Abdominal trauma

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Beka Aberra
C1 Medical Student bekaaberra@yahoo.com
Black Lion Hospital

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  • 07/20/12 Temple College EMS Professions
  • 07/20/12 Temple College EMS Professions
  • Shearing: inappropriate location of the lap belt contributing to bowel injury. 07/20/12 Temple College EMS Professions
  • 07/20/12 Temple College EMS Professions
  • The abdominal examination must be systematic. The abdomen is inspected for abrasions or ecchymosis. Particular attention should be paid to injury patterns that predict the potential for intra-abdominal trauma (eg, lap belt abrasions, steering wheel–shaped contusions). In most studies, lap belt marks have been correlated with rupture of the small intestine and an increased incidence of other intra-abdominal injuries. Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign) indicates retroperitoneal hemorrhage, but this is usually delayed for several hours to days. Visual inspection for abdominal distention, which may be due to pneumoperitoneum, gastric dilatation secondary to assisted ventilation or swallowing of air, or ileus produced by peritoneal irritation, is important. Auscultation of bowel sounds in the thorax may indicate the presence of a diaphragmatic injury. Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula. Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound tenderness, which suggests peritoneal injury. Such signs appearing soon after an injury suggest leakage of intestinal content. Peritonitis due to intra-abdominal hemorrhage may take several hours to develop. Fullness and doughy consistency on palpation may indicate intra-abdominal hemorrhage. Crepitation or instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries associated with lower rib injuries. Tenderness on percussion constitutes a peritoneal sign. Tenderness mandates further evaluation and probably surgical consultation. Rectal and bimanual vaginal pelvic examinations should be performed. [6] A rectal examination should be done to search for evidence of bony penetration resulting from a pelvic fracture, and the stool should be evaluated for gross or occult blood. The evaluation of rectal tone is important for determining the patient’s neurologic status, and palpation of a high-riding prostate suggests urethral injury. The genitals and perineum should be examined for soft tissue injuries, bleeding, and hematoma. Pelvic instability indicates the potential for lower urinary tract injury, as well as pelvic and retroperitoneal hematoma. Open pelvic fractures are associated with a mortality rate exceeding 50%. 07/20/12 Temple College EMS Professions
  • Kehr’s sign Rt & Lt shoulder pain due to ruptured spleen. Referred pain due to irritation of diaphragm, (Phrenic Nerve) 07/20/12 Temple College EMS Professions
  • Inspection: abrasions, contusions, lacerations, deformity Grey-Turner, Kehr, Balance, Cullen Cullen Peri-umbilical bruising Haemorrhagic pancreatitis or ectopic pregnancy Grey Turner Bruising of flank Haemorrhagic pancreatitis 07/20/12 Temple College EMS Professions
  • Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.) Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum 07/20/12 Temple College EMS Professions
  • Abdominal trauma

    1. 1. Abdominal Trauma By Beka Aberra 1
    2. 2. Outline Introduction Background Anatomy Mechanisms and Pathophysiology Clinical assessment Conclusion
    3. 3. INTRODUCTION Trauma is the commonest cause of death in young people. ABDOMINAL TRAUMA STANDS THIRD NEXT TO HEAD INJURY AND CHEST INJURY 25% of all major trauma victims require abdominal exploration. Abdominal evaluation is the challenging component of evaluating trauma. Penetrating torso injuries b/n nipple & perineum is a potential intra abdominal injury. Mechanism, Force & Location of injury & Hemodynamic status determine the priority & best method of assessment. 3
    4. 4.  75% OF ALL BLUNT TRAUMA TO ABDOMEN INVOLVES ROAD TRAFFIC ACCIDENT 60% OF INJURY OCCUR IN MALES (14-30) Trauma related deaths form 3 Peaks – First Peak accounts 50% die instantly or very soon. – Second Peak accounts 30% in hours of injury due to severe blood loss. – Third Peak accounts 20% in days to weeks due to infection/multi organ failure. 4
    5. 5. Background Anatomy Anterior abdomen Flank Back Intraperitoneal space contents Retroperitoneal space contents Pelvic cavity contents 5
    6. 6.  Anterior abdomen: Trans-nipple line, Anterior axillary lines, Inguinal ligaments and Symphysis pubis. Flank: Anterior and posterior axillary line; Sixth intercostal to iliac crest. Back: Posterior axillary line; Tip of scapula to Iliac crest.
