemic shock.

Seat belts

a. When worn properly, a seat belt lies below the anterior superior iliac spines of the pelvis and against the hip joints. b. Improper seat belt use can occasionally cause compression injuries to the pancreas, liver, spleen, small bowel, or kidneys when the car suddenly decelerates or stops.

liver injuries

Liver injuries i. The liver is the largest and most vascular organ in the abdominal cavity. (a) Most vulnerable organ in the abdomen ii. Suspect injury in all patients with: (a) Right-sided chest trauma (b) Abdominal trauma iii. The ligament in front of the liver (ligamentum teres) can slice the liver in accidents involving sudden deceleration. iv. The liver can be contused or lacerated, and a hematoma can develop. v. The patient may present with a history of the following injuries: (a) Upper right or central abdomen injuries (b) Right lower chest injuries (c) Fractures of the lower right ribs (d) Right upper quadrant ecchymosis and tenderness (e) Abdominal wall spasm and rigidity (f) Involuntary guarding and rebound tenderness (g) Hypotension or signs of hypovolemic shock

Pancreatic injuries

Pancreatic injuries i. The pancreas is relatively well protected in the retroperitoneum. ii. High-energy forces are needed to damage the pancreas and are most commonly produced by penetrating trauma. iii. When the pancreas is injured from either blunt or penetrating trauma, enzymes are released into the peritoneum. (a) Chemicals have an irritating effect on the peritoneum and intra-abdominal structures. (b) These chemicals start to break down the internal organs and tissue with which they have come in contact (autodigestion). (c) Enzymatic breakdown leads to chemical peritonitis. iv. Findings may be significantly delayed. (a) The posterior peritoneum separates the pancreas from the true abdomen.

blunt trauma- penetrating

Penetrating trauma results in tissue damage by lacerating or cutting. a. Results in an open abdominal injury i. A break in the surface of the skin or mucous membrane exposes deeper tissue to potential contamination. 2. Generally, gunshot wounds cause more injury than stab wounds. a. Bullets travel deep into the body and have more kinetic energy. i. The kinetic energy increases the damage lateral to the track of the missile due to temporary cavitation. ii. The extent of injury depends upon the weapon and bullet. 3. Gunshot wounds to the abdomen most commonly involve injury to: a. Small bowel b. Colon c. Liver d. Vascular structures 4. In penetrating trauma from stab wounds, the organs most frequently injured include: a. Liver b. Small bowel c. Diaphragm d. Colon

peritonitis

Peritonitis from a hollow organ injury may be present with a subjective complaint of abdominal pain as well as the objective finding of tenderness on palpation or percussion of the abdomen. i. Also guarding, rigidity, or distention

new techno?

Portable ultrasound machines i. FAST ultrasound (focused assessment with sonography for trauma) ii. Decrease time, treatment costs, and length of hospital stay b. Telemedicine i. Allows physicians from remote areas to receive and review images and diagnostic data from rural EMS providers

blunt trauma- crushing

Result of external factors at time of impact ii. Occurs when abdominal contents are crushed between the anterior abdominal wall and the spinal column iii. Solid organs the greatest risk: (a) Kidneys (b) Liver (c) Spleen iv. Direct application of crushing forces to the abdomen from objects such as (a) Dashboard (b) Front hood of a car (c) Falling objects (d) Improperly attached or incorrectly worn restraining device (e) Steering wheel c. Compression i. Can result from a direct blow or external compression from a fixed object ii. Will deform hollow organs iii. Increases pressure within the abdominal cavity (a) Can rupture the small intestine or diaphragm (1) Can lead to uncontrollable hemorrhage and peritonitis

Fournier gangrene

Results in Fournier gangrene i. This causes necrosis of the muscle and subcutaneous tissue within the scrotum. ii. Signs and symptoms include: (a) Spongy scrotum (b) Sounds of crepitus in the scrotal sac (c) Grey-black scrotal tissue (d) Drainage at the wound site (e) Fever and scrotal pain

blunt trauma- shearing

Shearing can be caused by rapid deceleration in a vehicle crash or fall. ii. Internal organs continue their forward motion, causing hollow, solid, and visceral organs and vascular structures to tear. (a) Especially at their points of attachment to the abdominal wall iii. Organs prone to shearing or tearing include: (a) Liver (b) Kidneys (c) Small and large intestines (d) Spleen iv. Described as a third collision in motor vehicle collisions

hemorrhage Signs and symptoms will vary greatly and depend on:

