Chapter 34Chapter 34Abdominal TraumaAbdominal Trauma

ObjectivesObjectives Describe mechanisms of injury, signs Describe mechanisms of injury, signs

and symptoms, and complications and symptoms, and complications associated with injuries of:associated with injuries of: Abdominal solid organsAbdominal solid organs Hollow organsHollow organs Retroperitoneal organsRetroperitoneal organs Pelvic organsPelvic organs

ObjectivesObjectives Outline the significance of injury to Outline the significance of injury to

intraabdominal vascular structuresintraabdominal vascular structures

Describe assessment priorities for the Describe assessment priorities for the patient suspected to have abdominal patient suspected to have abdominal injuryinjury

Outline the prehospital care of the Outline the prehospital care of the patient with abdominal traumapatient with abdominal trauma

ScenarioScenarioThe size-up from the first unit on the scene The size-up from the first unit on the scene said, “One vehicle into a tree, major said, “One vehicle into a tree, major damage.” Your patient, an unrestrained damage.” Your patient, an unrestrained male, is still seated in the front of an old male, is still seated in the front of an old pick-up truck, behind the severely bent pick-up truck, behind the severely bent steering wheel. He is pale, anxious and steering wheel. He is pale, anxious and confused, and has a small head wound. You confused, and has a small head wound. You can’t feel a radial pulse, but his carotid is can’t feel a radial pulse, but his carotid is fast and thready. His lungs are clear, but he fast and thready. His lungs are clear, but he moans when you touch the large reddened moans when you touch the large reddened area over his upper abdomen. You prepare area over his upper abdomen. You prepare for a rapid extrication. You can sense that for a rapid extrication. You can sense that time will be critical on this call.time will be critical on this call.

DiscussionDiscussion Was the mechanism of injury on this call Was the mechanism of injury on this call

suspicious for abdominal injury?suspicious for abdominal injury?

Which abdominal organs may be injured?Which abdominal organs may be injured?

What signs and symptoms lead you to What signs and symptoms lead you to believe that an abdominal injury is likely?believe that an abdominal injury is likely?

What are your priorities of care for this What are your priorities of care for this patient?patient?

Abdominal TraumaAbdominal Trauma

Blunt or penetrating traumaBlunt or penetrating trauma MVC major cause of abdominal MVC major cause of abdominal

traumatrauma OtherOther

Blows to abdomenBlows to abdomen FallsFalls

Abdominal TraumaAbdominal Trauma

Difficult to evaluate due to:Difficult to evaluate due to: Wide spectrum of potential injuries to Wide spectrum of potential injuries to

multiple organsmultiple organs Physical findings sometimes lacking or Physical findings sometimes lacking or

exaggeratedexaggerated

Abdominal TraumaAbdominal Trauma Assessment may be compromised Assessment may be compromised

by:by: Alcohol and/or recreational drugsAlcohol and/or recreational drugs Injury to brain, spinal cordInjury to brain, spinal cord Injury to ribs, spine, pelvis Injury to ribs, spine, pelvis

High degree of suspicion based on High degree of suspicion based on mechanism of injury and kinematicsmechanism of injury and kinematics

Boundaries of the AbdomenBoundaries of the Abdomen

DiaphragmDiaphragm Anterior abdominal Anterior abdominal

wallwall Pelvic bonesPelvic bones Vertebral columnVertebral column Muscles of the Muscles of the

abdomen and abdomen and flanksflanks

Surface Anatomy of the Surface Anatomy of the AbdomenAbdomen

QuadrantsQuadrants UpperUpper——right, leftright, left LowerLower——right, leftright, left

XiphoidXiphoid

Symphysis pubisSymphysis pubis

UmbilicusUmbilicus

Peritoneal CavityPeritoneal Cavity ““True” abdominal cavityTrue” abdominal cavity QuadrantsQuadrants

UpperUpper——right, leftright, left LowerLower——right, leftright, left

Liver, spleen, stomach, small Liver, spleen, stomach, small intestine, colon, gallbladder, intestine, colon, gallbladder, female reproductive organsfemale reproductive organs

