Transcript 09 - Abdominal Assessment

Abdominal
Provincial Reciprocity Attainment Program
Abdominal Organs
ADUKPIE
Types of Abdominal Organs
ABDOMINAL ORGANS
SOLID ORGANS
HOLLOW ORGANS
LIVER
STOMACH
SPLEEN
GALL BLADDER
PANCREAS
SMALL INTESTINE
KIDNEYS
LARGE INTESTINE
OVARIES
BLADDER
Abdominal Organs
RUQ
LUQ
Liver
Spleen
Gall Bladder
Stomach
Kidney
Kidney
Part of the Pancreas
Part of the Liver
Large Intestine
Kidney
Large Intestine
Small Intestine
Part of the Pancreas
Appendix
Lt Ureter
Large Intestine
Large Intestine
Rt Ureter
Small Intestine
Small Intestine
Femoral Artery/Vein to Left Leg
Femoral Artery/Vein to Rt Leg
RLQ
LLQ
Traumatic Injuries
Abdominal Trauma
 May be difficult to evaluate in the
prehospital setting due to:
 Wide spectrum of potential injuries to
multiple organs
 Physical findings that are sometimes
lacking or exaggerated
Abdominal Trauma
 Assessment may be compromised by:
 Use of alcohol and/or recreational drugs
 Injury to brain, spinal cord
 Injury to ribs, spine, pelvis
 Exercise a high degree of suspicion
based on mechanism of injury and
kinematics
Boundaries of the Abdomen
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Diaphragm
Anterior abdominal wall
Pelvic bones
Vertebral column
Muscles of the abdomen and flanks
Surface Anatomy of Abdomen
 Quadrants
 Upper - right, left
 Lower - right, left
 Xiphoid
 Symphysis pubis
 Umbilicus
Peritoneal Cavity
 Also called the “true” abdominal cavity
 Quadrants
 Upper - right, left
 Lower - right, left
 Contents-liver, spleen, stomach, small
intestine, colon, gallbladder, female
reproductive organs
Pelvic Cavity
 Surrounded by the pelvic bones
 Lower part of retroperitoneal space
 Contents:
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Rectum
Bladder
Urethra
Iliac vessels
In women, internal genitalia
Retroperitoneal Space
 Potential space behind the “true” abdominal cavity
 Contents (ADUCKPIE):
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Abdominal aorta
Duodenum
Ureter
Colon
Kidneys
Pancreas
Inferior vena cava
Esophagus
Mechanisms of Abdominal
Injury
 Blunt trauma
 Compression or crushing forces
 Shearing forces
 Deceleration forces
 Degree of injury is usually related to:
 Quantity and duration of force applied
 Type of abdominal structure injured (fluid
filled, gas filled, solid, hollow)
Blunt Trauma
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Motor vehicle collisions
Motorcycle collisions
Pedestrian injuries
Falls
Assault
Blast injuries
Penetrating Trauma
 Energy imparted to the body
 Low velocity - knife, ice pick
 Medium velocity - gunshot wounds,
shotgun wounds
 High velocity - high-power hunting rifles,
military weapons
 Ballistics
 Trajectory
 Distance
Solid & Hollow Organs
 Solid Organs
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Liver
Spleen
Pancreas
Kidneys
Adrenals
Ovaries (female)
 Hollow Organs
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Stomach
Intestines
Gallbladder
Urinary bladder
Uterus (female)
Solid Organ Injury
Liver
 Largest organ in the abdominal cavity
 Located in the right upper quadrant of
abdomen
 Commonly injured from trauma to the:
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Eighth through twelfth ribs on right side of body
Upper central part of abdomen
Damaged in 19% of blunt ABD trauma
37% of penetrating trauma
Liver
 Suspect liver injury in any patient with:
 Steering wheel injury
 Lap belt injury
 History of epigastric trauma
 After injury, blood and bile escape into
peritoneal cavity
 Produces signs and symptoms of shock
and peritoneal irritation, respectively
Spleen
 Lies in upper left quadrant of abdomen
 Rich blood supply
 Slightly protected by organs surrounding it
medially and anteriorly and by lower portion
of rib cage
 Most commonly injured organ from blunt trauma
(41%)
 Associated intraabdominal injuries common
 40% of patients do not show symptoms
Spleen
 Suspect splenic injury in:
 Motor vehicle crashes
 Falls or sport injuries in which there was an
