Content incorporates types, sign symptoms, treatment of abdominal injuries.

1. PEER GROUP PRESENTATION
ON
ABDOMINAL INJURY
Submitted by-
Sampurna Das
MSc. Nursing 2nd
year
College Of Nursing
Medical College & Hospital
INTRODUCTION:

2. Abdominal injury account for a large percentage of trauma related injuries and death. The visceral
organs contained within the abdomen can be classified as either hollow or solid.
Damage to a hollow organ can result in acute peritonitis leading to shock within a few hours & damage
to solid organs can result in lethal haemorrhage.
The abdomen can be injured in many ways. The abdomen alone may be injured or injuries elsewhere in
the body may also occur. Injuries can be relatively mild or very severe.
ANATOMY & PHYSIOLOGY OF ABDOMEN:
 The abdomen constitutes the part of the body between the thorax(chest) and pelvis, in humans and
in other vertebrates.
 The region enclosed by the abdomen is termed the abdominal cavity.
 The abdomen stretches from the thorax at the thoracic diaphragm to the pelvis at the pelvic brim.
The pelvic brim stretches from the lumbosacral joint (theintervertebral disc between L5 and S1) to
the pubic symphysis and is the edge of the pelvic inlet. The space above this inlet and under the
thoracic diaphragm is termed the abdominal cavity.
 The boundary of the abdominal cavity is the abdominal wall in the front and the peritoneal surface at
the rear.
 The abdomen contains most of the tubelike organs of the digestive tract, as well as several solid
organs.
 Hollow abdominal organs include the stomach, the small intestine, and the colon with its
attached appendix.
 Organs such as the liver, its attached gallbladder, and the pancreas function in close association with
the digestive tract and communicate with it via ducts.
 The spleen, kidneys, and adrenal glands also lie within the abdomen, along with many blood vessels
including the aorta and inferior vena cava.
 Anatomists may consider the urinary bladder, uterus, fallopian tubes, andovaries as either abdominal
organs or as pelvic organs.
 Finally, the abdomen contains an extensive membrane called the peritoneum. A fold of peritoneum
may completely cover certain organs, whereas it may cover only one side of (retroperitoneal) organs
that usually lie closer to the abdominal wall. Both the abdominal and pelvic cavities are lined by a
serous membrane known as the parietal peritoneum. This membrane is continuous with the visceral
peritoneum lining the organs.
 Digestive tract: Stomach, small intestine, large intestine with cecum and appendix
 Accessory organs of the digestive tract: Liver, gallbladder and pancreas
 Urinary system: Kidneys and ureters - but technically located in retroperitoneum - outside
peritoneal membrane.
 Other organs: Spleen.
In vertebrates, the abdomen is a large cavity enclosed by the abdominal
muscles, ventrally and laterally, and by the vertebral column dorsally. Lower ribs can also enclose
ventral and lateral walls. The abdominal cavity is upper part of the pelvic cavity. It is attached to
the thoracic cavity by the diaphragm. Structures such as the aorta, superior vena

3. cava and esophagus pass through the diaphragm. The abdomen in vertebrates contains a number
of organs belonging, for instance, to the digestive tract and urinary system.
Muscles
In human anatomy, the layers of the abdominal wall are (from superficial to deep):
 Skin
 Subcutaneous tissue
 Fascia
 Camper's fascia - fatty superficial layer.
 Scarpa's fascia - deep fibrous layer.
 Muscle
 External oblique abdominal muscle
 Internal oblique abdominal muscle
 Rectus abdominis
 Transverse abdominal muscle
 Pyramidalis muscle
 Fascia transversalis
 Peritoneum
TYPES OF ABDOMINAL INJURIES:
A. PENETRATINGVs. BLUNT TRAUMA:
BLUNT TRAUMA :
Involves a direct blow (for example, a kick) , impact with an object (for example, a fall onto bicycle
handlebars), or a sudden decrease in speed (for example, a fall from a height or a motor vehicle crash).
Trauma to the abdomen is usually associated with extra – abdominal injuries ( i.e. chest, head &
extremity injuries) & severe concomitant trauma to multiple intraperitoneal organs. The spleen & liver
are the two most commonly injured organs. Hollow organs are less likely to be injured. Causes more
delayed complications, especially if there is injury to liver, spleen & blood vessels , which can lead to
substantial blood loss into the peritoneal cavity.
PENETRATING TRAUMA :
This implies that either a gunshot wound (or other high velocity missile/ fragment ), sharpe or a stub
wound has entered the abdominal cavity.
A gunshot wound is associated with high energy transfer & the extent of intraabdominal injuries is
difficult to predict. Shotgun injuries ,especially at close range, are frequently associated with massive
tissue damage & should be regarded as high energy transfer injuries.
Stab wound injuries can be inflicted by many objects other than knives, including knitting needles,
garden forks, wire, fence railing, pipes & pencils. Blunt or penetrating injuries may cut or rupture
abdominal organs & / or blood vessels. Blunt injury may cause blood to collect inside the structure of a

