Chapter 30 Abdominal and Genitourinary Injuries

Female Genitalia

The female genitalia, except for the vulva, clitoris, and labia, are contained entirely within the pelvis.

Injuries can occur to:

The kidneys The urinary bladder The external male genitalia The internal female genitalia The external female genitalia

Left lower quadrant (LLQ)

The left lower quadrant holds both the large and small intestines, notably the descending colon and the left half of the transverse colon.

Male Genitalia

The male genitalia, except for the prostate gland and the seminal vesicles, lie outside the pelvic cavity.

peritoneum

The membrane lining the abdominal cavity (parietal peritoneum) and covering the abdominal organs (visceral peritoneum).

When ruptured or lacerated, these organs spill their contents into the peritoneal cavity causing an intense inflammatory reaction and possible infection.

The peritoneum may become inflamed and painful—a condition known as peritonitis.

flank

The region below the rib cage and above the hip.

Left upper quadrant (LUQ)

The stomach occupies most of the LUQ, but it shares this space with the spleen. The pancreas occupies some of this space but is mostly posterior to the region.

Right lower quadrant (RLQ)

`The right lower quadrant also holds portions of the large and small intestines that include the ascending colon and the right half of the transverse colon. The distal end of the descending colon, called the appendix, is located in this region. Swelling and inflammation are common because the appendix is a common source of intra-abdominal infection.

Solid organs include

the liver, spleen, pancreas, and kidneys

Right upper quadrant (RUQ)

Organs commonly found in the RUQ are the liver, gallbladder, duodenum of the intestines, and a small portion of the pancreas.

The internal female genitalia

The uterus, ovaries, and fallopian tubes are rarely damaged because they are small, deep in the pelvis, and well protected by the pelvic bones. 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. You can expect to see the signs and symptoms of shock with these patients. Note also that contractions may begin. Ask the patient when she is due to deliver, and report this information to the hospital staff. In the third trimester, 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. Place the patient 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.

In later stages of pregnancy, the gravid uterus displaces the urinary bladder to the anterior.

This 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.

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 that resembles 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.

Urinary bladder

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.

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.

Other signs and symptoms include:

Tenderness Bruising and discoloration

peritoneal cavity

The abdominal cavity

Solid Organs

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 colon occupies the lowest portion of the retroperitoneal space.

You may have to provide emergency medical care of genitourinary injuries to:

Kidneys Urinary bladder External male genitalia Female genitalia Rectum

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 nauseated and may vomit. The abdomen may become distended and firm to touch. Infection may occur.

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

Low-velocity injuries: Caused by hand-held or hand-powered 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

Hollow organs,

including the stomach, large and small intestines, ureters, and urinary bladder, are actually structures through which materials pass.

MOIs include:

Striking the handlebar of a bicycle or the steering wheel of a car Being struck by a wooden board or baseball bat Motorcycle crashes Falls Blast injuries Pedestrian injuries Compression Deceleration

The genital system is important to the reproductive processes. These systems allow for the production of sperm and egg cells and appropriate hormones; the act of sexual intercourse; and, ultimately, reproduction.

Male Genitalia Female Genitalia

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.

High- and medium-velocity injuries have temporary wound channels caused by cavitation in addition to the exit and entrance wounds.

A cavity forms as the pressure wave from the projectile is transferred to the tissues, causing microscopic tears to the blood vessels and nerves and 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.

External male genitalia

A few general rules apply to the treatment of injuries involving the external male genitalia: 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, identify and take avulsed parts to the hospital with the patient. Label the bag with the patient's name. 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. 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. 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. 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. 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. Save any voided urine for later examination at the hospital. 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. Apply an ice pack to the scrotal area while transporting the patient.

Emergency Medical Care of Open Abdominal Injuries

A large wound may have protrusions of bowel, fat, or other structures. In addition to pain, 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. In caring for a patient with a penetrating wound to the abdomen, follow the general procedures described for care of a blunt abdominal injury as well as the specific steps for the penetrating wound. Inspect the patient's back and sides for exit wounds. 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 minimize movement of the object.

