Transcript Slide 1

Abdominal Trauma
Victor Politi, M.D., FACP, Medical
Director, SVCMC School of Allied Health
Professions
The Abdomen
• Everything between diaphragm and pelvis
• Injury, illness very difficult to assess because
of large variety of structures
Introduction
• 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, and 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
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
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Liver, Gallbladder, Stomach
(Small Part) Small and Large
Intestine
Head of Pancreas
Upper Part of Kidney
Stomach,
Tail of Pancreas
Tail of Liver
Small and Large Intestine
Upper Part of Kidney
L
o
w
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Small and Large Intestine
Lower part of Kidney
Half of Bladder, Appendix,
Female Reproductive Organs
Small and Large Intestine
Lower part of Kidney
Half of Bladder, Female
Reproductive Organs
Right
Left
Hollow and Solid
Abdominal Organs
• Solid
• 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
• Kidneys
• Ureter
• Urinary Bladder
• Urethra
• Immune System
• Spleen
• Genitals
• 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
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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 deceleration 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 RBCs
• 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
Accessory Organs
• 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
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Components
• Kidneys
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Collect waste products in blood stream
Concentrate products into urine
Reabsorb water and salt
Regulate body osmotic balance
Adrenal glands
• Superior and attached to kidneys
• Component of endocrine system
• Release epinephrine and 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
• Uterus 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 RBCs
• Results in relative anemia
• Cardiac output increases by 40%
• Heart rate increases 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
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 and protects anterior surface of abdomen
Retroperitoneal Structures
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Kidneys
Duodenum
Pancreas
Urinary Bladder
Posterior portions of ascending and
descending colon
Rectum
Major vascular structures
Pathophysiology of Abdominal Injury
Mechanism of Injury
• Penetrating Trauma
• Energy transmitted to surrounding tissue
• Projectile cavitation, pitch, and yaw
• Results in:
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Uncontrolled hemorrhage
Organ damage
Spillage of hollow organ contents
Irritation and 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
• Example: ligamentum teres
Pathophysiology of Abdominal Injury
Mechanism of Injury
• Blast Injuries
• Blunt and penetrating MOIs
• Irregular shaped shrapnel and debris
• Pressure wave
• Compresses and relaxes air-filled organs
• Contuses or ruptures 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.
Pathophysiology of Abdominal Injury
• Injury to the Abdominal Wall
• Trauma to thorax, buttocks, flanks, and
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
Pathophysiology of Abdominal Injury
• Injury to the Hollow Organs
• 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
Pathophysiology of Abdominal Injury
• Injury to solid organs
• Specific Organs
• Spleen: pain referred to left shoulder
• Pancreas: pain radiates to back
• Kidneys: pain radiates from flank to
groin and hematuria
• Liver: pain referred to the right shoulder
Pathophysiology of Abdominal Injury
• Injury to the Vascular Structures
• Abdominal aorta and 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
• Disrupts blood vessels supplying the bowel
• Leads 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 and 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
Pathophysiology of Abdominal Injury
• Injury to the Peritoneum
• Blood does not induce peritonitis
• Progression
• 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 and fetus.
Pathophysiology of Abdominal Injury
• Injury During Pregnancy
• Maternal Changes
• Increasing size and weight of uterus
• Compresses inferior vena cava
• Reduces venous return to heart
• Increasing maternal blood volume
• Protects mother from hypovolemia
• 30–35% of blood loss 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 and 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 and smaller diameter
• Rib cage more cartilaginous
• Transmits injury to organs beneath easier
• Increased incidence of injury to
• Liver
• Kidney
• Spleen
Pathophysiology of Abdominal Injury
• Injury to Pediatric Patients
• 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 and 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, and pelvis
• Left impact
• Spleen, descending colon and pelvis
• Children and pedestrians
• Abdominal injuries common
Assessment of the Abdominal Injury
Patient
• Scene size-up
• Gunshot Wounds
• Type and caliber of weapon
• Check whether assailant still on scene
Assessment of the Abdominal Injury
Patient
• Initial Assessment
• LOC
• Drug or alcohol use
• Evaluate ABCs and immediate threats
Assessment of the Abdominal Injury
Patient
• Rapid Trauma Assessment
• Rapid and Full Trauma Assessment.
