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Abdominal injury
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- 5. 5 ๏Anterior abdomen ๏Flank ๏Back ๏Intraperitoneal spacecontents ๏Retroperitoneal space contents ๏Pelvic cavity contents Background Anatomy
- 6. โข Anterior abdomen: Trans-nippleline, Anterior axillary lines, Inguinal ligaments and Symphysis pubis. โข Flank: Anterior and posterior axillary line; Sixth intercostal to iliac crest. โข Back: Posterior axillary line; Tip of scapula to Iliac crest.
- 7. โข Upper Peritonealcavity Covered by lower aspect of bony thorax. Includes Diaphragm, Liver, Spleen, Stomach, Transverse colon. โข Lower Peritoneal cavity: Small bowel Ascending and Descending colon, Sigmoid colon โข Retroperitoneal space: A Potential space Behind โtrueโ abdominal cavity Abdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas, kidneys, Ureters and posterior aspects of Ascending and Descending colons โข Pelvic cavity: Rectum, Bladder, iliac vessels and Internal genitalia in women.
- 8. Organs by AbdominalQuadrant Small & Large Intestine Lower part of Kidney Half of Bladder, Female Reproductive Organs Small & Large Intestine Lower part of Kidney Half of Bladder, Appendix, Female Reproductive Organs Stomach, Tail of Pancreas Tail of Liver Small & Large Intestine Upper Part of Kidney Liver, Gallbladder, Stomach (Small Part) Small & Large Intestine Head of Pancreas Upper Part of Kidney U p p e r L o w e r Right Left
- 9. Vascular Anatomy 1. AbdominalAorta 2. Common Iliac Artery 3. Internal Iliac 4. External Iliac 5. Superior Gluteal 6. Obturator Artery
- 10. TYPES OF ABDOMINAL INJURIES BLUNTTRAUMA PENETRATING TRAUMA โขEnergy transmitted to surrounding tissue โขResults in- ๏ผUncontrolled hemorrhage ๏ผOrgan damage ๏ผSpillage of hollow organ contents ๏ผIrritation & Inflammation of abdominal lining โขLiver most commonly affected organ โขCommon causes -Shotgun Trauma, stab wound, cuts & tears โขProduces least visible signs of injury โขCauses ๏ถDeceleration Contents damaged by change in velocity ๏ถCompression Organs trapped between other structures ๏ถShear Part of an organ is able to move while another part is fixed
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- 12. DIAPHRAGMATIC INJURY DESCRIPTIONS โข Partiallyprotected by bony structures, diaphragm is commonly injured by penetrating trauma (Automobile deceleration may lead to rapid rise in intra- abdominal pressure and a burst injury โข Diaphragmatic tear usually indicates multi-organ involvement CLINICAL MANIFESTATIONS โข Decreased breath sounds โข Abdominal peristalsis heard in thorax โข Acute chest pain and shortness of breath may indicate diaphragmatic tear โข May be hard to diagnose because of multisystem trauma or the liver may "plug" the defect and mask it
- 13. ESOPHAGEAL INJURY DESCRIPTIONS โข Penetratinginjury is more common than blunt injury โข May be caused by knives, bullets, foreign body obstruction โข May be caused by iatrogenic perforation โข May be associated with cervical spine injury CLINICAL MANIFESTATIONS โข Pain at site of perforation โข Fever โข Difficulty swallowing โข Cervical tenderness โข Peritoneal irritation
- 14. STOMACH INJURY DESCRIPTIONS โข Penetratinginjury is more common than blunt injury; in one-third of patients, both the anterior and the posterior walls are penetrated โข May occur as a complication from cardiopulmonary resuscitation or from gastric dilation CLINICAL MANIFESTATIONS โข Epigastric pain โข Epigastric tenderness โข Signs of peritonitis โข Bloody gastric drainage
- 15. LIVER INJURY DESCRIPTIONS โข Mostcommonly injured organ; blunt injuries (70% of total) usually occur from motor vehicle crashes and steering wheel trauma โข Highest mortality from blunt injury and gunshot wound โข Hemorrhage is most common cause of death from liver injury; overall mortality 10%โ15% CLINICAL MANIFESTATIONS โข Persistent hypotension despite adequate fluid resuscitation โข Guarding over right upper or lower quadrant; rebound abdominal tenderness โข Dullness to percussion โข Abdominal distention and peritoneal irritation โข Persistent thoracic bleed
