Abdominal Injuries

Introduction

• Blunt abdominal trauma is the leading cause

of morbidity and mortality in all ages.

Abdominal Cavity

• Largest cavity in the body

• Extends from the diaphragm to the pelvis

• Assessment should be made quickly and cautiously.

Prevention Strategies

• Reduction of morbidity and mortality

– Safety equipment

– Prehospital education

– Advances in hospital care

– Development of trauma systems

• You are dispatched to the home of an older person who has fallen.

• When you arrive, you find the patient between the bed and a wall.

• He is conscious, alert, and orientated, answering all questions and following all commands.

Anatomy Review

• Anatomic boundaries

– Diaphragm to pelvic brim

• Divided into three sections

– Anterior abdomen

– Flanks

– Posterior abdomen or back

• Peritoneum

– Membrane that covers the abdominal cavity

• The internal abdomen is divided into three regions:

– Peritoneal space

– Retroperitoneal space

– Pelvis

Abdominal Organs

• Three types of organs

– Solid

– Hollow

– Vascular

Physiology Review

• The spleen and liver are the organs most commonly injured during blunt trauma.

• Few signs and symptoms may be present.

• Must have a high index of suspicion.

• The patient is complaining of pain to his right leg.

• You are able to place a backboard under him to facilitate moving him away from the bed.

– With the patient complaining of leg pain, after you have moved him, what do you want to look for?

Mechanism of Injury

• Eight percent of all significant trauma involves the abdomen.

• Unrecognized abdominal trauma is the leading cause of unexplained deaths due to a delay in surgical intervention.

• Two types of abdominal trauma

– Blunt

– Penetrating

Blunt Trauma

• Two thirds of all abdominal injuries

• Most are due to motor vehicle crashes

• Injuries are the result of compression or deceleration forces.

– Crush organs or rupture them

• Three common injury patterns

– Shearing

– Crushing

– Compression

Penetrating Trauma

• Most commonly from low velocity impacts

(i.e., gunshots or stab wounds).

• An open abdominal injury

– Skin is broken.

– Results in laceration of deeper structures

Motor Vehicle Collisions

• Five patterns

– Frontal

– Lateral

– Rear

– Rotational

– Rollover

Motorcycle Falls

• Less structural protection

• Rider protective devices

– Helmet

– Gloves

– Leather pants and/or jacket

– Boots

Falls

• Usually occur during criminal activity, attempted suicide, or intoxication

• Note or observe position or orientation of the body at the moment of impact.

Blast Injuries

• Commonly associated with military conflict

• Seen in mines, chemical plants, and with terrorist activities

• Four different mechanisms

– Primary blast

– Secondary blast

– Tertiary blast

– Miscellaneous blast injuries

Pathophysiology

• Hemorrhage is a major concern in abdominal trauma.

• Hemorrhage can be

– Internal

– External

Injuries to Solid Organs

• Liver

• Kidney

• Spleen (Kehr’s sign)

• Pancreas

• Diaphragm

Injuries to Hollow Organs

• Small/large intestine

• Stomach

• Bladder

Retroperitoneal Injuries

• Grey Turner’s sign

• Cullen’s sign

• Vascular injuries

• Duodenal injuries

• The patient has a lateral rotation of the leg and the leg appears to be shortened.

• You find and palpate a weak pedal pulse.

– What should you suspect? What do you want to look out for?

Assessment

• Look for evidence of hemorrhage.

• Have a high index of suspicion.

• Priorities begin with adequate tissue perfusion.

• Evaluation must be systematic.

• Prioritize injuries.

Scene Size-Up

• Scene safety

• Number of patients

• Need for additional help

Initial Assessment

• Mental status

• Patient’s airway, breathing, and circulatory status

• Prioritizing the patient 

Focused History

and Physical Exam

• Expose the abdomen.

• Inspect for signs of trauma.

– DCAP-BTLS

• Percuss the abdomen.

• Palpate the abdomen.

• In blunt trauma, determine

– The types of vehicles involved

– The speed they were traveling

– Collision patterns

– Use of seatbelts

– Air bag deployment

– The patient’s position in the vehicle

• In penetrating trauma caused by gunshot, determine

– Type of weapon used

– Number of shots

– Distance from victim

• In penetrating trauma caused by stabbing, determine

– Type of knife

– Possible angle of entrance wound

– Number of stab wounds

Detailed Physical Exam

• Should be conducted

en route to hospital

• Assess the same structures as a rapid trauma exam.

– Cullen’s sign

– Grey Turner’s sign

Ongoing Assessment

• Repeat initial exam.

• Retake vital signs.

• Check interventions.

Management

• Open airway with spinal precautions.

– Oxygen via NRB mask

– Two large-bore IVs

– Monitor

• Minimize external hemorrhage.

• Do not delay transport.

• Use of pain medications is somewhat controversial.

Pelvic Fractures

• The majority are a result of blunt trauma

• Suspect multi-system trauma.

• Signs and symptoms

– Pain to pelvis, groin, or hip

– Hematomas or contusions to pelvic region

– Obvious bleeding

– Hypotension without obvious external bleeding

• Types of MOIs in pelvic fractures

– Anterior-posterior compression in head-on collisions

– Lateral compression in side impacts

– Vertical shears in falls from heights

– Saddle injuries from falling on objects

Assessment and Management

• Search for entrance and exit wounds in penetrating trauma.

• Quick transport and treatment of hypotension

• In open-book fractures

– Splint the hips at the level of the superior anterior iliac crests.

– PASG is a controversial treatment.

• The pelvis is a ring, with its sacral, iliac, ischial, and pubic bones held together by ligaments.

• It takes a large amount of force to damage this area.

Summary

• Anatomy review

• Mechanism of injury

• Pathophysiology

• Assessment and management

• Pelvic fractures