4. solid organ (for example the liver) or in the wall of a hollow organ (such as the small intestine). Such
collections of blood are called hematomas.
Cuts & tears begin bleeding immediately. More serious injuries may cause massive bleeding with shock
& sometimes death. Bleeding from abdominal injury is mostly internal (within the abdominal cavity).
When there is a penetrating injury, a small amount of external bleeding may occur through the wound.
When a hollow organ is injured, the contents of the organ (for example, stomach acid, stool, or urine)
may enter the abdominal cavity & cause irritation & inflammation (peritonitis).
B. CLASSIFICATION AS PER STRUCTUREINVOLVED:
The types of structures include
 the abdominal wall
 solid organs (liver, spleen, pancreas, or kidneys)
 hollow organs (stomach , small intestine, bladder, colon, ureters)
 blood vessels
Injuries to the Abdomen
ORGAN OR
TISSUE
COMMON INJURIES SYMPTOMS
Diaphragm  Partially protected by bony structures, the
diaphragm is most commonly injured by
penetrating trauma (particularly gunshot
wounds to the lower chest)
 Automobile deceleration may lead to
rapid rise in intra-abdominal pressure and
a burst injury
 Diaphragmatic tear usually indicates
multi-organ involvement
 Decreased breath sounds
 Abdominal peristalsis heard in
thorax
 Acute chest pain and shortness of
breath may indicate diaphragmatic
tear
 May be hard to diagnose because
of multisystem trauma or the liver
may "plug" the defect and mask it
Esophagus  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
 Pain at site of perforation
 Fever
 Difficulty swallowing
 Cervical tenderness
 Peritoneal irritation
Stomach  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
 Epigastric pain
 Epigastric tenderness
 Signs of peritonitis
 Bloody gastric drainage

5. ORGAN OR
TISSUE
COMMON INJURIES SYMPTOMS
gastric dilation
Liver  Most commonly injured organ (both
blunt and penetrating injuries); blunt
injuries (70% of total) usually occur from
motor vehicle crashes and steering wheel
trauma
 Highest mortality from blunt injury
(more common in suburban areas) and
gunshot wound (more common in urban
areas)
 Hemorrhage is most common cause of
death from liver injury; overall mortality
10%–15%
 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 bleeding
Spleen  Most commonly injured organ with blunt
abdominal trauma
 Injured in penetrating trauma of the left
upper quadrant
 Hypotension, tachycardia,
shortness of breath
 Peritoneal irritation
 Abdominal wall tenderness
 Left upper quadrant pain
 Fixed dullness to percussion in left
flank; dullness to percussion in
right flank that disappears with
change of position
Pancreas  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)
 Pain over pancreas
 Paralytic ileus
 Symptoms may occur late (after 24
hr); epigastric pain radiating to
back; nausea, vomiting
 Tenderness to deep palpation
Small intestines  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 to liver
and spleen injury
 When small bowel ruptures from blunt
injury, rupture occurs most often at
proximal jejunum and terminal ileum
 Testicular pain
 Referred pain to shoulders, chest,
back
 Mild abdominal pain
 Peritoneal irritation
 Fever, jaundice, intestinal
obstruction
Large intestines  One of the more lethal injuries because of  Pain, muscle rigidity

