Alexander ch39 lecture

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 39
Abdominal Trauma

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely injured patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the gross anatomy of the abdominal cavity
and its contents.
3. Differentiate between the characteristics of solid and
hollow organs in the abdomen.
4. Give examples of both blunt and penetrating
mechanisms of abdominal trauma.
5. Recognize signs and symptoms associated with injuries
to the abdomen.
6. Describe the association between abdominal injury and
the potential for life-threatening hemorrhage.
Objectives (1 of 2)

7. Demonstrate an assessment-based approach to
management of the patient with open and closed
abdominal injury, including evisceration and impaled
objects.
8. Explain the special considerations for airway
management in the care of patients with abdominal
injuries.
9. Explain the process and elements of reassessment of
patients with abdominal injuries.
Objectives (2 of 2)

• Unrecognized abdominal trauma
– Leading cause of death in trauma patients
• MOI suggests abdominal injury
– Maintain high suspicion for intra-abdominal injury.
– Remain alert for signs and symptoms of internal
bleeding and shock.
Introduction (1 of 2)

• May be no visible external injuries to abdomen,
but bleeding internally
• Result of penetrating and blunt trauma
• Both can produce life-threatening internal bleeding
and risk of serious infection.
Introduction (2 of 2)

Think About It
• What types of injuries could the patient have
sustained from this mechanism?
• What potential injury would concern Jack and
Jamal the most if present? Why?
• What additional information would assist Jack and
Jamal in their decision making at this point?

Figure 39-1
The abdomen is lined by the parietal and visceral peritoneum, and consists of the
peritoneal and retroperitoneal cavities.

Anatomy and Physiology Review
(1 of 3)
• Abdominopelvic cavity
– Contains organs of circulatory, digestive, endocrine,
reproductive, lymphatic system, and urinary systems
– Held in place by mesenteries
• Peritoneum
– Thin, double-layered epithelial lining that surrounds
abdominal organs

Figure 39-2
The four quadrants of the abdomen and their contents.

(2 of 3)
• Retroperitoneal space
– Behind layer of peritoneum (kidneys, ureters,
duodenum, colon, pancreas)
• For assessment and documentation, abdomen is
divided into four quadrants.
• Organs of abdominal cavity are classified as
hollow or solid.

(3 of 3)
• Hollow organs are not as vascular as solid organs.
• Solid organs are inelastic and highly vascular.
– When injured, severe internal bleeding possible; death
may occur if injury cannot be surgically repaired.

Table 39-1
Hollow and Solid Abdominal Organs
Hollow Abdominal Organs Solid Abdominal Organs
Stomach Liver
Small intestines Spleen
Large intestines Kidneys
Ureters Pancreas
Gallbladder and bile ducts
Urinary bladder

General Assessment and Management
(1 of 7)
• Identify MOI or potential for underlying injury.
• Easy to overlook abdominal injury in patients with
distracting injuries or altered level of
responsiveness.
• Maintain high index of suspicion for intra-
abdominal injury.

(2 of 7)
• Look around scene for objects that created injury.
• If result of motor vehicle crash (MVC), inspect
vehicle; gather information.
• Other MOI:
– Crush injuries
– Falls
– Explosions
– Assault with objects

Table 39-2
Pertinent Information Regarding the MOI of an MVC
• How fast was the patient’s vehicle traveling on impact?
• What types of vehicles were involved in the MVC?
• If more than one vehicle was involved, how fast were the other vehicles traveling on
impact?
• What type of collision occurred (head-on, lateral, rotational, rear, rollover)?
• Was the patient ejected?
• Was the patient restrained?
• What path did the patient follow on impact (up and over versus down and under)?
• Are there deformities to the steering wheel and/or dashboard?

(3 of 7)
• Primary assessment
– Manually stabilize head and neck, if indicated.
– Provide oxygen to maintain an SpO2 of 95 percent or
higher.
– Control life-threatening bleeding.
– Assess skin color and temperature.
▪ Pale, cool, diaphoretic skin indicates shock and warrants rapid
transport.
– Assess pulse rate and quality.

