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Abdominal Trauma
 

Abdominal Trauma

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Gram McGregor, 1Lt, WA ANG

Gram McGregor, 1Lt, WA ANG
Critical Care Air Transport Nurse

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    Abdominal Trauma Abdominal Trauma Presentation Transcript

    • Abdominal Trauma Gram McGregor, 1Lt, WA ANG Critical Care Air Transport Nurse
    • The Abdomen
      • Everything between diaphragm and pelvis
      • Injuries very difficult to assess because of large variety of structures
    • Abdominal Anatomy
      • Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus
      • Organ located by quadrant
    • Abdominal Anatomy
      • Right Upper Quadrant
        • Liver
        • Gall Bladder
        • Right Kidney
        • Ascending Colon
        • Transverse Colon
    • Abdominal Anatomy
      • Left Upper Quadrant
        • Spleen
        • Stomach
        • Pancreas
        • Left Kidney
        • Transverse Colon
        • Descending Colon
    • Abdominal Anatomy
      • Right Lower Quadrant
        • Ascending Colon
        • Appendix
        • Right Ovary (female)
        • Right Fallopian Tube (female)
    • Abdominal Anatomy
      • Left Lower Quadrant
        • Descending Colon
        • Sigmoid colon
        • Left Ovary (female)
        • Left Fallopian Tube (female)
    • Abdominal Anatomy
      • Organs can be classified as:
        • Hollow
        • Solid
        • Major vascular
    • Solid Organs
      • Liver
      • Spleen
      • Kidney
      • Pancreas
      When solid organs are injured, they bleed heavily and cause shock
    • Solid Organs
      • 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
    • Solid Organs
      • 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
    • Solid Organs
      • 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
    • Hollow Organs
      • Stomach
      • Gall bladder
      • Large, small intestines
      • Ureters, urinary bladder
      Rupture causes content spillage , inflammation of peritoneum
    • Hollow Organs
      • Stomach
        • Acid, enzymes
        • Immediate peritonitis
        • Pain, tenderness, guarding, rigidity
    • Hollow Organs
      • Colon
        • Spillage of bacteria
        • May take 6 hrs to develop peritonitis
      • Small Bowel
        • Fewer bacteria
        • May take 24-48 hours to develop peritonitis
    • Major Vascular Structures
      • Aorta
      • Inferior vena cava
      • Major branches
      Injury can cause severe blood loss ; exsanguination (bleeding out)
    • Abdominal Trauma
      • Many survive to reach hospital
      • Most common factors leading to death
        • Failure to adequately evaluate
        • Delayed resuscitation
        • Inadequate volume
        • Inadequate diagnosis
        • Delayed surgery
    • 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
    • Mechanism
      • Look for signs of injury
        • Bruises
        • Tire marks
        • Obvious open injuries
      • Assume any abdominal injury is serious until proven otherwise!
      • Injury above umbilicus also involves chest until proven otherwise
    • Adequate* Assessment key
      • D-eformity
      • C-ontusions
      • A-brasions
      • P-enetrating Injuries
      • *per BTLS Guidelines
      • B-urns
      • T-enderness
      • L-acerations
      • S-welling
    • Blast Injuries
      • Most commonly found in ear, lungs and hollow abdominal organs.
      • Abdominal injuries include hemorrhage and hollow organ rupture.
    • Unexplained Shock
      • 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
    • Signs of Injured Abdomen
      • Diffuse tenderness
      • Pain
        • Pain referred to shoulder = Organ under diaphragm involved (?spleen)
        • Pain referred to back = Retroperitoneal organ involved (?kidney)
    • Abdominal Rigidity
      • NOT reliable
      • Bleeding may not cause rigidity if free hemoglobin absent
      • Bleeding in retroperitoneal space may not cause rigidity
    • Abdominal Trauma Management
      • Most Important fact in treating ALL types of abdominal trauma…
      • Initiation of life support measures including establishment and maintenance of adequate airway, breathing and circulatory support.
    • Abdominal Trauma Management
      • Less important to diagnose exact injury
      • Treat clinical findings-as able
      • Management same regardless of specific organ(s) injured
    • Abdominal Trauma Management
      • Airway
      • C-Spine if mechanism indicates
      • High flow O 2
      • Assist ventilations if needed
      • Give nothing by mouth
    • Impaled Object
      • Leave in place
        • Shorten if necessary for transport
        • Leave part of object exposed
        • Stabilize
    • Evisceration
      • With large laceration abdominal contents may spill out
      • Do NOT try to replace
    • Evisceration
      • Cover exposed organs with saline moistened multi-trauma dressing
      • Cover first dressing with second DRY dressing or nonpermeable item
    • Genitourinary Trauma Gram McGregor, 1Lt, WA ANG Critical Care Air Transport Nurse
    • Urinary System Kidney Ureter Urinary Bladder Urethra
    • Kidney Trauma
      • 50% of all GU trauma
    • Kidney Trauma
      • Penetrating
        • GSW
        • Stab wound
        • Blast injuries similar to other solid organs
      • Rare, usually associated with trauma to other abdominal organs
    • Kidney Trauma
      • Blunt
        • Direct blow to back, flank, upper abdomen
          • Suspect with fractures of 10th - 12th ribs or T 12 , L 1 , L 2
        • Acceleration/Deceleration
          • Shearing of renal artery/vein
    • Kidney Trauma
      • Signs and Symptoms
        • Gross Hematuria
          • 80% of cases
          • Absence does NOT exclude renal injury
        • Localized flank/abdominal pain
        • Palpable mass
    • Kidney Trauma
      • Signs and Symptoms
        • Tenderness: Lower ribs, upper L-spine, flank
        • Pain: groin, shoulder, back, flank
    • Ureter Trauma
      • Less than 2% of GU trauma
      • Usually secondary to penetrating trauma
      • Indicator
        • Wound to lower back with urine escaping
    • Urinary Bladder Trauma
      • Mechanisms
        • Blunt injury to lower abdomen
        • Seat belts
        • Pelvic fracture
        • Penetrating trauma to lower abdomen or perineum (pelvic floor)
        • Can display hollow or solid organ blast injuries dependant upon urine in bladder
    • Extraperitoneal Bladder Rupture
      • Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum
      • Dysuria
      • Hematuria
      • Suprapubic tenderness
      • Swelling, redness secondary to tissue damage from urine
    • Intraperitoneal Bladder Rupture
      • Urgency to void
      • Inability to void
      • Shock
      • Abdominal distension
    • Urethral Trauma
      • Mechanisms
        • Sudden decelerations (bladder shears off urethra)
        • Straddle injuries
    • Urethral Trauma
      • Signs and Symptoms
        • Blood at external meatus
        • Perineal bruising (butterfly bruise)
        • Scrotal hematoma
    • Questions?
    • References
      • Elsayed, N. (1997) Toxicology of overpressure.
      • Mayorga, M. (1997) The pathology of primary blast overpressure injury.
      • Phillips, Y.Y. and Zajtuk, J.T. (1991) The management of primary blast injury.
      • Browner, B.D. (2002) Emergency care and treatment of the sick and injured.