• Closely examine regions with a high index
of suspicion.
• Expose and Examine for DCAP-BTLS.
• If suspected pelvic injury, DO NOT test pelvis.
• Palpate entire abdomen.
• Evaluate for entrance and exit wounds.
Assessment of the Abdominal Injury
Patient
• 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 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 and capillary refill
Pulse rate and pulse oximetry
Mental status
Skin condition
Ineffective aggressive fluid resuscitation
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 and capillary refill
Pulse rate and 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
• PASG application
• Specific injury care
• Impaled objects or eviscerations
Management of the Abdominal Injury
Patient
• Fluid Resuscitation
• Large-bore IV with isotonic solution
• Consider 2 bolus if pulse does not slow
• Large-bore IV lock for use if patient’s BP
drops below 80 mmHg
• Fluid challenge 250 mL or 20 mL/kg
• Limit to 3 L
• Titrate to SBP of 80 mmHg
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.
To review - Abdominal Trauma Patients
• ABC in all patients
• Airway Obstruction
• Pneumothorax, Hemothorax
• Adequate IV Access: Short, Large-bore
• Hemodynamic stability
• ? Presence of abdominal injury
• Intraperitoneal
• Retroperitoneal
• Diagnostic interventions
• Therapeutic interventions
ED Ultrasound
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Not an echocardiogram
Learning curve and operator-dependent
Four quadrant evaluation for fluid
In common use
Useful in conjunction with CT and to
triage unstable patient
CT Scan
• Hemodynamically stable patients
• Visualizes retroperitoneum
• Duodenum, pancreas, kidneys
• Cystogram
• Poor sensitivity for bowel injury
• Seat belt injury associated with bowel injury
• L-2 to L-4 fracture
• Peri-umbilical abdominal contusion
Injuries Often Associated with Abdominal
Trauma
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Scapular Fracture: Aorta/GV
First/Second Rib: Aorta/GV
Lumbar Spine (L2): Pancreas, Duodenum
Femur/Humerus: Neurovascular
Knee Dislocation: Popliteal Artery
Fall: Calcaneus, T/L Spine
Rib Fractures: Pulmonary
Blunt Hepatic Trauma
• Many liver injuries stop bleeding
spontaneously
• Non-therapeutic laparotomies frequent
• CT grade does not predict need for surgery
• Mortality less in non-operative group
• Few failures with non-operative approach
Hepatic Injury
• Associated injuries affect mortality
• Hemorrhage: Packing with re-look laparotomy
in 24-48 hours
• Wide drainage with closure
• Bile Leak
• Interval closure may be required
• Vigilance for Abdominal Compartment
Syndrome
Blunt Abdominal Trauma
• Blunt abdominal trauma is a leading cause of
morbidity and mortality among all age
groups.
• Identification of serious intra-abdominal
pathology is often challenging.
Blunt Abdominal Trauma
• Many injuries may not manifest during the
initial assessment and treatment period.
Blunt Abdominal Trauma
• Mechanisms of injury often result in other
associated injuries that may divert attention
from potentially life-threatening intraabdominal pathology.
Missed Injuries
• Missed or delayed diagnoses of injuries occur
in about 10% of trauma patients
• “Life before limb” may preclude complete
exam in ER
• Altered mental status predisposes to
overlooked injuries
• Failure to examine, order appropriate tests,
interpret tests, follow-up
Just Remember !!!!
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ABC in every patient
ABC with every location change
Trauma series of radiographs in all patients
Consider ED ultrasound early
Travel to Radiology only with stable patient
Consider associated injuries