Transcript Bleeding and Shock

Abdominal Trauma
Temple College
EMS Professions
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The Abdomen
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Everything between diaphragm and
pelvis
Injury, illness very difficult to assess
because of large variety of structures
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Abdominal Anatomy
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Abdomen divided into four quadrants by
body mid-line, horizontal plane through
umbilicus
Organs can be located by quadrant
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Abdominal Anatomy
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Right Upper Quadrant
– Liver
– Gall Bladder
– Right Kidney
– Ascending Colon
– Transverse Colon
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Abdominal Anatomy
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Left Upper Quadrant
– Spleen
– Stomach
– Pancreas
– Left Kidney
– Transverse Colon
– Descending Colon
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Abdominal Anatomy
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Right Lower Quadrant
– Ascending Colon
– Appendix
– Right Ovary (female)
– Right Fallopian Tube (female)
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Abdominal Anatomy
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Left Lower Quadrant
– Descending Colon
– Sigmoid colon
– Left Ovary (female)
– Left Fallopian Tube (female)
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Abdominal Anatomy
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Periumbilical area
– Located around (peri) the navel (umbilicus)
– Small bowel lies in all quadrants in
periumbilical area
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Suprapubic area
– Located just above pubic bone
– Urinary bladder, uterus lie in this area
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Abdominal Cavity
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Peritoneum = abdominal cavity lining
Divides abdomen into two spaces
– Peritoneal cavity
– Retroperitoneal space
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Abdominal Anatomy
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Peritoneal
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–
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–
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Spleen
Liver
Stomach
Gall bladder
Bowel
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Retroperitoneal
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–
–
–
–
–
Pancreas
Kidney
Ureter
Inferior vena cava
Abdominal aorta
Urinary bladder
Reproductive organs
Disease, injury of retroperitoneal organs
often causes back pain
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Abdominal Anatomy
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Organs can be classified as:
– Hollow
– Solid
– Major vascular
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Solid Organs
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Liver
Spleen
Kidney
Pancreas
When solid organs are
injured, they bleed heavily
and cause shock
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Solid Organs
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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
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Solid Organs
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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
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Solid Organs
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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
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Hollow Organs
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Stomach
Gall bladder
Large, small intestines
Ureters, urinary bladder
Rupture causes content
spillage, inflammation of
peritoneum
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Hollow Organs
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Stomach
– Acid, enzymes
– Immediate peritonitis
– Pain, tenderness, guarding, rigidity
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Hollow Organs
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Colon
– Spillage of bacteria
– May take 6 hrs to develop peritonitis
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Small Bowel
– Fewer bacteria
– May take 24-48 hours to develop peritonitis
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Major Vascular Structures
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Aorta
Inferior vena cava
Major branches
Injury can cause severe
blood loss ; exsanguination
(bleeding out)
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Abdominal Trauma
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Most survive to reach hospital
Most common factors leading to death
– Failure to adequately evaluate
– Delayed resuscitation
– Inadequate volume
– Inadequate diagnosis
– Delayed surgery
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High Index of Suspicion
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Mechanism
Trauma to lower chest, back, flank,
buttocks, and perineum
Hypovolemic shock with no readily
identifiable cause
Diffusely tender abdomen
Pain in uninjured shoulder
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Mechanism
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Look for signs of injury
– Bruises
– Tire marks
– Obvious open injuries
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Assume any abdominal injury is serious
until proven otherwise!
Injury above umbilicus also involves
chest until proven otherwise
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Unexplained Shock
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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
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Signs of Injured Abdomen
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Diffuse tenderness
Pain
– Pain referred to shoulder = Organ under
diaphragm involved (?spleen)
– Pain referred to back = Retroperitoneal
organ involved (?kidney)
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Abdominal Rigidity
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NOT reliable
Bleeding may not cause rigidity if free
hemoglobin absent
Bleeding in retroperitoneal space may
not cause rigidity
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Abdominal Trauma Management
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Less important to diagnose exact injury
Treat clinical findings
Management same regardless of
specific organ(s) injured
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Abdominal Trauma Management
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Airway
C-Spine if mechanism indicates
High flow O2
Assist ventilations if needed
Give nothing by mouth
MAST may be helpful in slowing
intraabdominal bleeding with shock
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Impaled Object
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Leave in place
– Shorten if necessary for transport
– Leave part of object exposed
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Evisceration
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With large laceration abdominal
contents may spill out
Do NOT try to replace
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Evisceration
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Cover exposed organs with saline
moistened multi-trauma dressing
Do NOT use 4 x 4s
Cover first dressing with second DRY
dressing or aluminum foil
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Genitourinary Trauma
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Urinary System
Kidney
Ureter
Urinary Bladder
Urethra
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Kidney Trauma
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50% of all GU trauma
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Kidney Trauma
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Penetrating
– GSW
– Stab wound
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Rare, usually associated with trauma to
other abdominal organs
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Kidney Trauma
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Blunt
– Direct blow to back, flank, upper abdomen
• Suspect with fractures of 10th - 12th ribs or T12,
L1, L2
– Acceleration/Deceleration
• Shearing of renal artery/vein
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Kidney Trauma
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Signs and Symptoms
– Gross Hematuria
• 80% of cases
• Absence does NOT exclude renal injury
– Localized flank/abdominal pain
– Palpable mass
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Kidney Trauma
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Signs and Symptoms
– Tenderness: Lower ribs, upper L-spine,
flank
– Pain: groin, shoulder, back, flank
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Ureter Trauma
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Less than 2% of GU trauma
Usually secondary to penetrating
trauma
Indicator
– Wound to lower back with urine escaping
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Urinary Bladder Trauma
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Mechanisms
– Blunt injury to lower abdomen
– Seat belts
– Pelvic fracture
– Penetrating trauma to lower abdomen or
perineum (pelvic floor)
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Extraperitoneal Bladder Rupture
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Urine in umbilicus, anterior thighs, scrotum,
inguinal canals, perineum
Dysuria
Hematuria
Suprapubic tenderness
Swelling, redness secondary to tissue
damage from urine
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Intraperitoneal Bladder Rupture
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Urgency to void
Inability to void
Shock
Abdominal distension
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Urethral Trauma
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Mechanisms
– Sudden decelerations
(bladder shears off urethra)
– Straddle injuries
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Urethral Trauma
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Signs and Symptoms
– Blood at external meatus
– Perineal bruising (butterfly bruise)
– Scrotal hematoma
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Reproductive System Trauma
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Can occur to both external and internal
reproductive systems
– External
• More common
• Pain, extensive bleeding
– Internal
• Rarely injured
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Reproductive System Trauma
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Treat like blunt or penetrating soft tissue
injuries elsewhere on body
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Male Genitalia Trauma
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Usually NOT life-threatening
Very painful
Great source of concern to patient
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Male Genitalia Trauma
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Avulsion of skin of penis, scrotum
– Cover with a moist, sterile dressing
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Complete amputation of penis
– Treat as any amputated part
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Male Genitalia Trauma
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Blunt trauma to penis, scrotum
– Apply ice pack
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Urethral foreign bodies
– Do NOT remove
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Penis entrapped in zipper
– If 1 or 2 teeth involved, try to unzip
– If more involved, cut zipper out of trousers,
transport
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Female Genitalia Trauma
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Internal
– Rarely injured
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External
– Can cause pain, extensive bleeding
– Usually not life-threatening
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Treat with compresses, pressure
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Sexual Assault
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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
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