Pelvic CavityPelvic Cavity Surrounded by pelvic Surrounded by pelvic

bonesbones

Lower part of Lower part of retroperitoneal spaceretroperitoneal space

ContentsContents RectumRectum BladderBladder UrethraUrethra Iliac vesselsIliac vessels In women, internal In women, internal

genitaliagenitalia

Retroperitoneal SpaceRetroperitoneal Space

Potential space Potential space Behind “true” Behind “true”

abdominal cavityabdominal cavity ContentsContents

Abdominal aortaAbdominal aorta Inferior vena cavaInferior vena cava Most of duodenumMost of duodenum PancreasPancreas KidneysKidneys UretersUreters Ascending and Ascending and

descending colondescending colon

Mechanisms of Abdominal Mechanisms of Abdominal InjuryInjury

Blunt traumaBlunt trauma Compression or Compression or

crushing forcescrushing forces Shearing forcesShearing forces Deceleration Deceleration

forcesforcesMarks of impact sustained by the front-seat

passenger in a car crash

Mechanisms of Abdominal Mechanisms of Abdominal InjuryInjury

Degree of injury related to:Degree of injury related to: Quantity and duration of forceQuantity and duration of force Abdominal structure injuredAbdominal structure injured

Fluid filledFluid filled Gas filledGas filled SolidSolid HollowHollow

Blunt TraumaBlunt Trauma Motor vehicle collisionsMotor vehicle collisions Motorcycle collisionsMotorcycle collisions Pedestrian injuriesPedestrian injuries FallsFalls AssaultAssault Blast injuriesBlast injuries

Penetrating TraumaPenetrating Trauma Energy imparted to bodyEnergy imparted to body

Low velocity: Knife, ice pickLow velocity: Knife, ice pick Medium velocity: Gunshot wounds, shotgun Medium velocity: Gunshot wounds, shotgun

woundswounds High velocity: High-power hunting rifles, High velocity: High-power hunting rifles,

military weaponsmilitary weapons BallisticsBallistics TrajectoryTrajectory Distance Distance

Solid and Hollow OrgansSolid and Hollow Organs Solid organsSolid organs

LiverLiver Spleen Spleen PancreasPancreas Kidneys Kidneys AdrenalsAdrenals Ovaries (female)Ovaries (female)

Hollow organsHollow organs StomachStomach IntestinesIntestines GallbladderGallbladder Urinary bladderUrinary bladder Uterus (female)Uterus (female)

Hollow- Solid- & Hollow- Solid- & Retroperitoneal OrgansRetroperitoneal Organs

LiverLiver

Largest organ in Largest organ in abdominal cavityabdominal cavity

Right upper Right upper quadrantquadrant

Injured from trauma Injured from trauma to:to: Eighth through Eighth through

twelfth ribs on right twelfth ribs on right side of bodyside of body

Upper central part of Upper central part of abdomenabdomen

LiverLiver

Steering wheel Steering wheel injuryinjury Lap belt injuryLap belt injury Epigastric traumaEpigastric trauma

After injury, blood After injury, blood and bile leak into and bile leak into peritoneal cavityperitoneal cavity ShockShock Peritoneal irritationPeritoneal irritation

SpleenSpleen

Upper left quadrantUpper left quadrant Rich blood supplyRich blood supply Slightly protected by Slightly protected by

organs surrounding it organs surrounding it and by lower rib cageand by lower rib cage Most commonly injured Most commonly injured

organ from blunt organ from blunt traumatrauma

Associated Associated intraabdominal injuries intraabdominal injuries commoncommon

SpleenSpleen Suspect splenic injury in:Suspect splenic injury in:

Motor vehicle crashesMotor vehicle crashes Falls or sports injuries involving was Falls or sports injuries involving was

an impact to the lower left chest, an impact to the lower left chest, flank, or upper left abdomenflank, or upper left abdomen

Kehr’s Sign Referred PainKehr’s Sign Referred Pain Left upper quadrant pain radiates to Left upper quadrant pain radiates to

left shoulderleft shoulder Common complaint with splenic injuryCommon complaint with splenic injury

StomachStomach

Not commonly injured by Not commonly injured by blunt traumablunt trauma

Protected location in Protected location in abdomenabdomen

Penetrating trauma may Penetrating trauma may cause gastric transection or cause gastric transection or lacerationlaceration Signs of peritonitis from Signs of peritonitis from

leakage of gastric contentsleakage of gastric contents Diagnosis confirmed during Diagnosis confirmed during

surgery surgery Unless nasogastric Unless nasogastric

drainage returns blooddrainage returns blood

Colon and Small IntestineColon and Small Intestine Usually injured by penetrating Usually injured by penetrating

traumatrauma May be injured by compression May be injured by compression

forces:forces: High-speed motor vehicle crashesHigh-speed motor vehicle crashes Deceleration injuries associated with Deceleration injuries associated with

wearing personal restraintswearing personal restraints

Bacterial contamination commonBacterial contamination common

Retroperitoneal Organ InjuryRetroperitoneal Organ Injury

Blunt or Blunt or penetrating trauma penetrating trauma to:to: Anterior abdomenAnterior abdomen Posterior abdomen Posterior abdomen