- 16. SPLEEN INJURY DESCRIPTIONS โข Mostcommonly injured organ with blunt abdominal trauma โข Injured in penetrating trauma of the left upper quadrant CLINICAL MANIFESTATIONS โข Hypotension, tachycardia, shortness of breath โข Peritoneal irritation โข Abdominal wall tenderness โข Left upper quadrant pain โข Fixed dullness to percussion in left flank; dullness to percussion in right flank that disappears with change of position
- 17. PANCREAS INJURY DESCRIPTIONS โข Mostoften penetrating injury (gunshot wounds at close range) โข Blunt injury from deceleration; injury from steering wheel โข Often associated (40%) with other organ damage (liver, spleen, vessels) CLINICAL MANIFESTATIONS โข Pain over pancreas โข Paralytic ileus โข Symptoms may occur late (after 24 hr); epigastric pain radiating to back; nausea, vomiting โข Tenderness to deep palpation
- 18. SMALL INTESTINES INJURY DESCRIPTIONS โขDuodenum, ileum, and jejunum; hollow viscous structure most often injured by penetrating trauma โข Gunshot wounds account for 70% of cases โข Incidence of injury is third only to liver and spleen injury โข When small bowel ruptures from blunt injury, rupture occurs most often at proximal jejunum and CLINICAL MANIFESTATIONS โข Testicular pain โข Referred pain to shoulders, chest, back โข Mild abdominal pain โข Peritoneal irritation โข Fever, jaundice, intestinal obstruction
- 19. LARGE INTESTINES AINJURY DESCRIPTIONS โข One of the more lethal injuries because of fecal contamination; occurs in 5% of abdominal injuries โข More than 90% of incidences are penetrating injuries โข Blunt injuries are often from safety restraints in motor vehicle crashes CLINICAL MANIFESTATIONS โข Pain, muscle rigidity โข Guarding, rebound tenderness โข Blood on rectal examination โข Fever
- 20. RETROPERITONEAL INJURY DESCRIPTIONS โข Bluntor penetrating trauma to the abdomen or posterior abdomen. โข Kidney, ureters, pancreas, or duodenal injuries โข Associated with posterior posterior rib fractures & lumbar vertebral injuries. โข Deceleration forces may injure the renal artery CLINICAL MANIFESTATIONS โข Haemorrhage usually from pelvic or lumbar fractures: โข Gray turnerโs sign โ 12 hours or later โข cullenโs sign โ 12 hours or later
- 21. Renal Injury . Classification ofInjury โข Grade I : Contusion or Subcapsular Hematoma โข Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation โข Grade III: Laceration >1cm with urinary Extravasation โข Grade IV: Parenchymal Laceration โข Grade V: Renovascular injury
- 22. PATHOPHYSIOLOGY OF ABDOMINAL INJURY DECELERATION โขRapid 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. CRUSHING โข . 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. EXTERNAL COMPRESSION โข 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 โข Pain ortenderness โข A rapid heart rate โข Rapid breathing โข Sweating โข Cold, clammy, pale or bluish skin โข Confusion or low level of alertness โข Blunt trauma may cause bruising. โข Cullenโs sign โข Grey turnerโs sign โข Kehrโs sign
- 24. COMPLICATIONS: Hematoma rupture Peritonitis Intra abdominal collection of pus(abcess) Intestinal blockage (obstruction) Abdominal compartment syndrome
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- 26. HISTORY TAKING AMPLE History โขA: Allergy โข M: Medications โข P: Past medical history โข L: Last meal โข E: Event - What happened
- 27. General Examination :Relating to hemodynamic stability (Vital Signs) Abdominal findings: โข 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 โ Retroperitoneal hematoma PHYSICAL EXAMINATION
- 28. โข Palpation : Fortenderness, guarding and/or rigidity, rebound tenderness โ hemoperitoneum โข Percussion : Dullness/ shifting dullness Intraabdominal collection โข Auscultation : Where to auscultate & What to listen for??? All four quadrants for the +/- nce of bowel sounds PHYSICAL EXAMINATION cont.
