Chest, Abdominal and Genitourinary Injuries

Chest, Abdominal and
Genitourinary Injuries
Prepared by: Odane P. Hamilton, EMT
October 2015

Overview
Chest Trauma
 Recognition and management of:
 Blunt versus penetrating mechanisms
 Open chest wound
 Impaled object

Introduction
 Chest injuries can involve the heart, lungs, and great
blood vessels.
 Immediately treat injuries that interfere with normal
breathing function.
 Internal bleeding can compress the lungs and heart.
 Air may collect in the chest, preventing lung
expansion.

Anatomy and Physiology
 Ventilation is the body’s ability to move air in and out of
the chest and lung tissue.
 Respiration is the exchange of gases in the alveoli of the
lung tissue.
 The chest (thoracic cage) extends from the lower end of
the neck to the diaphragm.
 Vital organs, such as the heart, are protected by the ribs.
 Connected in the back to the vertebrae
 Connected in the front to the sternum
 The diaphragm is a muscle that separates the thoracic
cavity from the abdominal cavity.

Anatomy and Physiology (cont’d)

Injuries of the Chest
 Two types: open and closed
 Closed Chest Injuries
 In a closed chest injury, the skin is not broken.
 Generally caused by blunt trauma
 Can cause significant cardiac and pulmonary contusion
 If the heart is damaged, it may not be able to refill
with or receive blood.
 Rib fractures may cause further damage.

Injuries of the Chest (cont’d)
 Open Chest Injuries
 In an open chest injury, an object penetrates the chest
wall itself.
 Knife, bullet, piece of metal, or broken end of
fractured rib
 Do not attempt to move or remove object.

 Blunt trauma to the chest may cause:
 Rib, sternum, and chest wall fractures
 Bruising of the lungs and heart
 Damage to the aorta
 Vital organs to be torn from their attachment in the
chest cavity

 Signs and symptoms:
 Pain at the site of injury
 Localized pain aggravated or increased with breathing
 Bruising to the chest wall
 Crepitus with palpation of the chest
 Penetrating injury to the chest
 Dyspnea

 Signs and symptoms (cont’d):
 Hemoptysis(coughing up blood)
 Failure of one or both sides of the chest to expand
normally with inspiration
 Rapid, weak pulse
 Low blood pressure
 Cyanosis around the lips or fingernails

 Chest injury patients often have rapid and shallow
respirations.
 Hurts to take a deep breath
 The patient may not be moving air.
 Auscultate multiple locations to assess for adequate
breath sounds.

Patient Assessment
 Patient assessment steps
 Scene size-up
 Primary assessment
 History taking
 Secondary assessment
 Reassessment

Patient Assessment (cont’d)
 Scene Size Up
 Mechanism of injury/nature of illness
Chest injuries are common in motor vehicle crashes,
falls, and assaults.
Determine the number of patients.
Consider spinal immobilization.

 Primary Assessment
 Form a general impression.
Note the patient’s level of consciousness.
Perform a rapid scan.
Obvious injuries
Appearance of blood
Difficulty breathing
Cyanosis
Irregular breathing

 Form a general impression (cont’d).
Perform a rapid scan (cont’d).
Chest rise and fall on only one side
Accessory muscle use
Extended or engorged jugular veins
Assess the ABCs.
Assess overall appearance.

 Airway and breathing
Ensure that the patient has a clear and patent
airway.
Consider early cervical spine stabilization.
Are jugular veins distended?
Is breathing present and adequate?
Inspect for DCAP-BTLS.

 Airway and breathing (cont’d)
Look for equal expansion of the chest wall.
Check for paradoxical motion.
Apply occlusive dressing to all penetrating injuries.
Support ventilations.
Reassess the effectiveness of ventilatory support.
Be alert for decreasing oxygen saturation.
Be alert for impending pneumothorax.

 Circulation
Pulse rate and quality
Skin color and temperature
Address life-threatening bleeding immediately, using
direct pressure and a bulky dressing.

