abdominal trauma
TRANSCRIPT
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Division 3Trauma Emergencies
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 26Abdominal Trauma
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Abdominal InjuryAbdominal Anatomy and PhysiologyPathophysiology of Abdominal InjuryAssessment of the Abdominal Injury PatientManagement of the Abdominal Injury Patient
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Abdominal Injury
One of body’s largest cavities.Multiple vital organs.Large volumes of blood can be lost before signs and symptoms manifest.Must be alert for signs of transmitted injury:– Deformity, swelling, and ecchymosis
Prevention:– Highway safety
Seatbelt usageProper application
Airbags
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology (1 of 2)
Boundaries– Superior: Diaphragm– Inferior: Pelvis– Posterior: Vertebral column and posterior
and inferior ribs– Lateral: Muscles of the flank– Anterior: Abdominal muscles
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology (2 of 2)
Three Specific Spaces– Peritoneal Space
Organs covered by abdominal (peritoneal) lining
– Retroperitoneal SpaceOrgans posterior to the peritoneal lining
– Pelvic SpaceOrgans contained within pelvis
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Organs by Abdominal Quadrant
Small and Large IntestineLower part of KidneyHalf of Bladder, Female Reproductive Organs
Small and Large IntestineLower part of Kidney
Half of Bladder, Appendix, Female Reproductive
Organs
Stomach,Tail of PancreasTail of LiverSmall and Large IntestineUpper Part of Kidney
Liver, Gallbladder, Stomach (Small Part)
Small and Large IntestineHead of Pancreas
Upper Part of Kidney
Upper
Lower
Right Left
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hollow and Solid Abdominal Organs
Solid– Liver– Spleen– Pancreas– Kidneys– Ovaries
Hollow– Stomach– Small intestine– Large intestine– Gall bladder– Bladder– Uterus
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyMajor Abdominal Structures
Digestive Tract– AKA: Alimentary canal– Structures
StomachSmall IntestineLarge IntestineRectum
Accessory Organs– Liver– Gallbladder– Pancreas
Urinary System– Kidneys– Ureter– Urinary Bladder– Urethra
Immune System– Spleen
Genitals– Ovaries– Fallopian tubes– Uterus– Vagina
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyDigestive Tract
Function– Churn material to be digested– Excrete digestive juices– Absorb nutrients and water
Components– Stomach
Food mixed with HCl and enzymes to form chyme– Small bowel
Food moved through bowel by peristalsisDuodenumJejunumIleum
– Large bowel (Colon)– Rectum– Anus
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyAccessory Organs (1 of 3)
Liver– Located in upper right quadrant– 2.5% of total body weight– Receives 25% of cardiac output and has greatest blood
reserve– Suspended by ligamentum teres
Can lacerate liver in deceleration trauma– Function
Detoxifies bloodRemoves damaged or aged erythrocytesStores glycogen and agents for metabolism
– Liver tissue will grow to normal size following partial removal.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyAccessory Organs (2 of 3)
Gallbladder– Small hollow organ located behind and beneath
liver– Receives bile
Waste product from reprocessing of RBCsUsed to digest fatty foods (emulsification)
Pancreas– Produces endocrine hormones and exocrine
enzymesGlucagonInsulinDigestive enzymes that return the chyme pH to normal and break down proteins
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyAccessory Organs (3 of 3)
Spleen– Part of immune system– Located behind stomach and lateral to kidney in
upper left quadrant– Function
ImmunologyStores large volume of blood
– Most fragile abdominal organ– Commonly injured in blunt trauma affecting the
left flank
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyUrinary System
Components– Kidneys
Collect waste products in blood streamConcentrate products into urineReabsorb water and saltRegulate body osmotic balanceAdrenal glands
Superior and attached to kidneysComponent of endocrine systemRelease epinephrine and norepinephrine
– Ureters– Urinary bladder
Can contain as much as 500 mL of urine– Urethra
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Genitalia– Female sexual organs
Represent an open passage to the interior of the abdominal cavityComponents
OvariesFallopian tubesUterusVagina
– Male sexual organsExternal to the abdomenComponents
TestesPenis
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyPregnant Uterus (1 of 2)
Uterus and contents grow rapidly after conception and until delivery1st Trimester (0–12 weeks)– Well protected
2nd Trimester (12–24 weeks)– Uterus displaces organs upward
3rd Trimester (24 weeks to term)– Fills entire abdominal cavity– Displaces diaphragm upward
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyPregnant Uterus (2 of 2)
Effects on Maternal Physiology– Increases circulatory blood volume by 45%
Greater volume but fewer RBCsResults in relative anemia
– Cardiac output increases by 40%– Heart rate increases by 15 bpm– Compresses the vena cava in 3rd trimester
Reduces venous returnSupine hypotensive syndrome
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyVasculature (1 of 2)
Key Vessels– Abdominal aorta
Blood supply to abdomenLeft of spinal column
– Iliac arteriesBifurcation of aorta at the upper sacral level