impact to lower left chest, flank, or upper left
abdomen
 Kehr’s sign
 Left upper quadrant pain with radiation to left
shoulder
 Common complaint associated with splenic
injury
Kidneys
 Located high on posterior wall of
abdominal cavity in retroperitoneal
space
 Held in place by renal fascia
 Cushioned by a generous layer of
adipose tissue
 Partially enclosed and protected by lower
rib cage
Kidneys
 Injuries may involve fracture and
laceration
 Resulting in hemorrhage, urine
extravasation, or both
 Contusions usually are self-limiting
 Heal with bed rest and forced fluids
 Fractures and lacerations may require
surgical repair
Hollow Organ Injury
Stomach
 Not commonly injured after blunt trauma
because of its protected location in
abdomen
 Penetrating trauma may cause gastric
transection or laceration
 Patients exhibit signs of peritonitis rapidly
from leakage of gastric contents
 Diagnosis confirmed during surgery unless
nasogastric drainage returns blood
Colon and Small Intestine
 Injury is usually the result of
penetrating trauma
 Large and small intestine may also be
injured by compression forces
 High-speed motor vehicle crashes
 Deceleration injuries associated with
wearing personal restraints
 Bacterial contamination common
problem with these injuries
Retroperitoneal Organ Injury
 May occur because of blunt or
penetrating trauma to the:
 Anterior abdomen
 Posterior abdomen (particularly the flank
area) or
 Thoracic spine
Ureters
 Hollow organs
 Rarely injured in blunt trauma because
of their flexible structure
 Injury usually occurs from penetrating
abdominal or flank wounds (stab
wounds, firearm injuries)
Pancreas
 Solid organ that lies in the peritoneal
space
 Blunt injury usually occurs from a
crushing injury of the pancreas
between the spine and a steering
wheel, handlebar, or blunt weapon
 Most pancreatic injuries are due to
penetrating trauma
Duodenum
 Lies across the lumbar spine
 Seldom injured due to its location in
the retroperitoneal area, near
pancreas
 May be crushed or lacerated when
great force of blunt trauma or
penetrating injury occurs
 Usually associated with concurrent
pancreatic trauma
Pelvic Organ Injury
 Usually results from motor vehicle
crashes that produce pelvic fractures
 Less frequent causes:
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Penetrating trauma
Straddle-type injuries from falls
Pedestrian accidents
Some sexual acts
Urinary Bladder
 Hollow organ
 May be ruptured by blunt or
penetrating trauma or pelvic fracture
 Rupture more likely if bladder is
distended at time of injury
 Suspect bladder injury in inebriated
patients subjected to lower abdominal
trauma
Vascular Structure Injury
 Intraabdominal arterial and venous injuries
may be life-threatening
 Injury usually occurs from penetrating
trauma
 May also occur from compression or
deceleration forces applied to abdomen
 Usually presents as hypovolemia
 Occasionally associated with a palpable
abdominal mass
Vascular Structure Injury
 Major vessels most frequently injured:
 Aorta
 Inferior vena cava
 Renal, mesenteric, and iliac arteries and
veins
Pelvic Fractures
 Disruption of the pelvis may occur from:
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Motorcycle crashes
Pedestrian-vehicle collisions
Direct crushing injury to the pelvis
Falls from heights greater than 12 feet
 Blunt or penetrating injury may result in:
 Fracture
 Severe hemorrhage
 Associated injury to urinary bladder and urethra
Pelvic injury
 Most common injured organs are the urinary
bladder and urethra
 Mortality rate 6.4 – 19%
 Structural damage to the pelvis
 Room to empty large quantity of blood (shock)
 Inability to urinate
 Gross hematuria suspect bladder
 Blood at the meatus, suspect urethral damage
Pelvic Fractures
 Suspicion of pelvic injury should be
based on:
 Mechanism of injury
 Presence of tenderness on palpation of
iliac crests
 Force may be direct or indirect
 Assessment findings
 Management
Evisceration
 Protrusion of an internal organ through a
wound or surgical incision, especially in the