(4 of 7)
• Secondary assessment
– Determine chief complaint.
– Expose patient and perform focused or rapid trauma
exam.
– Inspect abdomen using DCAP-BTLS.
– Palpate all four quadrants .
▪ Abnormalities, tenderness, or rebound tenderness

(5 of 7)
• Secondary assessment (continued)
– Trauma can result in evisceration; you may see organs.
– Abdominal cavity allows for accumulation of significant
amount of blood.
▪ Look for Kehr’s sign and abdominal distention.
– Cullen’s sign and Grey Turner’s sign indicate
retroperitoneal bleeding.

(6 of 7)
• Secondary assessment (continued)
– Check for abdominal guarding.
▪ Voluntary and involuntary
– Assess posterior surface.
– Obtain SAMPLE history.
– Baseline vital signs
– Make transport decision.

Table 39-3
General Signs and Symptoms of Abdominal Injury
• Contusions, lacerations, and/or penetration of the abdomen
• Pain and/or tenderness to palpation
• Distended abdomen (indicates significant blood loss)
• Lying in a position of comfort (knees drawn toward the chest)
• Ecchymosis to the umbilicus or flank (late finding)
• Signs of shock
• Presence of MOI for abdominal injury

(7 of 7)
• Management
– Manage airway, breathing, circulation.
– Treat for shock.
– Keep the patient warm.
– Start IVs en route, per protocol.
– Pain management per protocol.
• Reassessment
– Critical, every 5 minutes
– Noncritical, every 15 minutes

Specific Abdominal Injuries (1 of 2)
• Blunt trauma
– Most common type of abdominal injury; mortality rates
of 10% to 30%
• Open injuries
– Easier to identify; bleeding and/or pain will be present
at site of injury
• Closed abdominal injury
– Rely on assessment skills to identify potential for
underlying internal injury.

Figure 39-4
An abdominal evisceration resulting from penetrating trauma.
(© Edward T. Dickinson, MD)

• Penetrating trauma
– Determine size of object used in stab wound and
caliber of bullet with gunshot wound.
– Look for multiple wounds (entrance and exit).
– Abdominal evisceration
▪ Abdominal organs protrude through opening.

Scan 39-1 (1 of 5)
Emergency Management of Abdominal Evisceration
1. An open abdominal wound with evisceration.

Scan 39-1 (2 of 5)
2. Cut away clothing from the wound.

Scan 39-1 (3 of 5)
3. Soak a dressing with sterile saline.

Scan 39-1 (4 of 5)
4. Place the moist dressing over the wound.

Scan 39-1 (5 of 5)
5. Apply an occlusive dressing over the moist dressing if your protocols recommend that
you do so. Cover the dressed wound to maintain warmth. Secure the covering with tape or
cravats tied above and below the position of the exposed organ.

• Impaled objects
– Do not remove object impaled in abdomen.
– Can result in uncontrollable hemorrhage
– Stabilize object in place.

• Blunt trauma
– Internal bleeding is primary concern.
– Results from direct injury
– Focus on airway, breathing, circulation.
– Treat for shock.
– Transport without delay to facility with immediate
surgical capabilities.

• Diaphragmatic rupture
– Diaphragm
▪ Primary muscle of ventilation that separates thoracic and
abdominal cavities
– Rupture
▪ Hole or tear in diaphragm; opening between thoracic and
abdominal cavities
– Abdominal organs can become strangulated, suffering
ischemic damage.

• Deceleration injuries
– Newton’s first law of motion
▪ Object in motion will remain in motion until acted on by
outside force.
– Impact of organs can result in laceration and rupturing
of organs and massive hemorrhage.

• Explosion injury
– Blasts from explosions can injure hollow organs.
– Pressure wave causes rapid increase in organ
pressure, which can lead to tearing or rupture of hollow
organs.

Chapter Summary
• Threat of life-threatening injury high with
abdominal trauma.
• Abdominal evisceration and impalement have
unique care considerations.
• In cases of intra-abdominal hemorrhage, patient
may deteriorate quickly.
• Rapidly transport patient to surgical facility.

Alexander ch39 lecture

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