6. ORGAN OR
TISSUE
COMMON INJURIES SYMPTOMS
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
 Guarding, rebound tenderness
 Blood on rectal examination
 Fever
Retroperitoneal
injuries:
 Blunt or penetrating trauma to the
abdomen or posterior abdomen.
 Kidney, ureters, pancreas, or
duodenal injuries.
 Haemorrhage usually from
pelvic or lumbar fractures:
 Gray turner’s sign – 12 hours
or later
 cullen’s sign – 12 hours or later
Renal injuries  Associated with posterior posterior
rib fractures & lumbar vertebral
injuries.
 Deceleration forces may injure the
renal artery
PATHOPHYSIOLOGY:
Intra abdominal injuries secondary to blunt force are attributed to collisions between the injured person
& external environment & to acceleration or decelaration forces acting on the person’s internal organs.
Blunt force injuries to the abdomen can generally be explained by 3 mechanisms.
1. The first mechanism is decelaration. Rapid decelaration causes differential movement among
adjacent structures. As a result, shear forces are created & cause hollow, solid, visceral organs &
vascular pedicles to tear, especially at relatively fixed points of attachment. For example, the distal aorta
is attached to the thoracic spine & decelerates much more quickly than the relatively mobile aortic
arch. As a result, shear forces in the aorta may cause it to rupture. Similar situations can occur at the
renal pedicles & at the cervicothoracic junction of the spinal cord. Classic deceleration injuries include
hepatic tear along the ligamentam teres & intimal injuries to the renal arteries. As bowel loops travel
from their mesenteric attachments, thrombosis & mesenteric tears, with resultant splanchnic vessels
injuries, can result.
2. The second mechanism involves crushing. Intra abdominal contents are crushed between the
anterior abdominal wall & the vertebral column or posterior thoracic cage. This produces a crushing
effect, to which solid viscera (eg. spleen, liver, kidneys) are especially vulnerable.
3. The third mechanism is external compression, whether from direct blows or from external
compression against a fixed object (eg. lap belt, spinal column). External compressive forces result in a

7. sudden & dramatic rise in intraabdominal pressure & culminate in rupture of a hollow organ (i.e., in
accordance with the principles of Boyle law).
SYMPTOMS:
1. Pain or tenderness
Pain is often mild, & person may not notice or complain about it because of other more painful
injuries (such as fractures) or because the person is not fully conscious.
2. People may have lost a large amount of blood may have :
 A rapid heart rate
 Rapid breathing
 Sweating
 Cold, clammy, pale or bluish skin
 Confusion or low level of alertness
3. Blunt trauma may cause bruising.
4. Cullen’s sign
5. Grey turner’s sign
6. Kehr’s sign
7. Shock.
COMPLICATIONS:
1. Hematoma rupture
2. Peritonitis
3. Intra abdominal collection of pus (abcess)
4. Intestinal blockage (obstruction)
5. Abdominal compartment syndrome
COLLABORATIVE MANAGEMENT:
HISTORY TAKING
For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by
including a detailed report from the prehospital professionals, witnesses, or significant others. AMPLE
is a useful mnemonic in trauma assessment: Allergies, Medications, Past medical history, Last meal,
and Events leading to presentation. Information regarding the type of trauma (blunt or penetrating) is
helpful. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient
was restrained, the patient's position in the vehicle, and whether the patient was thrown from the vehicle
on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a
helmet. In cases of traumatic injuries from falls, determine the point of impact, the distance of the fall,
and the type of landing surface. If the patient has been shot, ask the paramedics or police for ballistics
information, including the caliber of the weapon and the range at which the person was shot.
PHYSICAL EXAMINATION
INVESTIGATIONS