abdominal wall
 Common finding with stab wounds
 May be seen to a lesser degree with gunshot
wounds
 Do not replace organs back into abdomen
 Protect organs from further damage
 Cover with sterile saline moistened dressing
 Transport
Focused History and Physical
 Head injury and/ or intoxicants
(drugs/alcohol) mask signs and
symptoms
 Hemoperitoneum (solid organ/vascular
injuries)
 Adult abdomen will accommodate 1.5 liters
with no abdominal distention
 Often present even with normal abdominal exam
 Unexplained shock
 Shock out of proportion to known injuries
Peritonitis – S/S
 Pain (subjective symptom from patient)
 Tenderness (objective sign with
percussion/palpation)
 Guarding/rigidity
 Distention (late finding)
 Abrasions
 Ecchymosis
 Visible wounds
 Mechanism of injury
 Unexplained shock
Critical Findings
 Rapid assessment and transport
 Detailed assessment
 On-going assessment
Noncritical Findings
 Focused history and physical
examination
 Other interventions and transport
considerations
Comprehensive Assessment
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Vital signs
Inspection
Auscultation
Percussion
Palpation
Comprehensive Assessment
 Absence of signs and symptoms does
not rule out abdominal injuries
 Not necessary to determine definitively if
abdominal injuries are present
 Remember to examine the back
 Differential diagnosis
 Continued management
Management/Treatment Plan
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Surgical intervention only effective therapy
Rapid evaluation
Initiation of shock resuscitation
Rapid packaging and transport to nearest
appropriate facility
 Facility must have immediate surgical capability
 Rapid transport
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Defeated if hospital cannot provide immediate surgical
intervention
 Crystalloid fluid replacement en route to hospital
Indications for Rapid Transport
 Critical findings
 Surgical intervention required to control
hemorrhage and/ or contamination
 High index of suspicion for abdominal
injury
 Unexplained shock
 Physical signs of abdominal injury
Indications for Rapid Transport
 Hemorrhage continues until controlled
in OR
 Survival determined by length of time
from injury to definitive surgical control
of hemorrhage
 Any delay in the field negatively impacts
this time period
ABD and Renal Disease
Hiatal Hernia
 Herniation of the stomach through the
diaphragmatic opening
 S/S
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Chest pain (especially when lying down)
Difficulty swallowing
Reflux
Burping
Possible hemorrhage
May see signs of shock if severe
Hiatal Hernia
 Treatment
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ABC’s
Position of comfort
O2
Rule out ischemia
Treat for shock if applicable
Transport
Inguinal Hernia
 Herniation of intestine into inguinal
canal
 S/S
 Pain and/or discomfort
 Mass may increase with strenuous activity
 N/V
 Treatment
 ABC’s
 O2
 Position of comfort
Umbilical Hernia
 Herniation of intestines or fluids into
the umbilicus
 S/S:
 May increase with crying, strains or is upright
 Usually no pain associated with tightening
 Treatment:
 ABC’s
 Pt comfort
 O2 if necessary
Bowel Obstruction
 Blockage of the intestines due to tumor,
feces, adhesions or hernias
 S/S:
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N/V
Distention
Pain (Crampy and intermittent)
Diarrhea (early)/Constipation (Late)
Fever (late)
Absent bowel sounds (late)
BAD Breath
Signs of shock
Bowel Obstruction
 Treatment:
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ABC’s
O2
Position of comfort
IV
ALS ? (May need gravol or pain relief)
Diverticulitis
 Inflammation of the diverticula
 S/S:
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Maybe asymptomatic
Abdominal pain (usually LLQ)
Febrile
N/V
Cramps
Chills
Constipation/diarrhea
Bright red blood
Signs of shock
Diverticulitis
 Treatment:
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ABC’s
Position of comfort
Treat for shock
IV ?
