International Trauma Life Support, 7e Abdominal Trauma 13 Key Lecture Points Cover the anatomy of the abdomen. Stress the importance of the abdomen regarding morbidity and mortality associated with major trauma. Mention that a distended abdomen is a very late sign of hemorrhage within the abdomen. Mention that abdominal trauma with shock is a grim finding and must be rapidly managed. Discuss pelvic fractures and their potential for massive bleeding.

Abdominal Trauma IMAGE: Evisceration. © Pearson

Overview Basic abdominal anatomy Blunt and penetrating injuries How abdominal and chest injuries are related Blunt and penetrating injuries Complications associated with each Treatment for protruding viscera Relationship of exterior and underlying injuries

Overview Possible intra-abdominal injuries History, physical examination, mechanism of injury Abdominal trauma ALS interventions

Abdominal Trauma Difficult to evaluate Attention to scene and mechanism of injury Major cause of preventable death Hemorrhage Anticipate shock: immediate or delayed Requires surgical intervention Infection Gross contamination prevention Important information from scene: Note circumstances surrounding injury. Accurate but rapid assessment of scene will usually tip you off to possibility of abdominal trauma. Major cause of preventable death MUST be recognized and treated immediately. Early recognition and treatment can prevent these deaths. Hemorrhage has immediate consequences; look for early shock in all abdominal-injury patients. Infection, which presents late, may be just as deadly.

Anatomy of the Abdomen True abdomen IMAGE: 13-1 Thoracic abdomen. IMAGE: 13-2 True abdomen. IMAGE: 13-3 Retroperitoneal abdomen. Thoracic abdomen located underneath diaphragm and enclosed by lower ribs, which offer protection. Contains liver, gallbladder, spleen, stomach, and transverse colon. Point out why penetrating injury below 4th intercostal space may have penetrated abdomen. True abdomen contains small intestines and bladder. Intestinal injury can result in infection, peritonitis, and shock. In females, uterus, fallopian tubes, and ovaries are part of pelvic portion of true abdomen. Retroperitoneal abdomen is located behind thoracic and true abdomen. Contains kidneys, ureters, pancreas, posterior duodenum, ascending and descending colon, abdominal aorta, and inferior vena cava. Can conceal massive blood loss with little external signs (except shock). True abdomen

Abdominal Region Injury Thoracic region Life-threatening hemorrhage: liver, spleen True abdomen Infection, peritonitis, shock: intestines Severe hemorrhage with signs Retroperitoneal abdomen Severe hemorrhage hidden: major vessels Injury in retroperitoneal produces different symptoms than in true abdomen. True abdomen can present with distension, tenderness, and tenseness (guarding and rigidity). Retroperitoneal injury can conceal exsanguinating hemorrhage with no early symptoms.

Abdominal Trauma Blunt Penetrating Concern: Most common: mortality 10–30% Penetrating Gunshots: mortality 5–15% Stabbings: mortality 1–2% Concern: Intra-abdominal bleed with hemorrhagic shock Sepsis and/or peritonitis Can also be a combination of blunt and penetrating. Gunshot wounds have higher mortality (up to 15%), due to higher rates of damage to abdominal viscera. Stabbings: approximately one-third require surgery. Causes of mortality: hypovolemic shock, injury to abdominal viscera. Sepsis and/or peritonitis are late causes of death.

Abdominal Trauma Scene Size-up IMAGE: Interior of a crashed car with deployed and deflated air bag hanging from steering wheel and broken glass scattered on seats. Remember to lift and look! Scene Size-up and mechanism can provide valuable clues to possible abdominal injury. (Courtesy of Olivier Le Queinec, Shutterstock.com)

Blunt Abdominal Injury Mechanism Direct compression of abdomen Fracture of solid organs (spleen/liver) Blowout of hollow organs (intestines) Deceleration forces Tearing of organs and blood vessels Accompanying injuries Head, chest, extremity: 70% MVC victims Direct compression of abdomen: fracture of solid organs (spleen/liver) and blowout of hollow organs (intestines).

Blunt Abdominal Injury Liver and spleen injury most common Evidence of injury Often no or minimal external evidence Significant blood volume concealed in regions Seat-belt sign: 25% intra-abdominal Pain or tenderness Often no pain or overshadowed by other pain Multiple lower rib fractures—patients notorious for having severe intra-abdominal injuries without significant abdominal pain. Seat-belt sign is a large abrasion over abdomen and/or upper neck. It is indicative of intra-abdominal injury in approximately 25% of cases.