Signs and symptoms will vary greatly and depend on: i. Volume of blood lost ii. Rate of loss

intestines- hollow

Small and large intestines run from the end of the stomach to the anus. i. Majority of intestines in the intraperitoneal area ii. Digest and absorb water and nutrients

somatic pain

Somatic pain comes from skin and muscle, joints, ligaments, and tendons. i. Sharp and localized to area of injury ii. Bleeding, swelling, cramping iii. Usually responds well to opioids and nonsteroidal anti-inflammatory drugs

stomach

Stomach injuries i. Stomach injuries commonly result from penetrating trauma. ii. Rupture after blunt trauma is usually associated with: (a) Recent meal (b) Inappropriate use of a seat belt iii. Trauma results in the spilling of acidic material producing: (a) Abdominal pain (b) Peritoneal signs iv. Antacid medications may delay symptoms.

Evisceration

Strangulation of the bowel by the abdominal wall causes decreased blood flow to the protruding part. a. Early symptoms are: i. Localized pain ii. Nausea iii. Vomiting iv. Peritonitis if the bowel is leaking into the abdominal cavity Patients may feel more comfortable with their knees bent. Discourage the patient from coughing or bearing down.

pregnancy and trauma??

Traumatic injuries can be exacerbated by pregnancy. i. Heart rate can increase by 20 beats/min. ii. Blood volume increases by 50% iii. Anemia may occur from hemodilution. Pregnant patients have a higher risk of aspiration and an increase in gastric acidity. Patients should receive maximum oxygenation and reduced reserve ilt patients more than 20 weeks' gestation at least 15° to the left to relieve uterine pressure on the inferior cava and prevent supine hypotensive syndrome. (a) Use rolled towels to tilt if on a backboard.

leading cause of death in trauma patients.

Unrecognized abdominal trauma

visceral pain

Visceral pain comes from organs inside the body. i. Travels from nerve pain receptors to the brain ii. Can radiate to other locations (back and chest) iii. Felt in three main areas: (a) Thorax (b) Abdomen (c) Pelvis iv. Deep aching pain with cramping v. Opioids most effective

Injuries to hollow organs produce

a serious risk of infection. i. The bowel can spill its contents into the abdominal cavity. (a) Can cause peritonitis and systemic infection

Symptoms of cardiac dysfunction are exhibited by:

a. Chest pain b. Tachypnea with adventitious (abnormal) lung sounds c. Dysrhythmias d. Anaerobic metabolism and acidosis, if left untreated

When an adult falls from heights, the fall usually involves one of the following:

a. Criminal activity b. Attempted suicide c. Intoxication

Lateral, side-impact, or T-bone collision

a. Depending on which side of the patient was hit, the diaphragm, liver or spleen, and pelvis often are injured.

potential injury patterns, such as:

a. Hollow organ injury b. Vascular injury c. Solid organ injury d. Injuries to the retroperitoneal area

The likelihood of significant intra-abdominal injury is high when a patient has:

a. Hypotension in the field b. A major chest injury c. Pelvic fracture

Injuries to solid abdominal organs

a. Include the liver, spleen, kidneys, and pancreas i. Injury causes a release of blood into the peritoneal cavity. (a) This can cause nonspecific signs such as tachycardia and hypotension. (b) Findings relate to the size of the injury and the time since occurrence.

Injuries to hollow abdominal organs

a. Include the small and large intestines, stomach, and bladder i. The injury produces symptoms from peritoneal contamination. (a) Contents may release into the abdomen, causing irritation ii. Seat belt sign (contusion or abrasion across the lower abdomen) usually indicates intraperitoneal injuries.

Rear-impact collision

a. Intra-abdominal injuries can occur from compression and deceleration force. b. The patient is less likely to have an injury to his or her abdomen if he or she has been restrained properly. i. Potential for injury is great if restraints are improperly worn or not used at all

Kidney and ureter injuries

a. Kidney and ureter injuries can occur in association with abdominal trauma. b. These injuries are generally caused by large forces. i. Falls from height ii. High-speed motor vehicle crashes iii. Sports-related injuries c. Suspect injury with fractures of the 11th and 12th ribs or flank tenderness. d. Blunt renal trauma results when: i. Kidneys compress against the lower ribs or lumbar space (a) Sports injuries, kidney punch ii. Upper abdomen compresses below the rib cage. e. Contact sports cause most renal injuries. f. A ruptured kidney presents with pain on inspiration in the abdomen and flank areas, as well as gross hematuria. g. Penetrating renal trauma occurs with gunshot or stab wounds in the abdomen or lower chest. i. Maintain high suspicion of significant injury. ii. Penetrating renal trauma is likely to be associated with injury to the liver, lung, and spleen. h. Ureteral injuries are difficult, if not impossible, to identify in the prehospital setting. i. Rarely lead to an immediate life-threatening condition

Injuries to the testicle or scrotal sac

a. Loss of fertility is the major concern.