- 29. The classical โseatbeltโ sign. Thebruising on the left breast is from the shoulder belt and the low bruising to the abdominal wall is from the lap belt.
- 30. โข Left lowersix ribs โข Right lower six ribs โข Upper Lumbar vertebra โข Transverse Process โข Pelvis Spleen Liver Pancreas and Duodenum Kidneys Bladder Urethra Rectum 30 Associated with fractures
- 31. Diagnostic studies โข CECT โขFAST โข DPL โข Complete blood count โข Blood glucose determination โข Urinanalysis โข Coagulation profile โข Blood grouping, typing & cross matching โข Arterial blood gas analysis
- 32. Diagnostic studies โข Drug& alcohol screens โข Rigid sigmoidoscopy: is indicated for patients presenting with injuries in the pelvis or if blood is found on rectal examination. โข magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct injuries โข chest, and cervical spine radiographs โข Arteriographs
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- 34. Initial Assessment andResuscitation Primary survey Identification & treatment of life threatening conditions โข Airway , with cervical spine precautions โข Breathing โข Circulation โข Disability โข Exposure
- 35. Emergency Care โข IV fluids โข Control external bleeding โข Dressing of wounds โข Protect eviscerated organs with a sterile dressing โข Stabilize an impaled object in place โข Give high flow oxygen โข Immobilize the patient with a fractured pelvis โข Keep the patient warm โข Analgesics
- 36. MANGEMENT BASED ONORGANS โข DIAPHRAGMATIC TEARS : ๏ถ repaired surgically to prevent visceral herniation in later years. โข ESOPHAGEAL INJURY: ๏ถ gastric decompression with a nasogastric tube, antibiotic therapy ๏ถ surgical repair of the esophageal tear. โข GASTRIC INJURY: ๏ถpartial gastrectomy may be needed if extensive injury has occurred.
- 37. MANGEMENT BASED ONORGANS โข LIVER INJURY ๏ถ managed nonoperatively or operatively, depending on the degree of injury and the amount of bleeding. ๏ถ Albumin transfusion ๏ถ Blood glucose regulation โข SPLEEN INJURY โข splenectomy is the treatment of choice when the patient is markedly hemodynamically unstable, or when the spleen is totally macerated.
- 38. MANGEMENT BASED ONORGANS โข PANCREATIC INJURY : ๏ถdepends 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. โข SMALL AND LARGE BOWEL : ๏ถPerforation or lacerations are managed by surgical exploration and repair. ๏ถColostomy
- 39. Common operative procedures 1.Restrictive thoracotomy 2. Laparatomy & definitive repair
- 40. OTHER TREATMENT ๏ถNutritional supplementation: ๏TPN ๏Enteralfeeding ๏ถAntibiotics ๏ถIntravenous fluid infusion ๏ถBlood components transfusion
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- 42. Increased risk of hypovolemiaand shock related to abdominal trauma and internal bleeding.
- 43. Increased risk of sepsisrelated to acute inflammatory process and peritonitis.
- 44. Increased risk of severefluid, electrolyte, and metabolic imbalances related to injury or inflammation.
- 45. Pain and bowel distention , relatedto diagnosis.
- 46. Risk for imbalanced body temperature relatedto infection
- 47. Risk for impaired skinintegrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness
- 48. Impaired elimination due to abdominal& retroperitoneal injury , nerve injury
- 49. Body image disturbance related to presenceof colostomy bag, wound.
- 50. Deficient knowledge about abdominal injury, recovery,and the rehabilitation process
- 51. Anxiety related to the symptomsof disease and fear of death.
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