ABDOMINAL Injury

Abdominal Trauma The abdomen is the “Black Box” I.e., it is impossible to know what specific injuries have occurred at initial evaluation The key to saving lives in abdominal trauma is NOT to make an accurate diagnosis, but rather to recognize that there is an abdominal injury

Examples of Abdominal Injuries Blunt Trauma Aortic rupture Splenic rupture Liver rupture or laceration Diaphragmatic tear Pelvic fracture Intestinal tear Bladder rupture Penetrating Trauma Laceration of blood vessels Splenic rupture Liver rupture or laceration Kidney laceration Intestinal lacerations Bladder rupture

Causes of Abdominal Injuries BLUNT TRAUMA Motor vehicle accidents Auto vs. pedestrian Falls Blast injuries PENETRATING TRAUMA Gunshot wounds Stab wounds Shrapnel wounds Impalements

Types of Injuries Blunt and penetrating abdominal injuries may be associated with extensive damage to the viscera resulting in massive blood loss. Blunt or penetrating abdominal injuries are related to the: Type of force applied Tissue density of structure injured (e.g., fluid-filled, gas-filled, solid, or encapsulated) The liver and spleen are the most commonly injured organs from blunt trauma. The organs of the abdomen are vulnerable to penetrating injury not only through the anterior abdominal wall, but through the back, flank area and lower chest." The liver, small bowel and stomach are the most commonly injured organs from penetrating trauma.

Signs and Symptoms of Abdominal Injuries Blunt Trauma Significant mechanism Abdominal pain Distension Discoloration of abdomen or flank Unexplained shock Penetrating trauma Visible truncal injury including chest or abdomen Abdominal pain Bleeding Impaled object Evisceration Shock

Diagnostic Procedures Diagnostic Peritoneal Ravage (DPL) Ultrasound CT Scan Laparoscopy

Blunt Abdominal Trauma Flank ecchymosis from internal bleeding

Blunt Abdominal Trauma Compressive or shearing forces may deform and rupture abdominal organs Bruising across the lower abdomen is characteristic of a seat belt injury Visible signs may not reflect severity of underlying injury The Seat Belt Sign

Penetrating Abdominal Trauma Visible wounds may not reflect severity of underlying injury Significant internal bleeding likely Bowel injury likely Patient may be in shock

Evaluation and Examination Visually note wounds and abrasions Palpate abdomen for localized vs. diffuse tenderness Consider possible internal injuries Diffuse, severe tenderness is a sign of internal bleeding

Don’t forget the back Turn the casualty over when you can do so safely Visually inspect back Palpate ribs, spine, sacrum for tenderness and irregularities Dress the wound with an occlusive dressing

Impalement Injury

Impalement Injuries DO NOT REMOVE OBJECT OR EXERT ANY FORCE UPON IT! Severe bleeding may occur causing shock Check pulses distal to impaled object Immobilize the object Apply bulky support bandages to hold in place

Impalement Injuries Make a box shape large enough to surround the object and dressings Cut V notches into box top Place box over object and dressings and tape in place Tie cravats or Wraps around torso for stability, using V notches in box to ensure stability

Evisceration Extrusion of abdominal contents secondary to penetrating abdominal trauma

Management of Evisceration Injuries Use sterile side of dressing to place protruding organs near the wound (NOT into wound) Cover organs and wound completely with sterile or clean moist dressing DO NOT APPLY PRESSURE TO WOUND or expose internal parts Tie dressing tails loosely around wound Prepare evacuation to surgical assets

Hepatic Injuries Because of its size and location, the liver is frequently injured when force is applied to the abdomen. The friability of liver tissue, the extensive blood supply, and the blood storage capacity cause hepatic injury to result in profuse hemorrhage. These types of injuries require surgical control of bleeding. SIGNS AND SYMPTOMS • Upper right quadrant pain • Abdominal wall muscle rigidity, spasm, or involuntary guarding • Rebound tenderness • Hypoactive or absent bowel sounds • Signs of hemorrhage and/or hypovolemic shock

Splenic Injuries Injury to the spleen is usually associated with blunt trauma, but may also be associated with penetrating trauma. Fractures of the left 10th to 12th ribs are associated with underlying damage to the spleen. The most serious splenic injury is a severely fractured spleen or vascular tear, producing splenic ischemia and massive blood loss. Nonoperative management of the patient with an isolated splenic injury mandates that the patient be hemdynamically stable This may involve bed rest and possibly blood transfusions. SIGNS AND SYMPTOMS Signs of hemorrhage or hypovolemic shock Pain in the left shoulder (Kehr's sign) Tenderness in the upper left quadrant Abdominal wall muscle rigidity, spasm, or involuntary guarding

Hollow Organ Injuries Forces causing trauma to hollow organs may result in either blunt or penetrating injuries. The small bowel is the hollow organ most frequently injured. Deceleration may lead to shearing, which causes avulsion or tearing of the small bowel. Seat belts causing compression have resulted in rupture of the small bowel or colon. SIGNS AND SYMPTOMS Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntary guarding, rebound tenderness, and/or pain Evisceration of the small bowel or stomach Diagnostic Peritoneal Lavage (DPL) may show presence of bile, feces, or food fibers

Renal Injuries The most common injury to the kidney is a blunt contusion, Suspect renal injury if there are fractures of the posterior ribs or lumbar vertebrae. Renal parenchyma can be damaged by shearing and compression forces causing lacerations or contusion. SIGNS AND SYMPTOMS Ecchymosis over the flank Flank or abdominal tenderness elicited during palpation Gross or microscopic hematuria—the absence of hematuria does not rule out renal injury

Bladder and Urethral Injuries The majority of bladder injuries are blunt. If a distended bladder ruptures are perforated, urine is likely to extravasate into the abdomen. Most ruptures of the bladder occur in association with pelvic fractures. Urethral trauma is more common in males than females because the male urethra is longer and less protected. SIGNS AND SYMPTOMS Suprapubic pain Urge, but inability to urinate Hematuria (may be microscopic) Blood at the urethral meatus Blood in scrotum Rebound tenderness