Review your knowledge of the material by answering the following questions. Select whether each statement listed is true or false. A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard. TrueFalse Free air in the peritoneal cavity is abnormal and indicates that a hollow organ or loop of bowel has perforated. TrueFalse A very common early sign of a significant abdominal injury is tachycardia. TrueFalse You should allow patients with peritonitis to lie still with their legs drawn up. TrueFalse

A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard. TrueFalse Correct. A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard. Free air in the peritoneal cavity is abnormal and indicates that a hollow organ or loop of bowel has perforated. TrueFalse Correct. Free air in the peritoneal cavity is abnormal and indicates that a hollow organ or loop of bowel has perforated. A very common early sign of a significant abdominal injury is tachycardia. TrueFalse Correct. 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. You should allow patients with peritonitis to lie still with their legs drawn up. TrueFalse Correct. Patients with peritonitis generally prefer to lie very still with their legs drawn up to guard from pain in the abdomen. Allow a patient with a patent airway to remain in a position of comfort. Submit

Signs and Symptoms of an Open Injury

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.

Solid Organ Injuries

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. The liver, the largest organ in the abdomen, is very vascular and 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. The pancreas and spleen are responsible for filtering blood and are, therefore, 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. If the diaphragm is penetrated or ruptured, loops of bowel may herniate into the thoracic cavity. Because the bowel will displace lung tissue and vital capacity, patients will exhibit dyspnea or feel short of breath. 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. The kidneys can be sheared from their base, crushed, or fractured, causing significant blood loss. If the kidney is injured, a common finding is hematuria. 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.

Rectum

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: Sexual assault Rectal foreign bodies Hemorrhoids Colitis Ulcers of the digestive track Significant rectal bleeding can occur after hemorrhoid surgery and can lead to significant blood loss and shock.

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. For example:

Bruises in the right upper quadrant, left upper quadrant, or flank might suggest an injury to the liver, spleen, or kidney, respectively. Bruises around the umbilicus can predict significant internal abdominal bleeding.

Which of the following is true about injuries to the kidneys? Injuries are unusual because the kidneys are well protected. A penetrating wound that reaches the kidneys almost always involves other organs. An indication of kidney injury is bruising to the left upper quadrant. A sign of kidney damage is hematuria.

Correct. A penetrating wound to the kidney almost always involves other organs, and hematuria is a sign of kidney injury.

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. You will see signs of shock if the injury is associated with significant blood loss. 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.

Sexual Assault and Rape

Do not examine the genitalia of a victim of sexual assault unless obvious bleeding requires you to apply a dressing. Treat all other injuries according to appropriate procedures and protocols for your EMS system. Observe standard precautions. Take care to shield the patient from curious onlookers. Because you may have to appear in court as much as 2 or 3 years later, document in detail the patient's history, assessment, treatment, and response to treatment. Follow any crime scene policy to protect the scene and any potential evidence for police. Advise the patient not to wash, bathe, shower, douche (if female), urinate, or defecate until after a physician has examined him or her. If oral penetration has occurred, advise the patient not to eat, drink, brush teeth, or use mouthwash until he or she has been examined. If the patient will tolerate being wrapped in a sterile burn sheet, this may help investigators find any hair, fluid, or fiber from the alleged offender. Handle the patient's clothes as little as possible, placing articles and any other evidence in paper bags. If a female patient insists on urinating, have her do so in a sterile urine container (if available). Have her deposit the toilet paper in a paper bag. Seal and label the bag for the police because these items can be critical evidence. Whenever possible, the EMT who is caring for the patient should be the same gender as the patient. Treat the medical injuries, but also provide privacy, support, and reassurance.

An open abdominal injury that goes through the skin and muscle layer and through the fascia or the interior covering of the abdomen is an evisceration.

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.

History Taking

Establish 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. Common associated complaints with genitourinary injuries are: Nausea and/or vomiting Diarrhea Hematuria Hematemesis Abnormal bowel and bladder habits, such as an increase in frequency or the absence of the need to void Use SAMPLE to help determine the patient's baseline. 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. Ask about any allergies to medications or environmental triggers. 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. Addressing the events that led to the injury help determine the MOI and help you draw conclusions and develop an index of suspicion.

Later signs include

Evidence of shock (such as decreased blood pressure and pale, cool, moist skin) or changes in the patient's mental status Trauma to the abdomen In some cases, the abdomen may become distended from the accumulation of blood and fluid.

Emergency Medical Care of Closed Abdominal Injuries

If possible, position the patient for optimal comfort and apply high-flow oxygen if the patient has signs of hypoxia or shock. A patient who has sustained a blunt abdominal injury should be log rolled to a supine position onto a backboard. If the patient vomits, turn him or her to one side and clear the mouth and throat of vomitus. Monitor 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.