    7. 7.  Upper Peritoneal cavityCovered by lower aspect of bony thorax. Includes Diaphragm, Liver,Spleen, Stomach, Transverse colon. Lower Peritoneal cavity:Small bowel Ascending and Descending colon, Sigmoid colon Retroperitoneal space:A Potential space Behind “true” abdominal cavityAbdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas,kidneys, Ureters and posterior aspects of Ascending and Descendingcolons Pelvic cavity:Rectum, Bladder, iliac vessels and Internal genitalia in women.
    8. 8. The Abdomen Everything between diaphragm and pelvis Injuries very difficult to assess because of large variety of structures 8
    9. 9. Abdominal Anatomy Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus Organ located by quadrant 9
    10. 10. Abdominal Anatomy  Right Upper Quadrant – Liver – Gall Bladder – Right Kidney – Ascending Colon – Transverse Colon 10
    11. 11. Abdominal Anatomy  Left Upper Quadrant – Spleen – Stomach – Pancreas – Left Kidney – Transverse Colon – Descending Colon 11
    12. 12. Abdominal Anatomy Right Lower Quadrant – Ascending Colon – Appendix – Right Ovary (female) – Right Fallopian Tube (female) 12
    13. 13. Abdominal Anatomy Left Lower Quadrant – Descending Colon – Sigmoid colon – Left Ovary (female) – Left Fallopian Tube (female) 13
    14. 14. Abdominal Anatomy  Organs can be classified as: – Hollow – Solid – Major vascular 14
    15. 15. Solid Organs Liver Spleen Kidney Pancreas When solid organs are injured, they bleed heavily and cause shock 15
    16. 16. Hollow Organs Stomach Gall bladder Large, small intestines Ureters, urinary bladder Rupture causes content spillage, inflammation of peritoneum 16
    17. 17. Major Vascular Structures Aorta Inferior vena cava Major branches Injury can cause severe blood loss ; exsanguination (bleeding out) 17
    18. 18. 1. Abdominal Aorta 2. Common Iliac ArteryVascular Anatomy 4. External Iliac 3. Internal Iliac 5. Superior Gluteal 6. Obturator Artery
    19. 19. Can you tell me What are the top 3 most commonly injured organs in the abdomen?
    20. 20. Spleen (40-55%)Liver (35-45%)Small bowel (5-10%)
    21. 21. Mechanisms Blunt trauma:Motor Vehicle AccidentSeat belt injury Penetrating injuries:Stab woundsGun Shot wounds BlastBomb CrushBuilding collapse Thermal
    22. 22. Blunt Trauma Motor vehicle collisions Motorcycle collisions Pedestrian injuries Falls Assault Blast injuries
    23. 23. Penetrating Trauma Stab wounds Gun Shot wounds Surgical Incisions
    24. 24. Blunt Abdominal trauma is thecommonest cause of death in youngerpopulation with Polytrauma in RTA.Blunt abdominal injuries carry a greater risk of morbidity and mortality than penetrating abdominal injuries.Mostly due to • Inadequate diagnosis • Delayed resuscitation • Delayed surgery
    25. 25. Mechanism of Injury:BluntMotor Vehicle AccidentSeatbelt injury
    26. 26. Pathophysiology 1.Compression/Concussive forces – Direct blow – External compression vs. fixed object (e.g. lap belt, spinal column) Cause • Tears & Sub capsular hematoma to solid viscera. • Deform hollow organs & transiently Inc. intraluminal pressure. 2. Deceleration forces – Stretching & Linear shearing b/n relatively fixed & free object.  In BAT, Organs that cant yield to impact by elastic deformation are most likely to be injured i.e. solid organs 26
    27. 27.  Rapid decelerationShearing Force created that cause solid, visceralorgans and vascular pedicles to tear at relatively fixedpoints of attachment. Differential movements of fixedand non-fixed structures(e.g. liver and spleen laceration at sites of supporting ligaments) Crushing effectB/n anterior abdominal wall and vertebral column/posterior cage(e.g. direct blow to the epigastrium with crushing of the pancreas over the spine) Compressive effectSudden dramatic rise in Intra-abdominal pressure due to external compression, hollow viscus ruptures(e.g. direct blow to liver or blowout of the bowel) 27
    28. 28. Motor Vehicle Accidents The most common cause of blunt trauma is the motor vehicle Injuries Major global public health challenge but most of it occurs in low- and middle-income countries including Ethiopia. Every year about 1.2 million people are killed and more than 20 million are injured or disabled 28
    29. 29. Contributing Factors Poor road network Absence of knowledge on road traffic safety Mixed traffic flow system Poor legislation and failure of enforcement Poor conditions of vehicles; Poor emergency medical servicesTraffic accident compulsory insurance law is in effect Recently. 29
    30. 30. Several key Factors:Themass and speed of the vehicle at themoment of impact;Whether the occupants of the vehicle wererestrained;Whether the occupant was ejected; andThe interaction of the occupant or pedestrianwith vehicle parts. 30
    31. 31. Seatbelt injuriesAlthough seatbelts reduce mortality overall, theycause a specific pattern of internal injuries.Patients with seatbelt marks have been found tohave a fourfold increase in thoracic trauma and aneightfold increase in intra-abdominal traumacompared with those without seatbelt marksThe three-point shoulder-lap belt is the mosteffective restraining system and is associated withthe lowest incidence of abdominal injuries.
