Transcript Document

Abdominal Trauma
Sections
 Introduction to Abdominal Injury
 Abdominal Anatomy and
Physiology
 Pathophysiology of Abdominal
Injury
 Assessment of the Abdominal
Injury Patient
 Management of the Abdominal
Injury Patient
Introduction to
Abdominal Injury
 One of body’s largest cavities
 Multiple vital organs
 Large volumes of blood can be lost before
signs and symptoms manifest
 Must be alert for signs of transmitted injury
 Deformity, swelling, & ecchymosis
 Prevention
 Highway safety
 Seatbelt usage
• Proper application
 Airbags
Abdominal Anatomy
and Physiology
 Boundaries
 Superior: Diaphragm
 Inferior: Pelvis
 Posterior: Vertebral column and posterior
and inferior ribs
 Lateral: muscles of the flank
 Anterior: Abdominal muscles
(continued)
Abdominal Anatomy
and Physiology
 Three Specific Spaces
 Peritoneal Space
 Organs covered by abdominal (peritoneal) lining
 Retroperitoneal Space
 Organs posterior to the peritoneal lining
 Pelvic Space
 Organs contained within pelvis
Organs by Abdominal Quadrant
U
p
p
e
r
Liver, Gallbladder,
Stomach (Small Part)
Small & Large
Intestine
Head of Pancreas
Upper Part of Kidney
L
o
w
e
r
Small & Large
Intestine
Lower part of Kidney
Half of Bladder,
Appendix, Female
Reproductive Organs
Right
Stomach,
Tail of Pancreas
Tail of Liver
Small & Large
Intestine
Upper Part of Kidney
Small & Large
Intestine
Lower part of Kidney
Half of Bladder,
Female Reproductive
Organs
Left
Hollow & Solid
Abdominal Organs
 Solid
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Liver
Spleen
Pancreas
Kidneys
Ovaries
 Hollow
 Stomach
 Small Intestine
 Large
Intestine
 Gall Bladder
 Bladder
 Uterus
Abdominal Anatomy and Physiology
Major Abdominal Structures
 Digestive Tract
 AKA: Alimentary canal
 Structures
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Stomach
Small Intestine
Large Intestine
Rectum
 Accessory
Organs
 Liver
 Gallbladder
 Pancreas
 Urinary System
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Kidneys
Ureters
Urinary Bladder
Urethra
 Immune System
 Spleen
 Genitals
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Ovaries
Fallopian Tubes
Uterus
Vagina
Abdominal Anatomy and Physiology
Digestive Tract
 Function
 Churn material to be digested
 Excrete digestive juices
 Absorb nutrients and water
 Components
 Stomach
 Food mixed with HCl and enzymes to form Chyme
 Small bowel
 Food moved through bowel by peristalsis
 Duodenum
 Jejunum
 Ileum
 Large bowel (Colon)
 Rectum
 Anus
Abdominal Anatomy and Physiology
Accessory Organs
 Liver
 Located in upper right quadrant
 2.5% of total body weight
 Receives 25% of cardiac output and has greatest blood
reserve
 Suspended by ligamentum teres
 Can lacerate liver in deceration trauma
 Function
 Detoxifies blood
 Removes damaged or aged erythrocytes
 Stores glycogen and agents for metabolism
 Liver tissue will grow to normal size following partial
removal
Abdominal Anatomy and Physiology
Accessory Organs
 Gallbladder
 Small hollow organ located behind and beneath liver
 Receives bile
 Waste product from reprocessing of RBC’s
 Used to digest fatty foods (emulsification)
 Pancreas
 Produces endocrine hormones and exocrine enzymes
 Glucagon
 Insulin
 Digestive enzymes that return the chyme pH to normal
and break down proteins
Abdominal Anatomy
and Physiology
 Spleen
 Part of immune system
 Located behind stomach and lateral to kidney in upper
left quadrant
 Function
 Immunology
 Stores large volume of blood
 Most fragile abdominal organ
 Commonly injured in blunt trauma affecting the left
flank
Abdominal Anatomy and Physiology
Urinary System
 Components
 Kidneys
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Collect waste products in blood stream