 Transport decision
Priority patients are those with a problem with their
ABCs.
Pay attention to subtle clues, such as:
The appearance of the skin
Level of consciousness
A sense of impending doom in the patient

 History Taking
 Investigate the chief complaint.
Further investigate the MOI.
Identify signs, symptoms, and pertinent negatives.
 SAMPLE history
Focus on the MOI.

 SAMPLE history (cont’d)
A basic evaluation should be completed:
Signs and symptoms
Allergies
Medications
Pertinent medical problems
Last oral intake
Events leading to the emergency

 Secondary Assessment
 Physical examinations
Perform a full-body scan.
For an isolated injury, focus on:
Isolated injury
Patient’s complaint
Body region affected
Location and extent of injury
Anterior and posterior aspects of the chest wall
Changes in respirations

 Physical examinations (cont’d)
For significant trauma, use DCAP-BTLS to determine
the nature and extent of the thoracic injury.
Quickly assess the entire patient from head to toe.

 Vital signs
Assess pulse, respirations, blood pressure, skin
condition, and pupils.
Reevaluate every 5 minutes or less.
Pulse and respiratory rates may decrease in later
stages of the chest injury.
Use a pulse oximeter to recognize any downward
trends in the patient’s condition.

 Reassessment
 Repeat the primary assessment.
 Reassess the chief complaint.
Airway
Breathing
Pulse
Perfusion
Bleeding

 Interventions
Provide complete spinal immobilization for patients
with suspected spinal injuries.
Maintain an open airway.
Control significant, visible bleeding.
Place an occlusive dressing over penetrating trauma
to the chest wall.

 Interventions (cont’d)
Manually stabilize a flail segment using a bulky
dressing.
Provide aggressive treatment for shock and
transport patients with signs of hypoperfusion.
Do not delay transport to complete nonlifesaving
treatments.

 Communication and documentation
 Communicate all relevant information to the staff at
the receiving hospital.
 Describe all injuries and the treatment given.

Rib Fractures
 Common, particularly in older people
 A fracture of one of the upper four ribs is a sign of a very
substantial MOI.
 A fractured rib may cause a pneumothorax or a
hemothorax.
 Signs and symptoms
 Localized tenderness and pain when breathing
 Rapid, shallow respirations
 Patient holding the affected portion of the rib cage
 Prehospital treatment includes supplemental oxygen.

Flail Chest
 Caused by compound rib fractures that detach a segment of the chest wall
 Detached portion moves opposite of normal

Flail Chest (cont’d)
 Prehospital treatment
 Maintain the airway.
 Provide respiratory support, if needed.
 Give supplemental oxygen.
 Reassess for complications.
 To immobilize a flail segment:
 Tape a bulky dressing or pad against that segment of
the chest.
 Have the patient hold a pillow against the chest wall.
 Flail chest may indicate serious internal damage or spinal
injury.

Overview
 Recognition and management of:
 Evisceration
 Impaled object
 Pathophysiology, assessment, and management of:
 Solid and hollow organ injuries
 Evisceration

Introduction
 Abdomen is major body cavity extending from diaphragm
to pelvis.
 Contains organs that make up digestive, urinary, and
genitourinary systems.
 Important to know anatomy and function of abdominal
and pelvic cavities.
 Injuries to the abdomen that go unrecognized or are not
repaired in surgery are a leading cause of traumatic
death.

 Abdominal quadrants
 Abdomen is divided into four general quadrants.
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
“Right” and “left” refer to patient’s right and
left, not yours.

 Quadrant of bruising/pain can delineate which organs are
involved.
 RUQ
Liver, gallbladder, duodenum, pancreas
 LUQ
Stomach and spleen
 LLQ
Descending colon, left half of transverse colon
 RLQ
Large and small intestine, the appendix

 RLQ is a common
location for swelling
and inflammation.
 The appendix is a
source of infection if it
ruptures.