Penetrating Abdominal Injury Mechanism Direct trauma to organ and vasculature Projectile and fragments Energy transmitted from mass and velocity Caution: Vigorous fluid resuscitation may do more harm PASG may do more harm Penetrating injury often involves uncontrolled hemorrhage. Vigorous fluid administration may only worsen rate of hemorrhage. Good opportunity to review types of shock Reference Shock chapter material and fluid management

Penetrating Abdominal Injury Projectile pathway not always obvious Abdominal injury is chest; chest is abdominal Gluteal area in 50% of significant injuries IMAGE: Penetrating injury to abdomen. Path of penetrating object might not be readily apparent from wound location. Any penetrating wound of chest may penetrate abdomen, and vice versa. Bullet may pass through numerous structures in different body locations. As discussed in Scene Size-up, ballistics information (caliber, velocity, trajectory, range, etc.) contributes to extent of injury and is helpful information. Gluteal area (iliac crests to gluteal folds, including rectum) is associated with up to a 50% incidence of significant intra-abdominal injuries. © Edward T. Dickinson, MD

Abdominal Assessment ITLS Primary Survey: Abdomen Deformities Contusions Abrasions Punctures Evisceration Distension Tenderness IMAGE: Abdominal palpation. Keep high suspicion—rapid visual evaluation and palpation. Auscultation or percussion in field loses critical time, and little useful information is gained. If clothing removed to visualize injury, try to preserve important potential legal evidence by cutting around (rather than through) areas that have signs of possible penetration. © Pearson

Signs and Symptoms Splenic injury Liver injury Severe hemorrhage Referred left posterior shoulder pain Liver injury Referred right posterior shoulder pain Severe hemorrhage Distention, tenderness, tenseness Pelvic tenderness or bony crepitation NOTE: SUPPLEMENTAL INSTRUCTOR NOTES ON REFERRED PAIN. (This information is not part of chapter content.) Mechanisms for referred pain are not completely understood, but several methods/causes of referred pain have been identified. Visceral (organ) and somatic (skin, muscle, connective tissue) sensory nerves transmit pain signals to a spinal nerve ganglion where it is then transmitted to spinal cord and then to brain. Visceral pain is usually dull or poorly localized, and somatic pain is usually sharp and well-localized. Pain stimulation from a sensory nerve (visceral or somatic) that is compressed or damaged at or near its origin can be perceived as originating in additional areas innervated by injured sensory nerve. Pain stimulation from a damaged intervertebral disc can cause compression on nerve root coming from spinal cord at that level and be felt in additional regions served by compressed nerve. In addition, visceral pain stimulation can be felt in areas normally innervated by somatic sensory nerves. Visceral and somatic sensory signals converge in spinal cord. Signals from this level of spinal cord can be perceived as originating from somatic nerve: for example, irritation of diaphragm is signaled by phrenic nerve and can be perceived as pain in area above clavicle (Kehr's sign).

Stabilization Signs usually do not appear early. If present, injury is significant. Assess and treat for shock. NOTE: Timed animation Interventions should follow priorities established by the ITLS Primary Survey. They should proceed in the same order in which assessment occurred: (A) airway, (B) breathing, and (C) circulation. (This only changes to CABC if there is obvious severe uncontrolled external hemorrhage.) The patient should be readied for immediate transport with appropriate SMR. (Penetrating trauma to the abdomen or chest with no signs of neurological deficit should not have SMR because time is extremely critical.) Once en route to an appropriate facility, establish two large-bore IV lines of normal saline. If the patient's blood pressure drops below 90 mmHg systolic with signs of shock, then the IV fluids should be given at a rate to maintain the systolic blood pressure at 80 to 90 mmHg. (See Chapter 8.) It is thought that aggressive fluid resuscitation might dislodge protective clots and/or dilute clotting factors, both of which lead to worsening hemorrhage.

Special Situations Evisceration Do not push viscera back into abdomen Gently cover with moistened gauze Apply nonadherent material to prevent drying IMAGE: 13-1-1 Remove clothing. IMAGE: 13-1-2 Cover wound. IMAGE: 13-1-3 Cover dressing. If intestines are allowed to dry, they may become irreversibly damaged. Flex legs slightly at knees to take pressure off abdominal musculature. © Pearson

Special Situations Impaled object Do not remove Uncontrollable hemorrhage Gently stabilize object Avoid movement IMAGE: A piece of wood shot out of a planer entered this worker's abdomen. He complains of pain, nausea. He is tachycardic at 120 bpm, and he has peripheral pulses. Removal or manipulation may precipitate uncontrollable hemorrhage. Never flex legs with impaled objects—causes additional soft-tissue injuries. © Pearson

Areas of Current Study Destination protocols Serum lactate levels F.A.S.T. exam Deciding which patient should be taken to a local community hospital and which should be taken directly to a trauma center can be a difficult decision, Better tools are needed to distinguish between patients who have injuries that are either not severe or not time critical and will remain stable, and those with a significant mechanism of injury who appear stable initially, and then decompensate later, requiring emergent transfer to a trauma center. Tests performed quickly in the ambulance or on scene that could help predict which apparently stable patient might deteriorate would be very helpful. Current studies using finger-stick serum lactate levels and studies using abdominal ultrasound in the field (F.A.S.T. exam) show some promise. (See Chapter 2 for more about those studies.) F.A.S.T. - Focused Assessment with Sonography for Trauma.

Summary Intra-abdominal injury must be recognized and treated immediately Scene Size-up and detailed history Rapid patient assessment Early shock treatment Minimize delays to maximize survival