3Anas Bahnassi PhD CDM CDE
Anatomy and major abdominal trauma
Blunt abdominal trauma may push the abdominal content upward and
cause rupture of the diaphragm.
Abdominal trauma is a major component
of traumatic injury and can be deadly.
Blunt trauma can occur during falls, motor
vehicle accidents, or severe blows to the
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• The liver is a vascular solid organ
in the right upper quadrant,
protected by the lower ribs, than
may be lacerated by blunt trauma.
• The resultant bleeding can be
Gallbladder injury is unusual but may release bile into the abdominal
cavity causing a severe peritoneal reaction.
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• The spleen is a highly vascular
organ located behind the stomach
and protected by the lower ribs on
the left side of the body.
• The spleen is the most commonly
injured organ in blunt abdominal
trauma and it can bleed profusely
Fractures of lower ribs on the left side along with hypotension should
raise suspicion of spleen injury.
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Abdominal injuries can significantly delay
Bowels rupture is most frequently
associated to penetrating injuries.
Injuries that break bowel wall spill the
intestinal contents into the peritoneal cavity
causing peritoneal irritation with diffuse
abdominal pain, tenderness and ilus as the
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The urinary bladder is vulnerable to injury
when the pelvis is fractured.
The pancreas, duodenum, kidneys, ureters,
aorta and inferior cava are retroperitoneal
structures. Injuries to them are difficult to
detect for retroperitoneal bleeding does
produce neither abdominal distension nor
The pancreas. Seriously injury to the pancreas is
not common in accidents. Damage can be seen in
cases of kicking injuries, abdominal gunshot
wounds. When injured can bleed profusely and
release digestive juices into the abdomen
Types of Abdominal Trauma
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Most commonly, symptoms and
signs of blunt abdominal trauma
are subtle and the diagnosis of
intra-abdominal injury uncertain
therefore is important to assess
adequately the mechanisms of
Suspect intraabdominal injury whenever
penetrating trauma to the chest, abdomen,
back or buttocks has occurred.
Shotgun wounds may cause abdominal
Sharp instruments wounds cause local tissue
– Ensure an adequate airway since vomiting may compromised the
airway in abdominal trauma. (See indications for endotracheal
– Auscultate the chest for breath sounds. Impairment of breathing and
presence of bowel sounds may indicate rupture of the diaphragm.
– If there is an inadequate oxygenation, oxygen should be delivered at a
high flow rate.
– If adequate ventilation or oxygenation cannot be provided by other
means, bag-mask ventilation followed by pharyngeal or
tracheal intubation should be used.
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– Look for signs of hypotension or shock.
– Hypotension and left upper quadrant trauma is suggestive of ruptured
– Maintain a high index of suspicion for intra-abdominal or
retroperitoneal bleeding if the patient has unexplained hypotension or
shock. This is an indication for peritoneal lavage, exploratory
laparatomy or focused abdominal sonography for trauma. Computed
tomography is only recommended for the evaluation of
hemodynamically stable patients.
– Begin treatment for hypotension or shock if present.
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– Assess the level of responsiveness with the AVPU scale
– Check pupil size and reflection to light.
– Undress the patient for further examination.
– Monitor BP, HR, EGC, temperature, etc…
– Obtain arterial blood gases to evaluate the adequacy of ventilatory
function and the severity of tissue perfusion.
– Perform frequent monitoring of vital signs.
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• Perform a detailed head to toe survey and obtain as detail a
medical history of the patient as possible.
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Check for broken ribs than may
indicate abdominal organs
Fractures of the 7th -9th ribs on
the right or the left side may be
associated to liver injury or
– Altered level of consciousness due to
– intoxicated patients
confounding factors in the accuracy of
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– Levels of abdominal pain and reaction to
palpation are unreliable (often masked by
other major injuries.)
– Peritoneal irritation signs produced by
blood loss or spillage of bowel content
may not develop for one to four hours.
– Distention is a late and unreliable sing.
– Bruises may take several hours to
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– Fractures of the lower ribs, vertebral
fractures, transverse process
fractures are often associated
with renal injuries.
– Renal vessel lacerations may cause
intensive blood loss into the
– Major renal trauma causes gross
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– Palpate for a rigid, distended
abdomen or involuntary
guarding, which may
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Abdominal evisceration does not take precedence over the
ABCD approach of the primary survey.
• Cover any exposed abdominal viscera with
sterile saline-soaked packs do not attempt to
reduce the viscera into the abdomen
• Do not remove any impaled foreign matter.
Stabilize impaled objects with bulky dressings
that are bandaged in place.
• Assess the pelvis for associated fractures by
pressing over the anterior iliac crest to detect
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• A fractured pelvis may produce a blood loss up to
• Examine the anus and vagina to confirm their
integrity. Rectal bleeding may be suggestive of
trauma to the colon. Pelvic fractures may disrupt
the vaginal wall.
• Look for lacerations, haematoma, active bleeding,
scrotal contusions or haematomas than may
indicate testicular rupture.
• Look for associated urinary bladder or urethral
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• Pelvic fractures are often associated with
bladder injuries and gross haematuria.
• Extravagation of blood or urine may cause
perineal or genital swelling.
• High rising prostate or an absent prostate
indicates posterior urethral injury.
• Other signs or urethral injury include pelvic
fracture, perineal haematoma, blood at the
urethral meatus, inability to urinate.
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Pelvis Fracture – Management.
• Fluid resuscitation
• Determine if open or closed fracture
• Determine associated perineal /GU injuries
• Determine need for transfer
• Splint pelvic fracture
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– Liver or spleen injury may cause referred right
shoulder pain or referred left shoulder pain
respectively that may be enhanced by
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• Other Considerations
– Insert a nasogastric tube to drain and decompress
– Insert a urinary catheter to monitor urine output if
no contraindications exist (meatal bleeding,
scrotal haematoma or prostate malposition)
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Clinical Pharmacy VI:
Anas Bahnassi PhD CDM CDE