 Hollow organs
 Stomach, intestines, ureters, bladder
 Structures through which materials pass
Most of these contain digested food, urine, or bile.
 When ruptured or lacerated, contents spill into
peritoneal cavity.
Can cause intense inflammatory reaction and
infection such as peritonitis

 Hollow organs (cont’d)
 Small intestine
 Large intestine
 Intestinal blood supply comes from mesentery.
Mesentery connects the small intestine to the
posterior of the abdominal wall.

 Solid organs
 Liver, spleen, pancreas, kidneys
Solid masses of tissue
Perform chemical work of the body: enzyme
production, blood cleansing, energy production
Because of rich blood supply, hemorrhage can be
severe.

Abdominal Injuries
 Injuries to the abdomen are considered either open or
closed.
 They can involve hollow and/or solid organs.

Closed Abdominal Injuries
 Blunt trauma to abdomen without breaking the skin
 MOIs:
Steering wheel
Bicycle handlebars
Motorcycle collisions
Falls
Compression
Poorly placed lap belt
Being run over by a vehicle
Deceleration
Fast-moving vehicle strikes an immoveable object.

Closed Abdominal Injuries (cont’d)
 Pain can be deceiving
Often diffuse in nature
May be referred to another body location

 Signs and symptoms (cont’d)
 Difficult to determine location of pain.
Guarding: stiffening of abdominal muscles
Abdominal distention: result of free fluid, blood, or
organ contents spilling into peritoneal cavity
Abdominal bruising and discolouration
May appear as abrasions initially

 Seatbelts
 Prevent many injuries and save lives.
May cause blunt injuries of abdominal organs
Particularly when belt lies too high
Can cause bladder injuries to pregnant patients
 Air bags
 Air bags are a great advancement.
Must be used in combination with safety belts

Open Abdominal Injuries
 Foreign object enters abdomen and opens peritoneal
cavity to outside.
 Also called penetrating injuries
 Examples: stab wounds, gunshot wounds
 Open wounds can be deceiving.
Maintain a high index of suspicion.

Open Abdominal Injuries (cont’d)
 Injury depends on velocity of object.
 Low-velocity injuries
Knives, other edged weapons
 Medium-velocity injuries
Smaller caliber handguns and shotguns
 High-velocity injuries
High-powered rifles and handguns

 High- and medium-velocity injuries
 Have temporary wound channels
 Caused by cavitation
Cavity forms as pressure wave from projectile
transfers to tissues.
Can produce large amounts of bleeding

 Low-velocity injuries
 Also have capacity to damage organs
 Internal injury may not be apparent.

 Evisceration: bowel protrudes from peritoneum.
 Can be painful and visually shocking
 Do not push down on abdomen.
 Only perform visual assessment.
 Cut clothing close to wound.
 Never pull on clothing stuck to or in the wound
channel.

 Pain
 Tachycardia
Heart increases pumping action to compensate for
blood loss
 Later signs include:
Evidence of shock
Changes in mental status
Distended abdomen

Hollow Organ Injuries
 Often have delayed signs and symptoms
 Spill contents into abdomen
 Infection develops, which can take hours or days.
 Stomach and intestines can leak highly toxic and acidic liquids into
peritoneal cavity.
 Both blunt and penetrating trauma can cause hollow organ injuries
 Blunt: causes organ to “pop”
 Penetrating: causes direct injury
 Gallbladder and urinary bladder
 Contents are damaging.
 Air in peritoneal cavity causes pain.
 Can cause ischemia and infarction

Solid Organ Injuries
 Can bleed significantly and cause rapid blood loss
 Can be hard to identify from physical exam
 Slowly ooze blood into peritoneal cavity
 Liver is the largest organ in abdomen.
 Vascular, can lead to hypoperfusion
Often injured by fractured lower right rib or
penetrating trauma
Kehr sign is common finding with injured liver.

