1. Abdominal Trauma Kate Jessop RN, BSN Valley Hospital Medical Center Emergency Department

2. Objectives • List the major organs of the abdominal cavity and relate them to their anatomical location. • Correlate mechanism of injury with injuries to the abdominal organs. • List three classic signs of abdominal injury. • Identify the diagnostic modalities for abdominal injuries.

3. Review of Anatomical Structures http://movies-sawyerneilcaldwell.blogspot.com/2011/03/abdomen-organs-diagram.html

4. Hollow Organ Injuries • Esophagus, stomach, small bowel, colon (large bowel), urethra and bladder. • Blunt hollow viscous injuries occur in less than 1% of trauma patients. • Small bowel most common hollow organ injured in trauma. • Ecchymosis present in lower abdomen should alert provider to possible intestinal injury. http://jama.jamanetwork.com/data/journals/jama/23310/s_jrc25002f1.png

5. Hollow Organ Injuries: Mechanisms of Injury • Seat belts cause compression, which can result in rupture of small bowel or colon. • Deceleration injuries may lead to shearing, tearing or avulsion of the small bowel. • Majority of hollow organ injury is related to penetrating trauma.

6. Gastric Injuries • Signs and Symptoms • Peritoneal irritation • Patient guarding abdomen, pain with palpation, general sense of abdominal pain • Evisceration of stomach • Stomach and/or other abdominal organs outside of the peritoneal cavity, but still attached by muscle attachments or other organs. • Gross blood in gastric aspirate (after orogastric or nasogastric tube is in place) • This is a nonspecific sign! • Signs and symptoms of gastric injuries are related to chemical irritation of nearby tissues due to leaking of highly acidic gastric contents.

7. Gastric injuries • Gastric tear http://www.ispub.com/journal/the-internet-journal-of-gastroenterology/volume-7-number-2/isolated-gastric-tear-due-to-blunt-abdominal-trauma.html

8. Esophageal Injuries • Signs and symptoms • Pain in chest, shoulder and neck • Subcutaneous emphysema • Crackling sensation felt when palpating patient’s skin • Peritoneal irritation • Patient guarding abdomen, pain with palpation, general sense of abdominal pain • Gross blood in gastric aspirate (after orogastric or nasogastric tube is in place) • This is a nonspecific sign!

9. Large and Small Bowel Injuries • Signs and Symptoms • Peritoneal irritation • Abdominal muscle rigidity and/or pain • Spasm of abdominal muscle • Rebound tenderness • Evisceration of abdominal organs • Hypovolemic shock • Gross blood from rectum

10. Large and Small Bowel Injuries • Perforated intestines secondary to trauma http://www.openabdomen.org/diseases/trauma.cfm

11. Large and Small Bowel Injuries • Rupture and partial evisceration of bowel http://atlas-emergency-medicine.org.ua/ch.7.htm

12. Large and Small Bowel Injuries • Perforated small intestine leaking bowel contents http://www.ispub.com/journal/the-internet-journal-of-gynecology-and-obstetrics/volume-16-number-3/severe-intraabdominal-trauma-in-illegal-abortion-a-case-report.html

13. Bladder and Urethral Injuries • More common in males due to longer urethra • Most commonly due to blunt force trauma • Associated with pelvic fractures • Signs and symptoms • Suprapubic pain • Urge to urinate but inability to • Hematuria • Urinanalysis will reveal microscopic blood in urine • Blood at the urethral meatus • Blood in scrotum

14. Bladder and Urethral Injuries • Traumatic tear in the bladder http://www.ispub.com/journal/the-internet-journal-of-gynecology-and-obstetrics/volume-16-number-3/severe-intraabdominal-trauma

15. Solid Organ Injury • Liver, Spleen and Kidney • Highly vascular and prone to profuse bleeding • Injuries that result in shock, or continuing bleeding are indication for urgent surgery • Injuries with no hemodynamic abnormalities can be treated non-operatively

16. Hepatic Injuries • Hepatic injury should be stabilized hemodynamically and then sent straight to surgery if warranted • Severity of injury ranges controlled hematoma to profuse hemorrhage • Subcapsular hematomas • Parenchymal lacerations • Vascular injuries of hepatic veins • Hepatic avulsion

17. Hepatic Injuries • Subcapsular hematoma http://openi.nlm.nih.gov/detailedresult.php?img=3088753_crg0005-0223-f01&query=the&fields=all&favor=none&it=none&sub=none&uniq=0&sp=none&req=4&simCollection=3247745_sensors-10-06017f3&npos=38&prt=3

18. Hepatic Injuries • Liver laceration http://www.trauma.org/index.php/main/image/154/

19. Hepatic Injuries • Signs and symptoms • Right upper quadrant pain • Rigidity, spasm, or involuntary guarding • Rebound tenderness • Hypoactive or absent bowel sounds • Signs of hypovolemic shock

20. Splenic Injuries • Fractures of 10th to 12th ribs associated with splenic trauma. • Injuries vary in severity (from least to worst) • Laceration of capsule • Nonexpanding hematoma • Ruptured subcapsular hematomas • Parachymal laceration • Severely fractured spleen or vascular tear • Splenic ischemia and masive blood less

21. Splenic Injuries • Laceration of the spleen http://www.trauma.org/index.php/main/image/156/

22. Splenic Injuries • Signs and symptoms • Left upper quadrant tenderness • Pain in left shoulder while lying flat (Kehr’s sign) • Signs of hypovolemia or hemorrhage • Abdominal rigidity, spasm or guarding

23. Splenic Injuries • Splenic hematoma with laceration http://www.learningradiology.com/archives03/COW%20068-Splenic%20laceration/spleniclaccorrect.htm