– Inferior vena cavaAdjacent to spinal column
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyVasculature (2 of 2)
Portal System– Venous subsystem– Collects venous blood, fluid, and
nutrients absorbed by the bowel– Transports to liver
Detoxification, storage of excess nutrients Adds deficient nutrients
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Arteries
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and PhysiologyPeritoneum
Serous membrane that surrounds the interior of most of the abdominal cavityCovers most of small bowel and some of the abdominal organsSmall amount of fluid between peritoneal layersMesentery– Double fold of peritoneum– Supports and suspends small bowel from posterior
abdominal wall– Omentum
Additional foldInsulates and protects anterior surface of abdomen
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Retroperitoneal Structures
KidneysDuodenumPancreasUrinary BladderPosterior portions of ascending and
descending colonRectumMajor vascular structures
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reflections of the Peritoneum
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal InjuryMechanism of Injury (1 of 3)
Penetrating Trauma– Energy transmitted to surrounding tissue– Projectile cavitation, pitch, and yaw– Results in:
Uncontrolled hemorrhageOrgan damageSpillage of hollow organ contentsIrritation and inflammation of abdominal lining
– Liver most commonly affected organ– Shotgun trauma
Multiple projectiles
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal InjuryMechanism of Injury (2 of 3)
Blunt Trauma– Produces least visible signs of injury– Causes
DecelerationContents damaged by change in velocity
CompressionOrgans trapped between other structures
ShearPart of an organ is able to move while another part is fixedExample: ligamentum teres
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal InjuryMechanism of Injury (3 of 3)
Blast Injuries– Blunt and penetrating MOIs– Irregular shaped shrapnel and debris– Pressure wave
Compresses and relaxes air-filled organsContuses or ruptures organs
– Abdominal injury is secondary concern during blast injury.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (1 of 12)
Injury to the Abdominal Wall– Skin and muscles transmit blunt trauma to internal
structures.Typically only show erythema.Visible swelling and ecchymosis occur over several hours.
– Penetrating trauma may appear minimal externally in comparison to internal trauma.
Muscle may mask the size of the external wound.Evisceration may be present.
– Trauma to thorax, buttocks, flanks, and back may penetrate abdomen.
Lower chest may injure spleen, liver, stomach, or gallbladder.– Diaphragmatic tears:
Herniation of abdominal contents into thorax.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (2 of 12)
Injury to the Hollow Organs– May rupture with compression from blunt forces– May tear due to penetrating trauma– Spillage of contents into:
Retroperitoneal spacePeritoneal spacePelvic space
– Intestines have a large amount of bacteria:Leakage can result in sepsis
– Manifestations of Blood LossHematochezia: blood in stoolHematemesis: blood in emesisHematuria: blood in the urine
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (3 of 12)
Injury to the Solid Organs– Dense and less strongly held together– Prone to contusion
BleedingFracture (rupture)
– Unrestricted hemorrhage if organ capsule is ruptured
– Specific OrgansSpleen: pain referred to left shoulderPancreas: pain radiates to backKidneys: pain radiates from flank to groin and hematuriaLiver: pain referred to the right shoulder
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (4 of 12)
Injury to the Vascular Structures– Abdominal aorta and vena cava:
Prone to direct blunt or penetrating traumaMay be injured in deceleration injuries
– Blood accumulates beneath diaphragm.Irritation of muscular structuresProduces referred pain in the shoulder regionGreater volume of blood can be lostPresence of blood in abdomen stimulates vagus nerve resulting in slowing of heart rate
– Blood can isolate in any of the abdominal spaces.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (5 of 12)
Injury to the Mesentery and Bowel– Provides bowel with circulation, innervation, and
attachment– Disrupts blood vessels supplying the bowel
Leads to ischemia, necrosis, or rupture
– Blood loss minimalPeritoneal layers contain hemorrhage
– Tear of mesentery may rupture bowel– Penetrating trauma to the lateral abdomen likely
to injure large bowel
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (6 of 12)
Injury to the Peritoneum– Delicate and sensitive lining of anterior abdomen– Peritonitis
Inflammation of the peritoneum due to:Bacterial irritation
Due to torn bowel or open woundChemical irritation
Caustic nature of digestive enzymesUrine initiates inflammatory response
Blood does not induce peritonitisProgression
Slight tenderness at location of injuryRebound tendernessGuardingRigid, board-like feel
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (7 of 12)
Injury to the Pelvis– Serious skeletal injury
Life-threatening hemorrhagePotential injury to pelvic organs
UretersBladderUrethraFemale genitaliaProstateRectumAnus
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (8 of 12)
Injury During Pregnancy– Trauma is the number one killer of pregnant
females.Penetrating abdominal trauma accounts for 36% of maternal mortality.