8. Test Normal Result Abnormality With Condition Explanation
Contrast-enhanced
computed tomography
scan
Normal and
intact
abdominal
structures
Injured or ruptured organs;
accumulation of blood or air in
the peritoneum, in the
retroperitoneum, or above the
diaphragm
Provides detailed pictures
of the intra-abdominal
and retroperitoneal
structures, the presence of
bleeding, hematoma
formation, and the grade
of injury
Focused abdominal
sonogram for trauma
(FAST); four acoustic
windows (pericardiac,
perihepatic, perisplenic,
pelvic)
No fluid seen
in four
acoustic
windows
Accumulation of blood in the
peritoneum
Provides rapid evaluation
of hemoperitoneum;
experts consider FAST's
accuracy equal to that of
diagnostic peritoneal
lavage (DPL) (see below)
Diagnostic peritoneal
lavage (DPL); indicated
in spinal cord injury,
multiple injuries with
unexplained shock,
intoxicated or
unresponsive patients
with possible
abdominal injury
Negative
lavage without
presence of
excessive
bleeding or
bilious or fecal
material
Direct aspiration of 15 to 20 mL
of blood, bile, or fecal material
from a peritoneal catheter;
following lavage with 1 L of
normal saline, the presence of
100,000 red cells or 500 white
cells per mL is a positive lavage;
this is 90% sensitive for detecting
intra-abdominal hemorrhage
Determines presence of
intra-abdominal
hemorrhage or rupture of
hollow organs;
contraindicated when
there are existing
indications for
laparotomy
Other Tests:
1. Complete blood count: Normal haemoglobin & haematocrit results do not rule out significant
haemorrhage. Blood transfusions should not be withheld in patients who have relatively
normal haematocrit but have evidence of clinical shock, serious injuries or significant blood
loss.
2. Blood glucose determination: important for patients with altered mental status.
3. Urinanalysis: indications for diagnostic urinanalysis
4. Coagulation profile
5. Blood grouping, typing & cross matching
6. Arterial blood gas analysis
7. Drug & alcohol screens
8. Rigid sigmoidoscopy: is indicated for patients presenting with injuries in the pelvis or if
blood is found on rectal examination.
9. magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct
injuries
10. chest, and cervical spine radiographs
11. Arteriographs
EMERGENCY DEPARTMENT CARE
Upon the patient’s arrival in the emergency department or trauma center, a rapid primary survey should
be performed to identify immediate life threatening problems.

9. a) The initial care of the patient with abdominal trauma follows the ABCs (airway, breathing,
circulation) of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion
include the establishment of an effective airway and a supplemental oxygen source, support of
breathing,
b) Control of the source of blood loss, and replacement of intravascular volume.
c) Titrate intravenous fluids to maintain a systolic blood pressure of 100 mm Hg; overaggressive
fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to
surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization
of any life-threatening injuries are completed immediately.
MANGEMENT BASED ON ORGANS:
 Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years.
 Esophageal injury is often managed with gastric decompression with a nasogastric tube,
antibiotic therapy, and surgical repair of the esophageal tear.
 Gastric injury is managed similarly to esophageal injury, although a partial gastrectomy may be
needed if extensive injury has occurred.
 Liver injury may be managed nonoperatively or operatively, depending on the degree of injury
and the amount of bleeding. Patients with liver injury are apt to experience problems with
albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation,
resistance to infection, and nutritional balance.
 Management of injuries to the spleen depends on the patient's age, stability, associated injuries,
and type of splenic injury. Because removal of the spleen places the patient at risk for immune
compromise, splenectomy is the treatment of choice only when the spleen is totally separated
from the blood supply, when the patient is markedly hemodynamically unstable, or when the
spleen is totally macerated.
 Treatment of 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.
 Preoperative and postoperative antibiotics are administered to prevent sepsis.
OPERATIVE MANAGEMENT:
 Restrictive thoracotomy
 Laparotomy & definitive repair
NUTRITIONAL:
Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum
during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to
eliminate gastrointestinal feedings for extended periods of time depending on the injury and the surgical
intervention required. Total parenteral nutrition may be used to provide nutritional requirements.
NURSING MANAGEMENT:
Nursing Assessment
1. Assess for history of the injury, onset and progression of the symptoms.
2. Assess presence of signs and symptoms of internal bleeding or acute abdomen (pain, bowel
distention, muscle rebound) .
3. Assess abdomen wall for presence of wounds and hematomas.

