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. 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. Background
Anatomy
Anterior abdomen
Flank
Back
Intraperitoneal space contents
Retroperitoneal space contents
Pelvic cavity contents
5
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. The Abdomen
Everything between diaphragm and
pelvis
Injuries very difficult to assess
because of large variety of structures
8
9. Abdominal Anatomy
Abdomen divided into four quadrants
by body mid-line, horizontal plane
through umbilicus
Organ located by quadrant
9
10. Abdominal Anatomy
Right Upper Quadrant
– Liver
– Gall Bladder
– Right Kidney
– Ascending Colon
– Transverse Colon
10
24. Blunt Abdominal trauma is the
commonest cause of death in younger
population 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
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. Rapid deceleration
Shearing Force created that cause solid, visceral
organs and vascular pedicles to tear at relatively fixed
points of attachment. Differential movements of fixed
and non-fixed structures
(e.g. liver and spleen laceration at sites of supporting ligaments)
Crushing effect
B/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 effect
Sudden 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. 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. 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 services
Traffic accident compulsory insurance law is in
effect Recently.
29
30. Several key Factors:
Themass and speed of the vehicle at the
moment of impact;
Whether the occupants of the vehicle were
restrained;
Whether the occupant was ejected; and
The interaction of the occupant or pedestrian
with vehicle parts.
30
31. Seatbelt injuries
Although seatbelts reduce mortality overall, they
cause a specific pattern of internal injuries.
Patients with seatbelt marks have been found to
have a fourfold increase in thoracic trauma and an
eightfold increase in intra-abdominal trauma
compared with those without seatbelt marks
The three-point shoulder-lap belt is the most
effective restraining system and is associated with
the lowest incidence of abdominal injuries.
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. Compression
Of 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. 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. 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. 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. 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. 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. Gunshot Wounds
Handguns, Rifles, and Shotguns
“crush” Bones
The 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. 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. 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. Small bowel injury is the most
common injury resulting from ___
abdominal trauma.
penetrating
blunt
43. Small bowel injury is the most
common injury resulting from ___
abdominal trauma.
penetrating
blunt
45. Primary goal is to identify that an injury
exists, not necessarily making an accurate
diagnosis.
The patient's 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. 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
Patient's position in vehicle
Kehr’s Sign???
47. In blunt trauma: MVA
Details about accident
Fatality at the scene
Vehicle type and velocity
Whether the vehicle rolled over
Patient's 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 deployed
All patients involved in deceleration injuries and
bicycle injuries should be suspected of having
intraabdominal injury
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?
50. PHYSICAL EXAMINATION
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
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. 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.
53. PHYSICAL
EXAMINATION cont..
Rectal findings
Check for gross blood - Pelvic fracture
Determine prostate position – High riding
prostate – Urethral injury
Assess sphincter tone – Neurologic status
Distal pulses
- Assess for absence or asymmetry
Assessment of other associated injuries i.e.
multiple fractures, spinal injuries etc.
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. 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. The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury 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 (may
result from confined hemorrhage)
57. The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury 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 (may
result from confined hemorrhage)
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. 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. 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. 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. 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. 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. 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. 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.
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Editor's Notes
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