GSW account for 40–70% of penetrating trauma.Blunt trauma due to improperly worn seatbelts.
Auto collisions are leading cause of mortality.
– Changing dimensions of uterus:Protects abdominal organs.Endangers uterus and fetus.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (9 of 12)
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (10 of 12)
Injury During Pregnancy– Maternal Changes
Increasing size and weight of uterusCompresses inferior vena cavaReduces venous return to heart
Increasing maternal blood volumeProtects mother from hypovolemia30–35% of blood loss necessary before signs of shock
Uterus is thick and muscularDistributes forces of trauma uniformly to fetus
Reduces chances for injury
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (11 of 12)
Injury During Pregnancy– Risk of uterine and fetal injury increases with the
length of gestation.Greatest risk during 3rd trimester
– Penetrating trauma may cause fetal and maternal blood mixing.
– Blunt trauma complications:Uterine ruptureAbruptio placentaePremature rupture of amniotic sac
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury (12 of 12)
Injury to Pediatric Patients– Children have poorly developed abdominal
musculature and smaller diameter– Rib cage more cartilaginous
Transmits injury to organs beneath easier– Increased incidence of injury to
LiverKidneySpleen
– ShockCompensate well for blood lossMay not show signs and symptoms until 50% of blood is lost
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (1 of 6)
Scene Size-up– Must evaluate MOI to assess seriousness of
injury– Identify strength and direction of forces
Velocity of impactFocus observations and palpation on that siteDevelop a mental list of possible organs involved
– If auto crashDetermine if seatbelts used properlyInterior signs of impact
Steering wheel and dashboard deformity
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (2 of 6)
Scene Size-up– Auto Crash Injury Patterns
Frontal impactCompress abdomenLiver, spleen, and rupture of hollow organs
Right impactLiver, ascending colon, and pelvis
Left impactSpleen, descending colon, and pelvis
Children and pedestriansAbdominal injuries common
– Gunshot WoundsType and caliber of weapon Check whether assailant still on scene
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (3 of 6)
Initial Assessment– LOC– Drug or alcohol use– Evaluate ABCs and immediate threats
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (4 of 6)
Rapid Trauma Assessment– Rapid and full trauma assessment.– Closely examine regions with a high index of
suspicion.– Expose and examine for DCAP-BTLS.
If suspected pelvic injury, DO NOT test pelvis.Palpate entire abdomen.Evaluate for entrance and exit wounds.
– OPQRST AssessmentCharacteristics of pain
Tenderness versus rebound tenderness
– SAMPLE History– Vital Assessment
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (5 of 6)
Considerations with Pregnant Patients– Be observant for
Signs of shockPRETREAT: signs may not develop until 30% of blood volume lostBody begins shunting blood from GI/GU to primary organs
Supine hypotensive syndromePremature contractionsVaginal hemorrhage
Uterine rupture versus abruptio placentaeUterus development
Abnormal asymmetry
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal Injury Patient (6 of 6)
Ongoing Assessment– Trend vital signs
Every 5 minutes for critical patients– Evaluate for
Progressive peritonitisProgressive hemorrhage
BP and capillary refillPulse rate and pulse oximetryMental statusSkin conditionIneffective aggressive fluid resuscitation
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal Injury Patient (1 of 2)
General Management– Position patient
Position of comfort unless spinal injuryFlex knees or left lateral recumbent
– General shock care– PASG application– Specific injury care
Impaled objects or eviscerations
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal Injury Patient (2 of 2)
Fluid Resuscitation– Large-bore IV with isotonic solution
Consider 2 bolus if pulse does not slow– Large-bore IV lock for use if patient’s BP
drops below 80 mmHg– Fluid challenge 250 mL or 20 mL/kg
Limit to 3 L– Titrate to SBP of 80 mmHg
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Evisceration Care
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal Injury Patient – PASG
Contraindications– Concurrent
penetrating chest trauma
– Abdomen inflation contraindicated in pregnancy
Inflate legs only
Indications– Evisceration
If SBP <60 mmHg
– Intra-abdominal bleeding
– Shock
Incremental inflation titrated to BP and Pulse
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal Injury Patient
Management of the Pregnant Patient– Positioning:
Left lateral recumbent.If on backboard tilt backboard.
Facilitates venous return
– Oxygenation:High-flow O2.
Consider PPV by BVM if hypoxia ensues.
– Maintain high index of suspicion for intra-abdominal bleeding.
Consider IV and PASG.
Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Abdominal InjuryAbdominal Anatomy and PhysiologyPathophysiology of Abdominal InjuryAssessment of the Abdominal Injury PatientManagement of the Abdominal Injury Patient