    32. 32.  Use of seatbelts is thought to reduce the risk of death or serious injury for front-seat occupants by approximately 45%. Unbelted rear-seat occupants are also at increased risk of serious injury in motor vehicle accidents (MVAs); they may be ejected or thrown forward into the back of the front seat; the impact from unbelted rear-seat passengers on front-seat occupants can be a major determinant of injury. It is estimated that, when rear seatbelts are worn, the risk of death for belted front-seat occupants is reduced by 80%. In direct frontal MVAs, airbags provide a reduced risk of fatality of approximately 30%. 32
    33. 33.  CompressionOf the bowel between the belt and the vertebral column, an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.
    34. 34. Clinically, two symptom patterns emerge. ~1/4 of pt. develop evidence of a hemoperitoneum secondary to mesenteric lacerations. In the remainder 3/4 of pt. the intestinal injury most commonly involves the jejunum contusion or perforation. Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.
    35. 35. Mechanism of Injury:Penetrating Kinetic Energy imparted to body •Low velocity: Knife Ice pick •Medium velocity: Gunshot wounds Shotgun wounds •High velocity: High-power hunting rifles Military weapons
    36. 36. Pathophysiology Depends on the •Type of weapon •Velocity of bullet •Distance b/n assailant & victim Typically follow the tract/trajectory of the inflicting instrument & thus involve contiguous structures.
    37. 37. Stab Wounds Multiple in 20% of cases Involve the chest in up to 10% of cases Most stab wounds do not cause an intraperitoneal injury The incidence varies with the direction of entry into the peritoneal cavity The liver, followed by the small bowel, is the organ most often damaged by stab wounds.
    38. 38.  Knives are not the sole implement used in stabbings. Ice picks, pens, coat hangers, screwdrivers, and broken bottles. Most commonly in the upper quadrants, the left more commonly than the right???
    39. 39. Gunshot Wounds Handguns, Rifles, and Shotguns “crush” BonesThe degree of injury depends on Amount of kinetic energy imparted by the bullet to the victim Mass of the bullet and the square of its “stretch” Tissues velocity Distance
    40. 40. General Principles of GSW Low-velocity injury (<1000ft/sec), damage is confined to missile tract. High-velocity injury (<2000ft/sec), blast effect & cavitation occur in addition to damage by missile tract. 85% of ant. GSW violate the peritoneum; of these 95% require repair of intra abdominal injury. Organs occupying the most space are more often injured• Small bowel(29%)• Liver(28%)• Colon(23%) 40
    41. 41.  Type I wounds : long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia only. Type II wounds : distance of (3 to 7 yards) and may create a large number of perforated structures. Type III wounds : occur at point-blank range (<3 yards) and involve a massive destruction of tissue *1yard=0.9meter
    42. 42. Small bowel injury is the mostcommon injury resulting from ___abdominal trauma. penetrating blunt
    43. 43. Small bowel injury is the mostcommon injury resulting from ___abdominal trauma. penetrating blunt
    44. 44. CLINICAL ASSESSMENT HISTORY PHYSICAL EXAMINATION
    45. 45.  Primary goal is to identify that an injury exists, not necessarily making an accurate diagnosis. The patients history may be unobtainable, elusive, or temporarily abandoned while resuscitative measures are carried out. History from prehospital care team or transferring hospital : the vital signs, physical assessment, prehospital course, and response to therapy should be obtained Mechanism of injury is an important factor in developing a high index of suspicion; thus a detailed history is helpful if available.
