Abdominal Trauma The Abdomen Everything between diaphragm and
Abdominal Trauma
The Abdomen • Everything between diaphragm and pelvis • Injury, illness very difficult to assess because of large variety of structures 2
Abdominal Anatomy • Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus • Organs can be located by quadrant 3
Abdominal Anatomy • Right Upper Quadrant – Liver – Gall Bladder – Right Kidney – Ascending Colon – Transverse Colon 4
Abdominal Anatomy • Left Upper Quadrant – Spleen – Stomach – Pancreas – Left Kidney – Transverse Colon – Descending Colon 5
Abdominal Anatomy • Right Lower Quadrant – Ascending Colon – Appendix – Right Ovary (female) – Right Fallopian Tube (female) 6
Abdominal Anatomy • Left Lower Quadrant – Descending Colon – Sigmoid colon – Left Ovary (female) – Left Fallopian Tube (female) 7
Abdominal Anatomy • Periumbilical area – Located around (peri) the navel (umbilicus) – Small bowel lies in all quadrants in periumbilical area • Suprapubic area – Located just above pubic bone – Urinary bladder, uterus lie in this area 8
Abdominal Cavity • Peritoneum = abdominal cavity lining • Divides abdomen into two spaces – Peritoneal cavity – Retroperitoneal space 9
Abdominal Anatomy • Peritoneal – – – Spleen Liver Stomach Gall bladder Bowel • Retroperitoneal – – – – Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs Disease, injury of retroperitoneal organs often causes back pain
Abdominal Anatomy • Organs can be classified as: – Hollow – Solid – Major vascular 11
Solid Organs • • Liver Spleen Kidney Pancreas When solid organs are injured, they bleed heavily and cause shock 12
Solid Organs • Liver – Largest abdominal organ – Most frequently injured – Fractures of ribs 8 -12 on right side – Bleeding can be either: • Slow, contained under capsule • Free into peritoneal cavity 13
Solid Organs • Spleen – Frequently injured with trauma ribs 9 -11 on left side – Bleeds easily – Capsule around spleen tends to slow development of shock – Rapid shock onset when capsule ruptures 14
Solid Organs • Pancreas – Lies across lumbar spine – Sudden deceleration produces straddle injury – Very little hemorrhage – Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock 15
Hollow Organs • • Stomach Gall bladder Large, small intestines Ureters, urinary bladder Rupture causes content spillage, inflammation of peritoneum 16
Hollow Organs • Stomach – Acid, enzymes – Immediate peritonitis – Pain, tenderness, guarding, rigidity 17
Hollow Organs • Colon – Spillage of bacteria – May take 6 hrs to develop peritonitis • Small Bowel – Fewer bacteria – May take 24 -48 hours to develop peritonitis 18
Major Vascular Structures • Aorta • Inferior vena cava • Major branches Injury can cause severe blood loss; exsanguination (bleeding out) 19
Abdominal Trauma • Most survive to reach hospital • Most common factors leading to death – Failure to adequately evaluate – Delayed resuscitation – Inadequate volume – Inadequate diagnosis – Delayed surgery 20
High Index of Suspicion • Mechanism • Trauma to lower chest, back, flank, buttocks, and perineum • Hypovolemic shock with no readily identifiable cause • Diffusely tender abdomen • Pain in uninjured shoulder 21
Mechanism • Look for signs of injury – Bruises – Tire marks – Obvious open injuries • Assume any abdominal injury is serious until proven otherwise! • Injury above umbilicus also involves chest until proven otherwise 22
Unexplained Shock • Assess vital signs; skin color, temperature; capillary refill • Tachycardia; restlessness; cool, moist skin • In trauma, signs of shock suggest abdominal injury if no other obvious causes present 23
Signs of Injured Abdomen • Diffuse tenderness • Pain – Pain referred to shoulder = Organ under diaphragm involved (? spleen) – Pain referred to back = Retroperitoneal organ involved (? kidney) 24
Abdominal Rigidity • NOT reliable • Bleeding may not cause rigidity if free hemoglobin absent • Bleeding in retroperitoneal space may not cause rigidity 25
Abdominal Trauma Management • Less important to diagnose exact injury • Treat clinical findings • Management same regardless of specific organ(s) injured 26
Abdominal Trauma Management • • • Airway C-Spine if mechanism indicates High flow O 2 Assist ventilations if needed Give nothing by mouth MAST may be helpful in slowing intraabdominal bleeding with shock 27
Impaled Object • Leave in place – Shorten if necessary for transport – Leave part of object exposed 28
Evisceration • With large laceration abdominal contents may spill out • Do NOT try to replace 29
Evisceration • Cover exposed organs with saline moistened multi-trauma dressing • Do NOT use 4 x 4 s • Cover first dressing with second DRY dressing or aluminum foil 30
Genitourinary Trauma Kidney Ureter Urinary Bladder Urethra 31
Kidney Trauma • 50% of all GU trauma • Penetrating – GSW – Stab wound • Rare, usually associated with trauma to other abdominal organs 32
Kidney Trauma • Blunt – Direct blow to back, flank, upper abdomen • Suspect with fractures of 10 th - 12 th ribs or T 12, L 1, L 2 – Acceleration/Deceleration • Shearing of renal artery/vein 33
Kidney Trauma • Signs and Symptoms – Gross Hematuria • 80% of cases • Absence does NOT exclude renal injury – Localized flank/abdominal pain – Palpable mass 34
Kidney Trauma • Signs and Symptoms – Tenderness: Lower ribs, upper L-spine, flank – Pain: groin, shoulder, back, flank 35
Ureter Trauma • Less than 2% of GU trauma • Usually secondary to penetrating trauma • Indicator – Wound to lower back with urine escaping 36
Urinary Bladder Trauma • Mechanisms – Blunt injury to lower abdomen – Seat belts – Pelvic fracture – Penetrating trauma to lower abdomen or perineum (pelvic floor) 37
Extraperitoneal Bladder Rupture • Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum • Dysuria • Hematuria • Suprapubic tenderness • Swelling, redness secondary to tissue damage from urine 38
Intraperitoneal Bladder Rupture • • Urgency to void Inability to void Shock Abdominal distension 39
Urethral Trauma • Mechanisms – Sudden decelerations (bladder shears off urethra) – Straddle injuries 40
Urethral Trauma • Signs and Symptoms – Blood at external meatus – Perineal bruising (butterfly bruise) – Scrotal hematoma 41
Reproductive System Trauma • Can occur to both external and internal reproductive systems – External • More common • Pain, extensive bleeding – Internal • Rarely injured 42
Reproductive System Trauma • Treat like blunt or penetrating soft tissue injuries elsewhere on body 43
Male Genitalia Trauma • Usually NOT life-threatening • Very painful • Great source of concern to patient 44
Male Genitalia Trauma • Avulsion of skin of penis, scrotum – Cover with a moist, sterile dressing • Complete amputation of penis – Treat as any amputated part 45
Male Genitalia Trauma • Blunt trauma to penis, scrotum – Apply ice pack • Urethral foreign bodies – Do NOT remove • Penis entrapped in zipper – If 1 or 2 teeth involved, try to unzip – If more involved, cut zipper out of trousers, transport 46
Female Genitalia Trauma • Internal – Rarely injured • External – Can cause pain, extensive bleeding – Usually not life-threatening • Treat with compresses, pressure 47
Sexual Assault • Avoid examining genitalia unless obvious bleeding present • Ask patient to NOT wash, douche, urinate, defecate • Ask patient NOT to change clothes • Record history, but avoid extensive questioning about incident 48
QUESTIONS ?
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