Primary Assessment

If visible significant bleeding is present, control it. 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 significantly altered LOC, consider inserting an oropharyngeal airway or nasopharyngeal airway. Assess the patient for adequate breathing. Provide assisted ventilations using a BVM as needed, depending on the LOC and if your patient is breathing inadequately. Assess the patient's pulse rate and quality; determine the skin condition, color, and temperature; and check the capillary refill time. Closed injuries do not always have visible signs of bleeding, but 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. Take a patient with a genitourinary system injury to a trauma center for evaluation and treatment.

Primary Assessment (continued)

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 Keeping the patient warm Cover wounds and control bleeding as quickly as possible. Abdominal pain together with an MOI that suggests injury to the abdomen or flank is a good indication for rapid transport. Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable. Direct treatment at quickly addressing life threats and providing rapid transport to the nearest appropriate hospital. 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.

Signs and Symptoms of a Closed Injury

In patients with liver and spleen injuries, and/or with bleeding into the peritoneal space, pain is referred to the shoulder. Shoulder pain can be misleading, and injury to the liver or spleen could possibly be overlooked if the shoulder is also injured. Symptoms of an abdominal aneurysm that is dissecting include pain that is described as tearing going from the abdomen posteriorly. 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 can produce pain if the affected area is exposed to any jarring motion, 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.

The external female genitalia

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. 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's important to determine the possibility of pregnancy. 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.

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 and should not be given priority over other, more severe wounds, unless the rich blood supply causes significant bleeding. Pain from an injury to the testicles or another cause, such as infection or cancer, may be referred to the lower abdomen. When assessing men with lower abdominal pain, you should also consider injury or other causes of pain to the testicles.

The kidneys

Injuries to the kidneys are not unusual and rarely occur in isolation. A penetrating wound that reaches the kidneys almost always involves other organs. 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. 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

The urinary bladder

Injury to the urinary bladder, either blunt or penetrating, may result in its rupture. 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. Penetrating wounds of the lower mid-abdomen 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. In the second and third trimesters of pregnancy, the incidence of injury to the urinary bladder is increased by displacement of the uterus.

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 contusions and abrasions, which can help localize focal points of impact and may indicate significant internal injury. Do not overlook puncture wounds and other penetrating injuries because the intra-abdominal extent of these injuries may be life threatening. Note and manage the presence of burns, as in the case of flash burns or scalding fluids spilled onto the abdomen. 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.

Assessment of an Isolated Abdominal Injury

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, always check for a corresponding exit wound. 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. 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. Log rolling the patient onto a backboard provides a valuable chance to examine the back for signs of injury. Instruct and position helpers to ensure your ability to inspect and palpate the back briefly while the patient is rolled onto his or her side. If possible, pad the long backboard before returning the patient to a supine position. This helps reduce discomfort and prevents soft-tissue injury. Avoid log rolling patients with an evisceration because this can cause more of the abdominal organs to protrude from the wound. Instead, keep the patient in the supine position and allow him or her to flex the knees when possible to help relieve tension on the abdomen.

Reassessment

Manage airway and breathing conditions based on signs and symptoms found during the primary assessment. Provide spinal immobilization as needed. If the patient has signs of hypoperfusion, provide aggressive treatment of shock and rapid transport to the appropriate hospital. If there is an evisceration, 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. Document: The results of the physical examination Any pertinent negatives, such as no blood loss noted in bowel movements If you passed over any step of the physical examination (such as with a patient with acute abdominal pain in whom you opted not to perform palpation) 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. If assault is suspected, you may have a legal requirement to inform the hospital staff of your suspicions; 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. Always document in detail the information you provide to the patient and, if the patient refuses transport, have the patient sign a document of refusal or an "against medical advice" form.

History Taking

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. They will contract their abdominal muscles (guarding). Ask about previous injuries associated with a chief complaint of abdominal pain. Obtain a SAMPLE history. Use OPQRST to help explain an abdominal injury. If the patient is not responsive, attempt to obtain the SAMPLE history from friends or family members. Ask the patient if he or she has experienced any nausea, vomiting, or diarrhea. If so, 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.

Emergency Medical Care of Abdominal Evisceration

Never try to replace an organ that is protruding from an abdominal laceration. 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, and because exposed organs lose fluid rapidly, keep the organs moist and warm. Do not use any material that is adherent or loses its substance when wet (eg, 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.