Particularly flank Particularly flank Thoracic spineThoracic spine

KidneysKidneys

High on posterior wall of abdominal High on posterior wall of abdominal cavity in retroperitoneal spacecavity in retroperitoneal space Held in place by renal fasciaHeld in place by renal fascia Cushioned by layer of adipose tissueCushioned by layer of adipose tissue Partially protected by lower rib cagePartially protected by lower rib cage

KidneysKidneys Injuries may involve fracture and Injuries may involve fracture and

lacerationlaceration Resulting in hemorrhage, urine Resulting in hemorrhage, urine

extravasation, or bothextravasation, or both Contusions usually self-limitingContusions usually self-limiting

Heal with bed rest and forced fluidsHeal with bed rest and forced fluids Fractures and lacerations may need Fractures and lacerations may need

surgical repairsurgical repair

UretersUreters Hollow organsHollow organs Rarely injured in blunt trauma Rarely injured in blunt trauma

Flexible structureFlexible structure Injury from penetrating abdominal Injury from penetrating abdominal

or flank wounds (stab wounds, or flank wounds (stab wounds, firearm injuries)firearm injuries)

PancreasPancreas

Solid organ in Solid organ in peritoneal spaceperitoneal space

Blunt injury usually Blunt injury usually from crushing injury from crushing injury between spine and a between spine and a steering wheel, steering wheel, handlebar, or blunt handlebar, or blunt weaponweapon

Most pancreatic Most pancreatic injuries are due to injuries are due to penetrating trauma penetrating trauma

DuodenumDuodenum Lies across lumbar spineLies across lumbar spine Seldom injured due to location in Seldom injured due to location in

retroperitoneal area, near pancreasretroperitoneal area, near pancreas May be crushed or lacerated when May be crushed or lacerated when

great force of blunt trauma or great force of blunt trauma or penetrating injury occurspenetrating injury occurs Usually associated with pancreatic Usually associated with pancreatic

traumatrauma

Pelvic Organ InjuryPelvic Organ Injury Usually from motor vehicle crashes Usually from motor vehicle crashes

that produce pelvic fracturesthat produce pelvic fractures Less frequent causesLess frequent causes

Penetrating traumaPenetrating trauma Straddle-type injuries from fallsStraddle-type injuries from falls Pedestrian accidentsPedestrian accidents Some sexual actsSome sexual acts

Urinary BladderUrinary Bladder Hollow organHollow organ Ruptured by blunt or penetrating Ruptured by blunt or penetrating

trauma or pelvic fracturetrauma or pelvic fracture Rupture more likely if bladder is Rupture more likely if bladder is

distended at time of injurydistended at time of injury Suspect bladder injury in inebriated Suspect bladder injury in inebriated

patients subjected to lower abdominal patients subjected to lower abdominal traumatrauma

Vascular Structure InjuryVascular Structure Injury Intraabdominal Intraabdominal

arterial and venous arterial and venous injuries may be life injuries may be life threateningthreatening

Usually occur from Usually occur from penetrating traumapenetrating trauma

Also from Also from compression or compression or deceleration forces deceleration forces applied to applied to abdomenabdomen

Often presents Often presents as hypovolemiaas hypovolemia

May be a May be a palpable palpable abdominal massabdominal mass

Vascular Structure InjuryVascular Structure Injury

Major vessels most frequently Major vessels most frequently injured:injured: AortaAorta Inferior vena cavaInferior vena cava Renal, mesenteric, and iliac arteries Renal, mesenteric, and iliac arteries

and veinsand veins

Pelvic FracturesPelvic Fractures Disruption of Disruption of

pelvis from:pelvis from: Motorcycle crashesMotorcycle crashes Pedestrian-vehicle Pedestrian-vehicle

collisionscollisions Direct crushing Direct crushing

injury to pelvisinjury to pelvis Falls from heights Falls from heights

greater than 12 feetgreater than 12 feet

Blunt or Blunt or penetrating penetrating injury may result injury may result in:in: FractureFracture Severe hemorrhageSevere hemorrhage Associated injury to Associated injury to

urinary bladder and urinary bladder and urethra urethra

Pelvic FracturesPelvic Fractures Suspicion of pelvic injury should be Suspicion of pelvic injury should be

based on:based on: Mechanism of injuryMechanism of injury Presence of tenderness on palpation of Presence of tenderness on palpation of

iliac crestsiliac crests Direct or indirect forceDirect or indirect force Assessment findingsAssessment findings ManagementManagement

