1. ABDOMINAL Injury

2. 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

3. 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

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

5. 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.

6. 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

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

8. Blunt Abdominal Trauma
Flank ecchymosis from internal bleeding

9. 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

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

11. 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

12. 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

13. Impalement Injury

14. 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

15. 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

16. Evisceration
Extrusion of abdominal contents secondary to penetrating abdominal trauma

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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