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. • Upper Peritoneal cavity
Covered 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 cavity
Abdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas,
kidneys, Ureters and posterior aspects of Ascending and Descending
colons
• Pelvic cavity:
Rectum, Bladder, iliac vessels and Internal genitalia in women.
8. Organs by Abdominal Quadrant
Liver, Gallbladder,
Stomach (Small Part)
Small & Large
Intestine
Head of Pancreas
Upper Part of Kidney
Stomach,
Tail of Pancreas
Tail of Liver
Small & Large
Intestine
Upper Part of Kidney
Small & Large Small & Large
Intestine Intestine
Lower part of Kidney Lower part of Kidney
Half of Bladder, Half of Bladder,
Appendix, Female Female Reproductive
Reproductive Organs Organs
U
p
p
e
r
L
o
w
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r
Right Left
9. 1. AbdominalAorta
2. Common Iliac Artery
3. Internal Iliac
4. External Iliac
5. Superior Gluteal
6. ObturatorArtery
10. TYPES OF ABDOMINAL
INJURIES
BLUNT TRAUMA PENETRATING TRAUMA
•Energy transmitted to surrounding
tissue
•Results in-
Uncontrolled hemorrhage
Organ damage
Spillage of hollow organ contents
Irritation & Inflammation of abdominal
lining
•Liver most commonly affected organ
•Common causes -Shotgun Trauma,
stab wound, cuts & tears
•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
12. DIAPHRAGMATIC INJURY
DESCRIPTIONS
burst injury
• Partially protected by bony
structures, diaphragm is
commonly injured by
penetrating trauma
(Automobile deceleration may
lead torapid rise in intra-
abdominal pressure and a
• Diaphragmatic tear usually
indicates multi-organ
involvement
CLINICAL MANIFESTATIONS
• Decreased breath sounds
• Abdominal peristalsis heard
in thorax
• Acute chest pain and
shortness of breath may
indicate diaphragmatic tear
• May behard todiagnose
because of multisystem
trauma or the liver may
"plug" the defect and mask it
13. ESOPHAGEAL INJURY
DESCRIPTIONS
• Penetrating injury is more
common than blunt injury
• May be caused by knives,
bullets, foreign body
obstruction
• May be caused by iatrogenic
perforation
• May be associated with
cervical spine injury
CLINICAL MANIFESTATIONS
• Pain at site of perforation
• Fever
• Difficulty swallowing
• Cervical tenderness
• Peritoneal irritation
14. STOMACH INJURY
DESCRIPTIONS
• Penetrating injury is
more common than blunt
injury; in one-third of
patients, both the
anterior and the posterior
walls are penetrated
• May occur as a
complication from
cardiopulmonary
resuscitation or from
gastric dilation
CLINICAL MANIFESTATIONS
• Epigastric pain
• Epigastric tenderness
• Signs of peritonitis
• Bloody gastric
drainage
15. LIVER INJURY
DESCRIPTIONS
• Most commonly injured
organ; blunt injuries (70% of
total) usually occur from
motor vehicle crashes and
steering wheel trauma
• Highest mortality from blunt
injury and gunshot wound
• Hemorrhage is most common
cause of death from liver
injury; overall mortality
10%–15%
CLINICAL MANIFESTATIONS
• Persistent hypotension
despite adequate fluid
resuscitation
• Guarding over right upper or
lower quadrant; rebound
abdominal tenderness
• Dullness to percussion
• Abdominal distention and
peritoneal irritation
• Persistent thoracic bleed
16. SPLEEN INJURY
DESCRIPTIONS
• Most commonly injured
organ with blunt abdominal
trauma
• Injured in penetrating
trauma of the left upper
quadrant
CLINICAL MANIFESTATIONS
• Hypotension, tachycardia,
shortness of breath
• Peritoneal irritation
• Abdominal wall tenderness
• Left upper quadrant pain
• Fixed dullness topercussion
in left flank; dullness to
percussion in right flank that
disappears with change of
position
17. PANCREAS INJURY
DESCRIPTIONS
• Most often penetrating injury
(gunshot wounds at close
range)
• Blunt injury from
deceleration; injury from
steering wheel
• Often associated (40%) with
other organ damage (liver,
spleen, vessels)
CLINICAL MANIFESTATIONS
• Pain over pancreas
• Paralytic ileus
• Symptoms may occur late
(after 24 hr); epigastric pain
radiating toback; nausea,
vomiting
• Tenderness to deep palpation
18. SMALL INTESTINES INJURY
DESCRIPTIONS
• Duodenum, ileum, and
jejunum; hollow viscous
structure most often injured
by penetrating trauma
• Gunshot wounds account for
70% of cases
• Incidence of injury is third
only toliver and spleen
injury
• When small bowel ruptures
from blunt injury, rupture
occurs most often at
proximal jejunum and
CLINICAL MANIFESTATIONS
• Testicular pain
• Referred pain to shoulders,
chest, back
• Mild abdominal pain
• Peritoneal irritation
• Fever, jaundice, intestinal
obstruction
19. LARGE INTESTINES A INJURY
DESCRIPTIONS
• One of the more lethal
injuries because of fecal
contamination; occurs in 5%
of abdominal injuries
• More than 90% of incidences
are penetrating injuries
• Blunt injuries are often from
safety restraints in motor
vehicle crashes
CLINICAL MANIFESTATIONS
• Pain, muscle rigidity
• Guarding, rebound
tenderness
• Blood on rectal examination
• Fever
20. RETROPERITONEAL INJURY
DESCRIPTIONS
• Blunt or penetrating trauma
to the abdomen or posterior
abdomen.