24. Renal Injuries • Posterior rib or lumbar vertebrae fractures should raise concern for renal injury. • Signs and symptoms • Hematuria • Can be gross or microscopic • Approximately 95% of significant renal injuries have some degree of hematuria • Flank or abdominal tenderness upon palpation • Ecchymosis on flank • Grey Turner’s sign • Normally does not develop for 6-12 hours after injury

25. Renal Injuries http://www.surgical-tutor.org.uk/default-home.htm?core/trauma/renal_trauma.htm~right http://www.trauma.org/index.php/main/image/172/print/print

26. Renal Injuries • Grey Turner’s Sign http://clancyclark.blogspot.com/2012/06/grey-turner-s-sign.html

27. Pelvic Trauma • Pelvic fractures can lacerate major vessels, causing fatal hemorrhaging into the pelvic cavity • Four liters of blood can be held in the pelvic cavity—average human body contains 4-7 liters • Stabilize with a sheet or belt wrapped circumferentially around hips at level of greater trochanter

28. Abdominal Trauma-Assessment • Airway, Breathing, Circulation • Look (Inspection) • Swelling, bruising, lacerations or abrasions • Listen (Auscultate) • Bowel sounds: are there any and where are they? • Feel (Palpate) • Subcutaneous emphysema; soft, rigid or distended abdomen; palpable masses; stable pelvis; flank tenderness; anal sphincter-presence or absence of tone

29. Abdominal Trauma-Nursing Interventions • Establish two large bore intravenous catheters • Intravenous fluids as ordered • Start with 1-2 liters of isotonic crystalloid solution, continue as needed or ordered • Blood products as ordered • In active hemorrhage O negative blood is a universal donor • Antibiotics as ordered • Early administration helps combat infection • Pain medication and antibiotics as ordered • Reassess frequently for pain • Is there a intense increase in pain? Did the location of pain change? Reassess patient’s status, vital signs, physical assessment—make sure your patient is not deteriorating.

30. Abdominal Trauma-Nursing Interventions • Gastric tube • Decompresses the stomach and prevents aspiration • Prevents bradycardia secondary to vagal stimulation • Minimizes gastric leakage into abdominal cavity • May assist in identifying possible organ injury (test aspirate for occult blood) • Urinary catheter • Minimizes urine leakage into the surrounding tissues • Contraindications: • Gross blood at urethral meatus indicates possible urethral trauma • Suprapubic catheterization should be considered at this point

31. Abdominal Trauma-Nursing Interventions • Cover wounds with sterile dressing • Both surgical and non-surgical wounds • Evisceration of abdominal contents requires a sterile dressing soaked in an isotonic crystalloid solution (such as 0.9% sodium chloride) • Do not push abdominal contents back into the torso • Stabilize impaled objects • Do NOT remove, stabilize instead • Use gauze, tape, any supplies available…if it works, use it! • Be careful not to move object during stabilization, remember movement of object means damage of underlying tissue • Stabilization should be at least a two person job • One person to hold object in place, another to stabilize object with materials

32. Stabilizing Impaled Objects http://www.medskills.eu/index.php/dropbox/en/Body/level=3/topic=8/null/1434/ http://www.moondragon.org/health/disorders/specificwoundtreatment.html

33. Stabilizing Impaled Objects http://members.tripod.com/cynthia_gray/emsphotos/injuries.html http://www.medskills.eu/index.php/wiki/en/body/medical%20fundamentals/critical%20trauma%20patients/abdominal%20trauma/

34. Diagnosing Trauma • Classic signs and symptoms • Pain, guarding, rigid abdomen • Chemical peritonities: pancreatic injury • Kehr’s sign: pain that radiates to shoulder during inspiration indicates splenic injury • Physical exam and interventions • Vital signs • Inspection • Auscultation • Percussion • Palpation • Gastric tube (orogastric or nasogastric) • Urinary Catheter

35. Diagnosing Trauma • Diagnostic exams continued • Diagnostic Peritoneal lavage • Presence of bile, feces or food fibers indicate bowel leakage • False negatives are a possibility • Decompress bladder and stomach via catheter and gastric tube to prevent accidental puncture • If initial aspiration of peritoneal fluid includes 10cc or more of blood equals an automatic positive—assume abdominal trauma present • Inexpensive, highly useful for intra-abdominal hemorrhage or with a hemodynamically unstable patient • Can be used to replace computerized tomography or focused assessment sonography for trauma

36. Diagnosing Trauma • Diagnostic exams continued • Focused Assessment Sonography for Trauma • Rapid, accurate, inexpensive, noninvasive and can be repeated multiple times • Can detect as little as 100 cc of fluid • Evaluates four areas for free fluid: hepatorenal fossa, splenoreal fossa, pericardial sac, and pelvis • Radiographic study • Used when computerized tomography is unavailable • Useful to diagnose diaphragmatic rupture, free air indicating disruption of the gastrointestinal tract, and foreign bodies • Computerized tomography • Noninvasive and highly accurate but expensive • Patient needs to be hemodynamically stable

37. Diagnosing Trauma • Laboratory Tests • Hematocrit and Hemoglobin levels • Is a blood transfusion needed? Have levels changed from patient’s initial baseline values? • Serum lactate • Lactic acid is produced during sepsis (systemic infection). • Coagulation studies • Is the patient prone to hemorrhage due to coagulation abnormalities? • Is the patient on blood thinners? • Analysis of urine, stool or gastric contents for blood • Possible injury of related organ

38. Bibliography • TNCC: trauma nursing core course (5th ed.). (2000). Park Ridge, Ill.: Emergency Nurses Association.