Solid Organ Injuries (cont’d)
 Spleen and pancreas
 Vascular and prone to heavy bleeding
 Spleen is often injured.
Motor vehicle collisions
Steering wheel trauma
Falls from heights
Bicycle and motorcycle accidents involving
handlebars

Solid Organ Injuries (cont’d)
 Diaphragm
 When penetrated or ruptured, loops of bowels invade
thoracic cavity.
May cause bowel sounds during auscultation of lungs
Patient may exhibit dyspnea.
 Kidneys
 Can cause significant blood loss
 Common finding is blood in urine (hematuria).
 Blood visible on urinary meatus indicates significant
trauma to genitourinary system.

Patient Assessment of Abdominal Injuries
 Patient assessment steps
 Scene size-up
 Primary assessment
 History taking
 Secondary assessment
 Reassessment

Emergency Medical Care of Abdominal
Injuries
 Closed abdominal injuries
 Biggest concern is not knowing the extent of injury.
Patient requires expedient transport.
Primarily to trauma center with surgeon
Position for comfort
Apply high-flow oxygen.
Treat for shock.

Emergency Medical Care of Abdominal Injuries
(cont’d)
 Closed abdominal injuries (cont’d)
 Patient with blunt abdominal wounds may have:
Severe bruising of abdominal wall
Liver and spleen laceration
Rupture of intestine
Tears in mesentery
Rupture of kidneys or avulsion of kidneys
Patient with blunt abdominal injury should be log rolled to a
supine position on a backboard.
Protect the spine.
Monitor vital signs.

Injuries (cont’d)
 Open abdominal injuries
 Patients with penetrating injuries
Generally obvious wounds, external bleeding
High index of suspicion for serious unseen blood loss
Surgeon will assess damage.
Inspect patient’s back and sides for exit wound.
Apply dry, sterile dressing to all open wounds.
If penetrating object is still in place, apply
stabilizing bandage around it.

Injuries (cont’d)
 Open abdominal injuries
(cont’d)
 Evisceration
Severe lacerations
of abdominal wall
may result in
internal organs or
fat protruding
through wound.

Injuries (cont’d)
 Open abdominal injuries (cont’d)
 Never try to replace a protruding organ.
Keep the organs moist and warm.
Cover with moistened, sterile gauze or occlusive
dressing.
Secure dressing with bandage.
Secure bandage with tape.

 Controls reproductive functions and waste discharge
 Generally considered together
 Male genitalia lie outside pelvic cavity.
Except prostate gland and seminal vesicles
 Female genitalia lie within pelvic cavity.
Except vulva, clitoris, labia

 Kidney injuries
 Rarely seen but not unusual
 Kidneys lie in well-protected area.
Forceful blow or penetrating injury often involved

Genitourinary Injuries (cont’d)
 Suspect kidney damage if patient has a history or physical
evidence of any of the following:
Abrasion, laceration, contusion in the flank
Penetrating wound in region of flank or upper
abdomen
Fractures on either side of lower rib cage or of
lower thoracic or upper lumbar vertebrae
A hematoma in the flank region

 Urinary bladder injuries
 May result in rupture
Urine spills into surrounding tissues.
Blunt injuries to lower abdomen or pelvis can
rupture urinary bladder.
 In males, sudden deceleration can shear the bladder
from the urethra.
 In later trimesters of pregnancy, bladder injuries
increase.

 External male genitalia injuries
 Soft-tissue wounds
 Painful and of great concern for patient
Rarely life threatening
Should not be given priority over more severe
wounds

 Female genitalia injuries
 Internal female genitalia
Uterus, ovaries, fallopian tubes are rarely damaged.
Exception is pregnant uterus
Uterus enlarges substantially and rises out of
pelvis
Injuries can be serious.
Also keep fetus in mind.
In last trimester of pregnancy, uterus is large and
may obstruct vena cava.

 Female genitalia injuries (cont’d)
 External female genitalia
Vulva, clitoris, major and minor labia
Consider sexual assault and pregnancy.
If there is external bleeding, a sterile absorbent
sanitary pad may be applied to the labia.
Do not insert anything into the vagina.

 Potential for patient embarrassment
 Maintain a professional presence.
 Provide privacy .
 Have colleague of same gender perform assessment.
 Look for blood on patient’s undergarments.