Concentrate products into urine
Reabsorbs water and salt
Regulate body osmotic balance
Adrenal Glands
• Superior & Attached to kidneys
• Component of endocrine system
• Release epinephrine & norepinephrine
 Ureters
 Urinary bladder
 Can contain as much as 500 ml of urine
 Urethra
Abdominal Anatomy
and Physiology
 Genitalia
 Female sexual organs
 Represent an open passage to the interior of the abdominal
cavity
 Components
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Ovaries
Fallopian Tubes
Uterus
Vagina
 Male sexual organs
 External to the abdomen
 Components
• Testes
• Penis
Abdominal Anatomy and Physiology
Pregnant Uterus
 Uterine and contents grow rapidly
after conception and until delivery
 1st Trimester (0-12 weeks)
 Well protected
 2nd Trimester (12-24 weeks)
 Uterus displaces organs upward
 3rd Trimester (24 weeks to term)
 Fills entire abdominal cavity
 Displaces diaphragm upward
Abdominal Anatomy and Physiology
Pregnant Uterus
 Affects on Maternal Physiology
 Increases circulatory blood volume by 45%
 Greater volume, but fewer RBC’s
• Results in relative anemia
 Cardiac output increases by 40%
 Heart rate increased by 15 bpm
 Compresses the vena cava in 3rd trimester
 Reduces venous return
• Supine Hypotensive Syndrome
Abdominal Anatomy and Physiology
Vasculature
 Key Vessels
 Abdominal aorta
 Blood supply to abdomen
 Left of spinal column
 Iliac arteries
 Bifurcation of aorta at the upper sacral level
 Inferior Vena Cava
 Adjacent to spinal column
(continued)
Abdominal Anatomy and Physiology
Vasculature
 Portal System
 Venous subsystem
 Collects venous blood, fluid and nutrients absorbed
by the bowel
 Transports to liver
• Detoxification, Storage of excess nutrients
• Adds deficient nutrients
Abdominal Anatomy and Physiology
Peritoneum
 Serous membrane that surrounds the
interior of most of the abdominal cavity
 Covers most of small bowel and some of the
abdominal organs
 Small amount of fluid between peritoneal
layers
 Mesentery
 Double fold of peritoneum
 Supports and suspends small bowel from posterior
abdominal wall
 Omentum
 Additional fold
 Insulates & protects anterior surface of abdomen
Retroperitoneal Structures
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Kidneys
Duodenum
Pancreas
Urinary Bladder
Posterior portions of ascending &
descending colon
 Rectum
 Major vascular structures
Pathophysiology of Abdominal Injury
Mechanism of Injury
 Penetrating Trauma
 Energy transmitted to surrounding tissue
 Projectile cavitation, pitch & yaw
 Results in
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Uncontrolled hemorrhage
Organ damage
Spillage of hollow organ contents
Irritation & Inflammation of abdominal lining
 Liver most commonly affected organ
 Shotgun Trauma
 Multiple projectiles
Pathophysiology of Abdominal Injury
Mechanism of Injury
 Blunt Trauma
 Produces least visible signs of injury
 Causes
 Deceleration
• Contents damaged by change in velocity
 Compression
• Organs trapped between other structures
 Shear
• Part of an organ is able to move while another part is fixed
• i.e.: Ligamentum teres
Pathophysiology of Abdominal Injury
Mechanism of Injury
 Blast Injuries
 Blunt & Penetrating MOI’s
 Irregular shaped shrapnel and debris
 Pressure wave
 Compresses and relaxes air-filled organs
 Contuse or rupture organs
 Abdominal injury is secondary concern
during blast injury
Pathophysiology of
Abdominal Injury
 Injury to the Abdominal Wall
 Skin and muscles transmit blunt trauma to internal
structures
 Typically only show erythema
 Visible swelling and ecchymosis occur over several hours
 Penetrating trauma may appear minimal externally in
comparison to internal trauma
 Muscle may mask the size of the external wound