10. 4. Assess vital signs, CVP, fluid balance and urine output.
5. Assess diagnostic tests and procedures for abnormal values (US, x-ray, CT, etc.).
Nursing Diagnosis
1. Increased risk of hypovolemia and shock related to abdominal trauma and internal bleeding..
2.Increased risk of sepsis related to acute inflammatory process and peritonitis.
3. Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or inflammation.
4. Pain and bowel distention , related to diagnosis.
5.Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the
brain
6. Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or
restlessness
7. Deficient knowledge about abdominal injury, recovery, and the rehabilitation process
8. Anxiety related to the symptoms of disease and fear of death.
Goals:
1. Promote adequate respiratory and cardiovascular function.
2. Provide measures for prevention of the shock and sepsis.
3. Prevent avoidable injury and complications.
4. If surgical intervention prescribed, prevent postoperative complications.
5. Relief or diminish symptoms.
7. Decreased anxiety with increased knowledge of disease, it treatment, and follow-up.
Interventions
1. Assess, report , and record signs and symptoms and reactions to treatment.
2. Monitor fluids input and output closely, insert urinary catheter and IV catheter.
3. Provide positioning of the client in semi-Fowler position.
4. Monitor client for pain and signs of gastrointestinal decompensation.
5. Administer antibiotics and other medications as prescribed, monitor for side effects.
6. Monitor client’s vital signs and signs of possible hemorrhage, sepsis and shock closely, report
immediately.
7. Observe patency of tubes and drains, and drainage characteristics.
8. Monitor client’s laboratory tests results for abnormal values.
9. Keep client NPO as ordered.
10. Administer IV therapy and blood transfusions as prescribed.
11. Prepare client and his family for surgical intervention if required.
12. For client after surgical intervention provide postoperative care and teach about possible
postoperative complications.
13. Instruct client for cough and deep breathing to prevent respiratory complications.
14. Provide appropriate skin care to prevent possibility of skin lesions.
15. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain
cooperation.
16. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications,
home care, daily activities, restrictions and follow-up.

11. CONCLUSION:
Abdominal trauma can be life-threatening because abdominal organs, especially those in
the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. Solid
abdominal organs, such as the liver and kidneys, bleed profusely when cut or torn, as do major blood
vessels such as the aorta and vena cava. Hollow organs such as the stomach, while not as likely to result
in shock from profuse bleeding, present a serious risk of infection, especially if such an injury is not
treated promptly. Gastrointestinal organs such as the bowel can spill their contents into the abdominal
cavity. Hemorrhage and systemic infection are the main causes of deaths that result fromabdominal
trauma. One or more of the intra-abdominal organs may be injured in abdominal trauma. The
characteristics of the injury are determined in part by which organ or organs are injured. Abdominal
injury can be from mild to severe, depeding on that treatment also range from first aid to surgery with
lifelong rehabilitation. So health teaching to patient & family is very necessary to make the client able to
return in a normal life.
BIBLIOGRAPHY:
1. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Textbook of medical-Surgical Nursing. 11th ed. New
Delhi:Wolters kluwer;2008. p. 2180-85.
2. Lewis LS, Heitkmper MM, Dirksen SR, Brien PG, Bucher L. Medical Surgical Nursing. 7th ed.
Noida: Elsevier;2009. P. 1485-89.
3.Black JM, Hawks JH. Medical Surgical Nursing. 8th ed. Noida: Elsevier;2009. P. 1933-39
4.Available in: https://www.google.co.in/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-
8#q=nursing+care+plan+for+abdominal+pain
5.Abdominal trauma.Available in: https://en.wikipedia.org/wiki/Abdominal_trauma
6. Penetrating abdominal trauma.Available in: http://emedicine.medscape.com/article/2036859-treatment