ALS ? (Pain, N/V)
Intussusception
 Telescoping of intestine onto itself
(commonly at the small/large intestine
juncture), usually in infants
 S/S:
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Sudden onset of ABD pain
N/V (with feces)
Distention
Febrile
Possible bleeding
Intussusception
 Treatment:
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ABC’s
O2
Position of comfort
ALS ?
Adhesions
 Scar tissue forming between two
surfaces of the body, usually in the
intestines, as a result of surgery or
traumatic insult
 S/S:
 If severe
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N/V
Pain
Fever
Change in bowel habits
Reflux
 Weakness of esophageal sphincter
allowing gastric contents to enter
esophagus
 S/S:
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Heartburn
Burning sensation
Burping
N/V
etc
IBS
 Spastic colon
 S/S:
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Stress
Change in bowel habits
ABD pain or cramping
Excessive gas
Decrease in appetite
Acute Appendicitis
 Inflammation of the appendix
 S/S:
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Sever pain (periumbilical moving to LRQ)
Febrile
Loss of appetite
Rebound tenderness
If ruptured
 Signs of shock
Colitis
 Inflammation of the large intestine
 S/S:
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Diarrhea
Loss of appetite
Rectal bleeding
Signs of shock if severe
Chrone’s Disease
 Chronic inflammatory disease causing
ulcerations in the small intestines (but
may affect large and other regions of
the tract)
 S/S:
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Diarrhea
ABD pain
N/V
Anorexia
Dependant on area and amount of damage
Acute Peritonitis
 Acute inflammation of the peritoneum
 S/S:
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ABD pain
Tenderness
Guarding
Is severe signs of shock
Anorexia & Bulemia
 Eating disorders usually connect to the
psychology of the patient
 S/S:
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Obsession with weight loss
May be purging, using laxatives, diuretics…
Dehydration
Signs of shock (metabolic and hypovolemia)
Acute Pancreatitis
 Inflammation of the pancreas due to
stones, necrosis, infections…
 S/S:
 Severe epigastric pain
 N/V
 If severe
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Infection
Hemorrhage
Complications to other organs
Acites
Renal Calculi
 Kidney stones
 S/S:
 Abdominal pain starting in back and radiating
to groin
 Infection
 Hematurea
 Severe may show signs of sepsis
Hepatitis
 Inflammation of the liver
 S/S:
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Fatigue
Anorexia
General malaise
N/V
Photophobia
Muscle and joint pain
Dark urine
RUQ pain
Clay colored stools
Jaundice
Hepatic Failure
 Liver failure due to disease or insult
 S/S:
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Jaundice
Fatigue
Edema
Metabolic changes (expect EKG changes)
Hepatomegaly
Febrile
Severe may show shock
Cirrhosis
 Necrosis of the liver cells
 S/S:
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Fatigue
Anorexia
GI bleed
Ascites
Jaundice
Signs of shock (late)
Cholecystitis
 Inflammation of the gall bladder
 S/S:
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URQ pain radiating to the right shoulder
History of gall stones
Febrile
Fatty food intolerance
N/V
Severe may be shocky
Renal Failure
 Kidney failure
 S/S:
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Oliguria leading to anurea
Edema
Acidosis
Metabolic changes
Leading to MOF
May see
 LOC changes
 N/V…..
Pelvic Inflammatory Disease
 Inflammation of the female pelvic
organs
 S/S:
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ABD pain with rebound
Guarding
Febrile
Pain with intercourse
Changes in menstruation
Painful urination
Testicular Torsion
 Twisting of spermatic cord depleting
supply of blood
 S/S:
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Swelling
SEVERE PAIN
N/V
Hematuria
Glomerulonephritis
 Inflammation of the glomerulus
 S/S:
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N/V
Edema
Decrease in output (may be absent)
Hypertension
Nephrotic Syndrome
 Increase in permeability of nephrons
 S/S:
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Proteinuria
Edema
Swelling of the scrotum
Distention
May see signs of shock
Flank Pain
N/V