Emergency Medical Care of
 Kidney injuries
 Injuries may not be obvious.
However, you will see:
Signs of shock
Blood in urine (hematuria)
 Treat for shock, transport promptly, monitor vital signs
en route.

 Urinary bladder injury
 Suspect if you see:
Blood at urethral opening
Signs of trauma to lower abdomen, pelvis, perineum
 In presence of shock or associated injuries:
Transport promptly.
Monitor vital signs en route.

 External male genitalia
 General rules for treatment:
Make patient comfortable.
Use sterile, moist compresses to cover areas
stripped of skin.
Apply direct pressure with dry, sterile gauze
dressings to control bleeding.
Never move or manipulate foreign objects in
urethra.

 External male genitalia (cont’d)
 General rules for treatment (cont’d):
Identify and take avulsed parts in bag to hospital
with patient.
 Amputation of penile shaft
Managing blood loss is top priority.
Use local pressure with sterile dressing.

 If connective tissue surrounding erectile tissue is
damaged, shaft can be fractured or angled.
Sometimes requires surgical repair
Injury may occur during active sexual intercourse.
Associated with intense pain, bleeding, and fear

 Laceration of head of penis
Associated with heavy bleeding
Apply local pressure with sterile dressing.
 Skin of shaft or foreskin caught in zipper
If small segment of zipper is involved, try to unzip.
If long segment of zipper is involved, cut the zipper
out of the pants with heavy scissors.

 Urethral injuries are not uncommon
Important to know if patient can urinate and if
there is blood in urine
Save urine for hospital examination.
Foreign bodies protruding from urethra will have to
be surgically removed.

 Avulsion of the skin of the scrotum may damage scrotal
contents.
Preserve avulsed skin in a moist sterile dressing.
Wrap scrotal contents or perineal area with a sterile
moist compress; use local pressure for bleeding.
 Direct blows to scrotum can result in rupture of a
testicle or accumulation of blood around testes.
Apply ice to scrotal area.

 Female genitalia
 Treat lacerations and avulsions with moist, sterile
compresses.
Use local pressure to control bleeding.
Hold dressings in place with diaper-type bandage.
 Do not pack dressings into vagina.

 Female genitalia (cont’d)
 Leave any foreign bodies in place after stabilizing with
bandages.
 Injuries are painful but not life threatening.
In-hospital evaluation required.
Transport urgency determined by associated
injuries, amount of hemorrhage, presence of shock.

 Rectal bleeding
 Common complaint
May present as blood in or soaking through
undergarments
 Possible causes include sexual assault, hemorrhoids,
colitis, ulcers.
Rectal bleeding possible after hemorrhoid surgery

 Rectal bleeding (cont’d)
 Acute rectal bleeding should never be passed off as
something minor.
Pack crease between buttocks with compresses.
Consult medical control to determine need for
transport.

Review
1. During your assessment of a patient who was stabbed,
you see an open wound to the left anterior chest. Your
MOST immediate action should be to:
A. position the patient on the affected side.
B. transport immediately.
C. assess the patient for a tension pneumothorax.
D. cover the wound with an occlusive dressing.

Review (cont’d)
Answer: D
Rationale: If you encounter an open chest wound, you must
cover it with an occlusive dressing. This will prevent air from
moving in and out of the wound. After the dressing is
applied, however, you must monitor the patient for signs of
a developing tension pneumothorax.

Review (cont’d)
2. During your assessment of a patient with a closed chest
injury, you should NOT intentionally assess for:
A. bruising.
B. deformities.
C. crepitus.
D. breath sounds.

Review (cont’d)
Answer: C
Rationale: Crepitus, the sound made (or sensation felt)
when broken bone ends rub together, is not intentionally
assessed for in patients with any injury; it is a coincidental
finding that should be documented. Intentionally assessing
for crepitus—which involves moving or manipulating the
injured area—may worsen the injury and should be avoided.

Review (cont’d)
3. Paradoxical chest movement is typically seen in patients
with:
A. a flail chest.
B. a pneumothorax.
C. isolated rib fractures.
D. a ruptured diaphragm.