    46. 46. Assessment: HistoryMechanismMVC:  Speed  Type of collision (Frontal, Lateral, Sideswipe, Rear, Rollover)  Vehicle intrusion into passenger compartment  Types of restraints  Deployment of air bag  Patients position in vehicle  Kehr’s Sign???
    47. 47. In blunt trauma: MVADetails about accidentFatality at the sceneVehicle type and velocityWhether the vehicle rolled overPatients location within the vehicleExtent of intrusion into the passenger compartmentExtent of damage to the vehicleSteering wheel deformityWhether seat belts were used and, if so, what typeWhether front or side air bags were deployedAll patients involved in deceleration injuries andbicycle injuries should be suspected of havingintraabdominal injury
    48. 48. In penetrating trauma: GSW/MSW No. of shots or stabs? Type of weapon? Number of shots heard? Position of the patient when shot? Distance of the patient from the gun? What instrument was used? How long and how wide was the instrument? How was the patient positioned during the stabbing? What path did the implement travel?
    49. 49. Assessment: Physical Exam
    50. 50. PHYSICAL EXAMINATIONGeneral Examination : Relating to hemodynamic stability (Vital Signs)Abdominal findings:• Inspection : For abdominal distension For contusions or abrasions Lap belt ecchymosis Mesenteric, Bowel, and Lumbar spine injuries Periumblical (Cullen sign) andFlank (Grey Turner Sign) ecchymosis – Retroperitoneal hematoma
    51. 51. PHYSICAL EXAMINATION cont.• Palpation : For tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum• Percussion : Dullness/ shifting dullness Intraabdominal collection• Auscultation : Where to auscultate & What to listen for??? All four quadrants
    52. 52. The classical‘seatbelt’ sign.The bruising onthe left breast isfrom the shoulderbelt and the lowbruising to theabdominal wall isfrom the lap belt.
    53. 53. PHYSICAL EXAMINATION cont..Rectal findings Check for gross blood - Pelvic fracture Determine prostate position – High riding prostate – Urethral injury Assess sphincter tone – Neurologic statusDistal pulses- Assess for absence or asymmetryAssessment of other associated injuries i.e. multiple fractures, spinal injuries etc.
    54. 54. Associated with fractures Left lower six ribs Spleen Right lower six ribs Liver Upper Lumbar Pancreas and vertebra Duodenum Transverse Kidneys Process Bladder Pelvis Urethra Rectum 54
    55. 55. Reliability of clinical evaluation Low sensitivity Unreliable in 35/45% of pt. Why?? – Head Injury Caution – Spinal A missed abdominal – Alcohol injury can cause a preventable death. – Drug Repeated physical examination is 55 Mandatory.
    56. 56. The major findings with injury of the solidabdominal organs are those ofhemorrhagic shock. Signs with solid organinjury include all of the following EXCEPT: abdominal pain and tenderness early bacterial peritonitis development of rebound, guarding and rigidity hypotension and tachycardia palpable mass and radiographic mass effect (mayresult from confined hemorrhage)
    57. 57. The major findings with injury of the solidabdominal organs are those ofhemorrhagic shock. Signs with solid organinjury include all of the following EXCEPT: abdominal pain and tenderness early bacterial peritonitis development of rebound, guarding and rigidity hypotension and tachycardia palpable mass and radiographic mass effect (mayresult from confined hemorrhage)
    58. 58. High Index of Suspicion Mechanism Tachycardia early, hypotension, and pale, diaphoretic skin late Hypovolemic shock with no readily identifiable cause Diffusely tender abdomen Pain in uninjured shoulder 58
    59. 59. Blunt Abdominal Trauma Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially
    60. 60. Blunt Abdominal Trauma Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially
    61. 61. Blunt Abdominal Trauma Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially
    62. 62. Blunt Abdominal Trauma Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially
    63. 63. Blunt Abdominal Trauma Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially
    64. 64. Conclusion Abdominal trauma is often difficult to evaluate in the prehospital setting. Therefore the paramedic must exercise a high degree of suspicion based on the mechanism of injury and kinematics. Death from abdominal injury usually results from hemorrhage and delayed surgical repair.
    65. 65. The KEY to Saving Lives The abdomen is the “Black Box” – i.e, its impossible to know what specific injuries have occurred at initial evaluation. The Key to saving lives in abdominal trauma is NOT to make an accurate diagnosis, but rather to recognize that there is an abdominal injury. 65

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