Scene Size-up

Observe the scene for hazards and threats to safety. Assess the impact that hazards have on patient care and address those hazards. Assess the potential for violence and assess for environmental hazards. Take standard precautions—a minimum of gloves and eye protection. Because of the color of blood and how well it soaks through clothing, often you can identify patients with an open injury as you approach the scene. 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. Look for indicators of the MOI. Be aware that the patient may avoid discussing the injury to avoid undergoing a physical examination. The patient may provide an MOI that seems "less embarrassing" than the actual MOI.

Hollow Organs

Peritonitis is serious and may become life threatening. The 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. 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.

Secondary Assessment (continued)

Palpate for tenderness and attempt to localize to a specific quadrant of the abdomen. Start by palpating the quadrant farthest away from the quadrant that is exhibiting signs and symptoms of injury and pain. This 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. Your goal is not to identify the extent of all the injuries, but to determine whether other injuries are present. If you find a life-threatening injury, stop and treat it immediately; otherwise, move on. Assess the patient's need for spinal immobilization and apply per local protocol. 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. Inspect and palpate the flank region of the back for tenderness, bruising, swelling, or other signs of trauma. You may not be able to trigger pain from the specific organ, but the tissues around it may cause the patient to exhibit symptoms of pain. Hollow organs will spill their contents into the peritoneal cavity and will typically produce 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. Obtain the patient's vital signs. Record vital signs as early as possible and periodically thereafter (every 5 minutes in the patient who you suspect has a serious injury) to identify changes in the patient's condition; be alert to signs of decompensation from blood loss. Use pulse oximetry and noninvasive blood pressure devices when available. It is recommended you always assess the patient's first blood pressure manually with a sphygmomanometer and stethoscope.

Secondary Assessment

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 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. Do not force a patient without suspected spinal injury 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.

The genitourinary system controls:

Reproductive functions The waste discharge system

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 or spleen Rupture of the intestine Tears in the mesentery 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

Primary Assessment

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. Check for responsiveness using the AVPU scale. Ask the alert patient about his or her chief complaint. Unresponsiveness may indicate a life-threatening condition. Administer high-flow oxygen via a nonrebreathing mask to trauma patients whose level of consciousness (LOC) is less than alert and oriented and provide rapid transport to the emergency department (ED). Your general impression of how the patient is doing is based on information as simple as the MOI and the patient's LOC. In trauma patients, life-threatening external hemorrhage must be addressed before airway or breathing concerns. 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. 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 LOC. Note the nature of the vomitus: undigested food, blood, mucus, or bile. Assess for adequate breathing. A distended abdomen or pain may prevent adequate inhalation. Providing supplemental oxygen with a nonrebreathing mask will help improve oxygenation. If the patient's LOC 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.

Female genitalia

Treat lacerations, abrasions, and avulsions 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. The urgency for transport will be determined by associated injuries, the amount of hemorrhage, and the presence of shock.

Hollow Organ Injuries

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. Blunt trauma causes the hollow organs to "pop," 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 contents of the gallbladder and the urinary bladder, bile and urine, are potentially irritating and damaging to the tissues of the abdomen if ruptured. 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 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.

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.

Reassessment

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.

Injuries from Seat Belts and Air Bags

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. Occasionally, fractures of the lumbar spine have been reported.

Secondary Assessment

When your patient has an isolated injury with a limited MOI, focus your assessment on the isolated injury, the patient's concern, and the body region affected. Look for DCAP-BTLS. Ensure that wounds are identified and bleeding is controlled. Note the location and extent of the injury. If there is significant trauma likely affecting multiple systems, start with an exam of the entire body looking for DCAP-BTLS to determine the nature and extent of injury. 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. Note the presence of burns and manage them appropriately. Palpate for tenderness to localize the injury and the presence of fractures. Look for lacerations and local swelling. Obtain the patient's vital signs. 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. 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.

Scene Size-up

Your scene size-up begins with the information reported from dispatch. Take standard precautions prior to arrival at the scene; gloves and eye protection should be a minimum. Observe the scene for hazards and threats to your safety. If additional resources are needed, call for them early, and consider early ALS intercept for patients who may become unstable. Look for indicators of the MOI and consider early spinal stabilization. Consider the possible injuries the MOI could have produced. 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. 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.

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.

Closed abdominal injuries

are those in which blunt force trauma results in injury to the abdomen without breaking the skin.