 Evisceration may be present
 Trauma to thorax, buttocks, flanks & back may
penetrate abdomen
 Lower chest may injure spleen, liver, stomach or
gallbladder
 Diaphragmatic tears
 Herniation of abdominal contents into thorax
Pathophysiology of
Abdominal Injury
 Injury to the Hollow Organs
 May rupture with compression from blunt forces
 May tear due to penetrating trauma
 Spillage of contents into
 Retroperitoneal space
 Peritoneal space
 Pelvic space
 Intestines have a large amount of bacteria
 Leakage can result in sepsis
 Manifestations of Blood Loss
 Hematochezia: Blood in stool
 Hematemesis: Blood in emesis
 Hematuria: Blood in the urine
Pathophysiology of
Abdominal Injury
 Injury to the Solid Organs
 Dense and less strongly held together
 Prone to contusion
 Bleeding
 Fracture (rupture)
 Unrestricted hemorrhage if organ capsule is ruptured
 Specific Organs
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Spleen: pain referred to left shoulder
Pancreas: pain radiate to back
Kidneys: pain radiate from flank to groin & hematuria
Liver: pain referred to the right shoulder
Pathophysiology of
Abdominal Injury
 Injury to the Vascular Structures
 Abdominal Aorta & Vena Cava
 Prone to direct blunt or penetrating trauma
 May be injured in deceleration injuries
 Blood accumulates beneath diaphragm
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Irritation of muscular structures
Produces referred pain in the shoulder region
Greater volume of blood can be lost
Presence of blood in abdomen, stimulates vagus nerve
resulting in slowing of heart rate
 Blood can isolate in any of the abdominal spaces
Pathophysiology of
Abdominal Injury
 Injury to the Mesentery and Bowel
 Provides bowel with circulation, innervation, and
attachment
 Disrupt blood vessels supplying the bowel
 Lead to ischemia, necrosis, or rupture
 Blood loss minimal
 Peritoneal layers contain hemorrhage
 Tear of mesentery may rupture bowel
 Penetrating trauma to the lateral abdomen likely to
injure large bowel
Pathophysiology of
Abdominal Injury
 Injury to the Peritoneum
 Delicate & sensitive lining of anterior abdomen
 Peritonitis
 Inflammation of the peritoneum due to
• Bacterial irritation
 Due to torn bowel or open wound
• Chemical irritation
 Caustic nature of digestive enzymes
 Urine initiates inflammatory response
 Blood does not induce peritonitis
 Progression
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Slight tenderness at location of injury
Rebound tenderness
Guarding
Rigid, board-like feel
Pathophysiology of
Abdominal Injury
 Injury to the Pelvis
 Serious skeletal injury
 Life threatening hemorrhage
 Potential injury to pelvic organs
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Ureters
Bladder
Urethra
Female Genitalia
Prostate
Rectum
Anus
Pathophysiology of
Abdominal Injury
 Injury During Pregnancy
 Trauma is the number one killer of pregnant females
 Penetrating abdominal trauma accounts for 36% of
maternal mortality
• GSW account for 40-70% of penetrating trauma
 Blunt trauma due to improperly worn seatbelts
• Auto collisions are leading cause of mortality
 Changing dimensions of uterus
 Protects abdominal organs
 Endangers uterus & fetus
Pathophysiology of
Abdominal Injury
 Injury During Pregnancy
 Maternal Changes
 Increasing size & weight of uterus
• Compression of inferior vena cava
• Reduce venous return to heart
 Increasing maternal blood volume
• Protect mother from hypovolemia
• 30-35% of blood less necessary before signs of shock
 Uterus is thick and muscular
• Distributes forces of trauma uniformly to fetus
 Reduces chances for injury
Pathophysiology of
Abdominal Injury
 Injury During Pregnancy
 Risk of uterine & fetal injury increases with