EviscerationEvisceration Protrusion of internal Protrusion of internal

organ through woundorgan through wound Common with stab Common with stab

woundswounds Do not replace Do not replace

organs into abdomenorgans into abdomen Protect from damageProtect from damage Cover with sterile Cover with sterile

saline dressingsaline dressing

Focused History and Focused History and PhysicalPhysical

Head injury, drugs, Head injury, drugs, alcohol mask signs alcohol mask signs and symptomsand symptoms

Hemoperitoneum Hemoperitoneum (solid (solid organ/vascular organ/vascular injuries)injuries)

Adult abdomen Adult abdomen holds 1.5 L with no holds 1.5 L with no distentiondistention

May have normal May have normal abdominal examabdominal exam

Unexplained shockUnexplained shock Shock out of Shock out of

proportion to proportion to known injuriesknown injuries

PeritonitisPeritonitis——Signs and Signs and SymptomsSymptoms

Pain (subjective Pain (subjective symptom from symptom from patient)patient)

Tenderness Tenderness (objective sign with (objective sign with percussion/palpatiopercussion/palpation)n)

Guarding/rigidityGuarding/rigidity

Distention (late Distention (late finding)finding)

AbrasionsAbrasions EcchymosisEcchymosis Visible woundsVisible wounds Mechanism of Mechanism of

injuryinjury Unexplained shockUnexplained shock

Critical FindingsCritical Findings

Rapid assessment and transportRapid assessment and transport Detailed assessmentDetailed assessment Ongoing assessmentOngoing assessment

Noncritical FindingsNoncritical Findings Focused history and physical Focused history and physical

examinationexamination

Other interventions and transport Other interventions and transport considerationsconsiderations

Comprehensive AssessmentComprehensive Assessment Vital signsVital signs InspectionInspection AuscultationAuscultation Percussion Percussion PalpationPalpation

Comprehensive AssessmentComprehensive Assessment

Absence of signs and symptoms does Absence of signs and symptoms does not rule out abdominal injuriesnot rule out abdominal injuries

Remember to examine the backRemember to examine the back Differential diagnosisDifferential diagnosis Continued managementContinued management

Management/Treatment Management/Treatment PlanPlan Surgical intervention only effective Surgical intervention only effective

therapytherapy Rapid evaluationRapid evaluation Shock resuscitationShock resuscitation Rapid packaging and transport to Rapid packaging and transport to

nearest appropriate facilitynearest appropriate facility Facility must have immediate surgical Facility must have immediate surgical

capabilitycapability

Crystalloid fluid en route (per protocol)Crystalloid fluid en route (per protocol)

Indications for Rapid TransportIndications for Rapid Transport Critical findingsCritical findings

Surgical intervention required to control Surgical intervention required to control hemorrhage and/or contaminationhemorrhage and/or contamination

High index of suspicion for abdominal High index of suspicion for abdominal injuryinjury

Unexplained shockUnexplained shock Physical signs of abdominal injuryPhysical signs of abdominal injury

Indications for Rapid TransportIndications for Rapid Transport Hemorrhage Hemorrhage

Survival related to time from injury to Survival related to time from injury to surgical control of hemorrhagesurgical control of hemorrhage Any delay in the field negatively affects Any delay in the field negatively affects

this time periodthis time period

ConclusionConclusion Abdominal trauma is often difficult to Abdominal trauma is often difficult to

evaluate in the prehospital setting. evaluate in the prehospital setting. Therefore the EMT must exercise a high Therefore the EMT must exercise a high degree of suspicion based on the degree of suspicion based on the mechanism of injury and kinematics. mechanism of injury and kinematics.

Death from abdominal injury usually Death from abdominal injury usually results from hemorrhage and delayed results from hemorrhage and delayed surgical repair.surgical repair.

Questions?Questions?