Blast injuries are seen in:

a. Military conflict b. Mines c. Shipyards d. Chemical plants e. Association with terrorist activities

Assessment can be difficult if:

a. Other system injuries have changed a patient's mental status and sensation. b. The patient is intoxicated. c. The patient has used illicit drugs. d. The patient has an injury to the brain or spinal cord. e. The patient has sustained injuries to an adjacent structure.

Rollover impacts

a. Rollovers present the greatest potential to inflict lethal injuries. b. Unrestrained occupants may change direction several times, with an increased risk of ejection or partial ejection from the vehicle. c. Occupants may collide with each other as well as with the vehicle interior.

Diaphragm injuries

a. Signs and symptoms are ventilatory compromise. b. Injuries are not isolated. i. Associated injury to thoracic, abdominal, head, and extremity regions c. Diaphragm injuries are rare; they may result from blunt and penetrating trauma. i. Lateral impact during motor vehicle crash can cause rupture. ii. Frontal motor vehicle crashes can cause tear.

Suspect bladder injury if:

a. The patient has trauma to the lower abdomen or pelvis. b. The patient reports an inability to urinate. c. Blood is present in the penile opening. d. Tenderness occurs on palpation of the suprapubic region.

Frontal (head-on) impact

a. The patient is often pushed down and under the dashboard. i. Especially an unbelted driver or front-seat passenger b. This can result in patients being thrown forward through the windshield and up and over the hood of the car. c. Traumatic aortic disruptions, liver and spleen injuries, and many nonabdominal injuries can result.

Retroperitoneal injuries

a. The retroperitoneal cavity i. This cavity holds the pancreas, kidneys, vascular structures, and part of the small intestine. ii. Injuries to this area do not present with signs and symptoms of peritonitis. iii. Occasionally bleeding can lead to: (a) Ecchymosis of the flanks (Grey Turner sign) (b) Ecchymosis around the umbilicus (Cullen sign)

injuries to organs can result in the spillage of their contents into the abdominal cavity.

a. This can cause irritation of the nerve endings found in the fascia of surrounding tissues. b. Inflammation will eventually result in localized pain. i. Pain is localized if contamination is confined. ii. Pain is generalized if the entire peritoneal cavity is involved.

Penis injuries

a. This organ is vital for proper urination and sexual function. b. Injuries may result from: i. Blunt or penetrating trauma ii. Sexual behavior iii. Self-mutilation c. Priapism (painful, tender, persistent erection) can have nontraumatic causes. i. Sickle cell disease ii. Adverse medication reaction d. A fractured penis may occur when an erect penis is: i. Impacted against the partner's pubic symphysis ii. Bent too far via self-manipulation e. Penetrating trauma is often caused by gunshot wounds.

There has been a concerted effort to reduce morbidity and mortality resulting from abdominal trauma.

a. This process has taken shape at several different levels. i. Education of prehospital providers in recognizing the need for rapid transport ii. Advances in hospital care (a) Improved diagnostic care (b) Surgical techniques (c) Postoperative care iii. Trauma system development

Bladder and urethra injuries

a. Trauma to this area is associated with other significant injuries. b. Injury may result in bladder rupture or laceration. i. Injury varies based on severity of mechanism and degree of bladder distention. (a) A full bladder is at greater risk for injury. c. Injuries are usually associated with pelvic injuries from motor vehicle crashes, falls from heights, and physical assaults. i. May cause pelvic fracture to perforate the bladder d. Rupture is associated with a high mortality rate. i. Trauma required to pierce the bladder often causes damage to other organs or vascular structures. ii. Urine may spill into either part of the abdominal cavity. (a) Leads to intraperitoneal, extraperitoneal, retroperitoneal rupture

Vascular injuries

i. Vascular structures in the retroperitoneal space include: (a) Kidneys (b) Descending aorta (c) Superior phrenic artery (d) Inferior phrenic artery (e) Inferior vena cava (f) Mesenteric vessels ii. Penetrating trauma is the most common injury. (a) Associated with injuries to multiple intra-abdominal organs iii. Blunt trauma can cause vascular structures in the intraperitoneal space to be sheared from their points of attachment. iv. Compression or deceleration forces applied to the abdomen can result in avulsion of small vessels, resulting in exsanguination. v. Intimal tears within the vessel itself can occur, resulting in thrombosis formation.