the length of gestation
 Greatest risk during 3rd Trimester
 Penetrating trauma may cause fetal and
maternal blood mixing
 Blunt trauma complications
 Uterine rupture
 Abruptio placentae
 Premature rupture of amniotic sac
Pathophysiology of
Abdominal Injury
 Injury to Pediatric Patients
 Children have poorly developed abdominal
musculature & smaller diameter
 Rib cage more cartilaginous
 Transmits injury to organs beneath easier
 Increased incidence of injury to
 Liver
 Kidney
 Spleen
 Shock
 Compensate well for blood loss
 May not show signs and symptoms until 50% of blood is
lost
Assessment of the
Abdominal Injury Patient
 Scene Size-up
 Must evaluate MOI to assess seriousness of
injury
 Identify strength and direction of forces
 Velocity of impact
 Focus observations and palpation on that site
 Develop a mental list of possible organs involved
 If auto crash
 Determine if seatbelts used properly
 Interior signs of impact
• Steering wheel & dashboard deformity
Assessment of the
Abdominal Injury Patient
 Scene Size-up
 Auto Crash Injury Patterns
 Frontal Impact
• Compress abdomen
• Liver, spleen, and rupture of hollow organs
 Right Impact
• Liver, ascending colon, & pelvis
 Left Impact
• Spleen, descending colon and pelvis
 Children & Pedestrians
• Abdominal injuries common
 Gunshot Wounds
 Type & Caliber of weapon
 Is assailant still on scene???
Assessment of the
Abdominal Injury Patient
 Initial Assessment
 LOC
 Drug or alcohol use
 Evaluate ABC’s and immediate threats
Assessment of the
Abdominal Injury Patient
 Rapid Trauma Assessment
 Rapid & Full Trauma Assessment
 Closely examine regions with a high index of
suspicion
 Expose & Examine for DCAP-BTLS
 If suspected pelvic injury DO NOT test pelvis
 Palpate entire abdomen
 Evaluate for entrance & exit wounds
 OPQRST Assessment
• Characteristics of pain
 Tenderness versus Rebound tenderness
 SAMPLE History
 Vital Assessment
Assessment of the
Abdominal Injury Patient
 Considerations with Pregnant
Patients
 Be observant for
 Signs of shock
• PRETREAT: signs may not develop until 30% of blood
volume is lost
• Body begins shunting blood from GI/GU to primary organs
 Supine hypotensive syndrome
 Premature contractions
 Vaginal hemorrhage
• Uterine Rupture versus Abruptio placentae
 Uterus development
• Abnormal asymmetry
Assessment of the
Abdominal Injury Patient
 Ongoing Assessment
 Trend vital signs
 Every 5 minutes for critical patients
 Evaluate for
 Progressive peritonitis
 Progressive hemorrhage
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BP & Capillary Refill
Pulse rate & Pulse Oximetry
Mental Status
Skin condition
Ineffective aggressive fluid resuscitation
Management of the
Abdominal Injury Patient
 General Management
 Position Patient
 Position of comfort unless spinal injury
• Flex knees or left lateral recumbent
 General shock care
 Fluid resuscitation
 Large bore IV with isotonic solution
• Consider 2 bolus if pulse does not slow
 Fluid challenge 250 ml or 20 ml/kg
• Limit to 3 L
 Titrate to SBP of 90 mmHg
 PASG application
 Specific injury care
 Impaled Objects or Eviscerations
Management of the Abdominal Injury Patient
PASG
 Contraindications
 Concurrent
penetrating chest
trauma
 Abdomen inflation
contraindicated in
pregnancy
 Inflate legs only
 Indications
 Evisceration
 If SBP <60 mmHg
 Intra-abdominal
bleeding
 Shock
Incremental inflation
titrated to BP and
Pulse
Management of the
Abdominal Injury Patient
 Management of the Pregnant
Patient
 Positioning
 Left Lateral Recumbent
 If on backboard tilt backboard
• Facilitates venous return
 Oxygenation
 High flow O2
 Consider PPV by BVM if hypoxia ensues
 Maintain high index of suspicion for intraabdominal bleeding
 Consider IV and PASG