• Kidney, ureters, pancreas, or
duodenal injuries
• Associated with posterior
posterior rib fractures &
lumbar vertebral injuries.
• Deceleration forces may
injure the renal artery
CLINICAL MANIFESTATIONS
• Haemorrhage usually from
pelvic or lumbar fractures:
• Gray turner’s sign – 12
hours or later
• cullen’s sign – 12 hours or
later
21. Renal Injury
.
Classification of Injury
• Grade I : Contusion or Subcapsular
Hematoma
• Grade II: Non Expanding Hematoma, <1
cm deep ,no extravasation
• Grade III: Laceration >1cm with urinary
Extravasation
• Grade IV: Parenchymal Laceration
• Grade V: Renovascular injury
22. PATHOPHYSIOLOGY OF ABDOMINAL
INJURY
DECELERATION
•Rapid decelaration causes
differential movement
among adjacent structures.
As a result, shear forces are
created &cause hollow,
solid, visceral organs &
vascular pedicles totear,
especially at relatively fixed
points of attachment.
CRUSHING
• . Intra abdominal
contents are crushed
between the anterior
abdominal wall & the
vertebral column or
posterior thoracic cage.
This produces a crushing
effect, towhich solid
viscera (eg. spleen, liver,
kidneys) are especially
vulnerable.
EXTERNAL
COMPRESSION
•Direct blows or from
external compression
against a fixed object
(eg. lap belt, spinal
column). External
compressive forces
result in a sudden &
dramatic rise in
intraabdominal pressure
& culminate in rupture
of a hollow organ .
23. SYMPTOMS
• Pain or tenderness
• A rapid heart rate
• Rapid breathing
• Sweating
• Cold, clammy, pale or bluish skin
• Confusion or low level of alertness
• Blunt trauma may cause bruising.
• Cullen’s sign
• Grey turner’s sign
• Kehr’s sign
26. HISTORY TAKING
AMPLE History
• A: Allergy
• M: Medications
• P: Past medical history
• L: Last meal
• E: Event - What happened
27. General 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) and
Flank (Grey Turner Sign) ecchymosis –
Retroperitoneal hematoma
PHYSICAL EXAMINATION
28. • 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
for the +/- nce of bowel sounds
PHYSICAL EXAMINATION cont.
29. The classical
‘seatbelt’ sign.
The bruising on
the left breast is
from the
shoulder belt
and the low
bruising to the
abdominal wall
is from the lap
belt.
30. • Left lower six ribs
• Right lower six ribs
• Upper Lumbar
vertebra
• Transverse
Process
• Pelvis
Spleen
Liver
Pancreas and
Duodenum
Kidneys
Bladder
Urethra
Rectum 30
Associated with fractures
32. Diagnostic studies
• Drug & alcohol screens
• Rigid sigmoidoscopy: is indicated for
patients presenting with injuries in the
pelvis or if blood is found on rectal
examination.
• magnetic resonance
cholangiopancreatography (MRCP) for
the diagnosis of bile duct injuries
• chest, and cervical spine radiographs
• Arteriographs
34. Initial Assessment and Resuscitation
Primary survey
Identification & treatment of life threatening
conditions
• Airway , with cervical spine precautions
• Breathing
• Circulation
• Disability
• Exposure
35. Emergency Care
• I V fluids
• Control external bleeding
• Dressing of wounds
• Protect eviscerated organs with a sterile
dressing
• Stabilize an impaled object in place
• Give high flow oxygen
• Immobilize the patient with a fractured pelvis
• Keep the patient warm
• Analgesics
36. MANGEMENT BASED ON ORGANS
• DIAPHRAGMATIC TEARS :
repaired surgically to prevent visceral
herniation in later years.
• ESOPHAGEAL INJURY:
gastric decompression with a nasogastric
tube, antibiotic therapy
surgical repair of the esophageal tear.
• GASTRIC INJURY:
partial gastrectomy may be needed if
extensive injury has occurred.
37. MANGEMENT BASED ON ORGANS
• LIVER INJURY
managed nonoperatively or operatively, depending on
the degree of injury and the amount of bleeding.
Albumin transfusion
Blood glucose regulation
• SPLEEN INJURY
• splenectomy is the treatment of choice when the
patient is markedly hemodynamically unstable, or
when the spleen is totally macerated.
38. MANGEMENT BASED ON ORGANS
• PANCREATIC INJURY :
depends on the degree of pancreatic
damage, but drainage of the area is usually
necessary to prevent pancreatic fistula
formation and surrounding tissue damage
from pancreatic enzymes.
• SMALL AND LARGE BOWEL :
Perforation or lacerations are managed by
surgical exploration and repair.
Colostomy