Review (cont’d)
Answer: A
Rationale: Paradoxical chest movement occurs when an area
of the chest wall bulges out during exhalation and collapses
during inhalation. This type of abnormal chest movement is
seen in patients with a flail chest—a condition in which
several adjacent ribs are fractured in more than one place,
resulting in a free-floating segment of fractured ribs.

Review (cont’d)
4. Which of the following organs would be the MOST likely
to bleed profusely if severely injured?
A. Liver
B. Kidney
C. Stomach
D. Gallbladder

Review (cont’d)
Answer: A
Rationale: The liver is a highly vascular solid organ, and
contains approximately 40% of the body’s total blood volume
at any given time. If severely injured, bleeding from the
liver would be profuse and rapid. Other solid organs, such as
the spleen and kidneys, may also produce severe bleeding if
injured, though not as rapid as the liver. The stomach and
gallbladder are hollow organs; if lacerated, they would spill
their contents into the abdominal cavity, resulting in
peritonitis.

Review (cont’d)
5. Which of the following statements regarding intra-
abdominal bleeding is FALSE?
A. Intra-abdominal bleeding often causes abdominal
distention.
B. Intra-abdominal bleeding is common following blunt
force trauma.
C. The absence of pain and tenderness rules out intra-
abdominal bleeding.
D. Bruising may not occur immediately following blunt
abdominal trauma.

Review (cont’d)
Answer: C
Rationale: Intra-abdominal bleeding is common following
blunt trauma to the abdomen. Signs include abdominal
distention, rigidity, bruising (may not occur immediately),
and in some cases, pain to palpation. However, unlike gastric
juices and bacteria, blood within the abdominal cavity does
not provoke an inflammatory response; therefore, the
absence of pain and tenderness does not rule out internal
bleeding.

Review (cont’d)
6. While inspecting the interior of a wrecked automobile,
you should be MOST suspicious that the driver
experienced an abdominal injury if you find:
A. a deformed steering wheel.
B. that the airbags deployed.
C. a crushed instrument panel.
D. damage to the lower dashboard.

Review (cont’d)
Answer: A
Rationale: Airbags save lives when used in conjunction with
properly worn seatbelts. Unfortunately, however, not all
drivers wear their seatbelts. If unrestrained, the driver’s
abdomen may strike the steering wheel, resulting in
significant trauma. Suspect this if you lift the airbag and
note that the lower part of the steering wheel is deformed.

Review (cont’d)
7. Other than applying a moist, sterile dressing covered
with a dry dressing to treat an abdominal evisceration,
an alternative form of management may include:
A. placing dry towels over the open wound.
B. cleaning the exposed bowel with sterile saline.
C. applying the PASG to stop the associated bleeding.
D. applying an occlusive dressing, secured by trauma
dressings.

Review (cont’d)
Answer: D
Rationale: Although the preferred management for an
abdominal evisceration includes the application of a moist,
sterile dressing covered by a dry dressing, protocols in some
EMS systems call for an occlusive dressing, secured by
trauma dressings. An occlusive dressing may help prevent
the loss of body heat through the abdominal wound.

Review (cont’d)
8. When caring for a female with trauma to the external
genitalia, the EMT should:
A. use local pressure to control bleeding.
B. carefully pack the vagina to reduce bleeding.
C. remove any impaled objects from the vagina.
D. cover any open wounds with moist, sterile
dressings.

Review (cont’d)
Answer: A
Rationale: Bleeding from the external genitalia should be
controlled by applying a dry, sterile dressing and local direct
pressure. Never pack anything into the vagina to try to
control bleeding; this increases the risk of infection, and
anything you place into the vagina will only need to be
removed at the hospital. Impaled objects in the genitalia
should be carefully stabilized in place, not removed.

Reference
 Jones and Bartlett – Emergency Care and Transportation of the Sick and
Injured – Andrew N. Pollak, et al (10th Ed.)

Chest, Abdominal and Genitourinary Injuries

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