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Paramedic Care:

Principles & Practice


Volume 5
Trauma Emergencies

Abdominal Trauma

Topics
Introduction to Abdominal Injury
Abdominal Anatomy and Physiology
Pathophysiology of Abdominal Injury
Assessment of the Abdominal Injury Patient
Management of the Abdominal Injury Patient

Introduction to Abdominal
Injury

Introduction to Abdominal
Injury
One of bodys largest cavities
Multiple vital organs
Large volumes of blood can be lost before
signs and symptoms manifest
Must be alert for signs of transmitted injury:
Deformity, swelling, and ecchymosis

Prevention:
Highway safety

Abdominal Anatomy
and Physiology

Abdominal Anatomy
and Physiology
Boundaries
Superior: Diaphragm
Inferior: Pelvis
Posterior: Vertebral column and posterior and
inferior ribs
Lateral: Muscles of the flank
Anterior: Abdominal muscles

Abdominal Anatomy
and Physiology
Three Specific Spaces
Peritoneal Space
Organs covered by abdominal (peritoneal) lining

Retroperitoneal Space
Organs posterior to the peritoneal lining

Pelvic Space
Organs contained within the pelvis

Abdominal Organs by
Quadrant

Click here to view an animation on abdominal organs.

Hollow and Solid


Abdominal Organs
Solid

Liver
Spleen
Pancreas
Kidneys
Ovaries

Hollow

Stomach
Small intestine
Large intestine
Gall bladder
Bladder
Uterus

Major Abdominal Structures


Digestive Tract
AKA: Alimentary canal
Structures
Stomach
Small Intestine
Large Intestine
Rectum

Accessory Organs
Liver
Gallbladder
Pancreas

Urinary System

Kidneys
Ureter
Urinary Bladder
Urethra

Immune System
Spleen

Genitals

Ovaries
Fallopian tubes
Uterus
Vagina

Digestive Tract
Function
Churn material to be digested
Excrete digestive juices
Absorb nutrients and water

Digestive Tract
Components
Stomach
Food mixed with HCl and enzymes to form chyme

Small bowel
Duodenum
Jejunum
Ileum

Large bowel (Colon)


Rectum
Anus

Accessory Organs
Liver
Located in upper right quadrant
Receives 25% of cardiac output
Greatest blood reserve

Suspended by ligamentum teres


Can lacerate liver in deceleration trauma

Function
Detoxifies blood
Removes damaged or aged erythrocytes
Stores glycogen and agents for metabolism

Liver tissue will grow to normal size following


partial removal

Accessory Organs
Gallbladder
Small hollow organ located behind and beneath
liver
Receives bile
Waste product from reprocessing of red blood cells
Used to digest fatty foods (emulsification)

Accessory Organs
Pancreas
Produces endocrine hormones and exocrine
enzymes
Glucagon
Insulin
Digestive enzymes that return the chyme pH to normal
and break down proteins

Accessory Organs
Spleen
Part of immune system
Located behind stomach and lateral to kidney in
upper left quadrant
Function
Immunology
Stores large volume of blood

Most fragile abdominal organ


Commonly injured in blunt trauma affecting the left
flank

Urinary System
Components
Kidneys
Collect waste products in blood stream
Concentrate products into urine
Reabsorb water and salt
Regulate body osmotic balance

Adrenal glands
Superior and attached to kidneys
Component of endocrine system
Release epinephrine and norepinephrine

Urinary System
Ureters
Urinary
bladder
Can contain
as much as
500 mL of
urine

Urethra

Genitalia
Female sexual
organs
Represent an open
passage to the
interior of the
abdominal cavity
Components
Ovaries
Fallopian tubes
Uterus
Vagina

Genetalia
Male sexual
organs
External to the
abdomen
Components
Testes
Penis

Pregnant Uterus
Uterus and
contents grow
rapidly after
conception and
until delivery

Pregnant Uterus
Affects on Maternal Physiology
Increases circulatory blood volume by 45%
Greater volume but fewer red blood cells
Results in relative anemia

Cardiac output increases by 40%


Heart rate increases by 15 bpm
Compresses the vena cava in 3rd trimester
Supine hypotensive syndrome

Vasculature
Key Vessels
Abdominal aorta
Blood supply to abdomen
Left of spinal column

Iliac arteries
Bifurcation of aorta at the upper sacral level

Inferior vena cava


Adjacent to spinal column

Vasculature
Portal System
Venous subsystem
Collects venous blood, fluid, and nutrients
absorbed by the bowel
Transports to liver
Detoxification, storage of excess nutrients
Adds deficient nutrients

Abdominal Vasculature

Click here to view an animation on abdominal vasculature.

Peritoneum
Serous membrane that surrounds the interior
of most of the abdominal cavity
Covers most of small bowel and some of the
abdominal organs
Small amount of fluid between peritoneal
layers
Mesentery
Omentum
Additional fold
Insulates and protects anterior surface of abdomen

Retroperitoneal Structures
Kidneys
Duodenum
Pancreas
Urinary Bladder
Portion of Colon
Rectum
Major vascular
structures

Pathophysiology of
Abdominal Injury

Pathophysiology of
Abdominal Injury
Mechanism of Injury
Penetrating Trauma
Energy transmitted to surrounding tissue
Results in:
Uncontrolled hemorrhage
Organ damage
Spillage of hollow organ contents
Irritation and inflammation of abdominal lining

Liver most commonly affected organ


Shotgun trauma
Multiple projectiles

Mechanism of Injury
Blunt Trauma
Produces least visible signs of injury
Causes
Deceleration
Contents damaged by change in velocity

Compression
Organs trapped between other structures

Shear
Part of an organ is able to move while another part is fixed
Example: ligamentum teres

Mechanism of Injury
Blast Injuries
Blunt and penetrating MOIs
Irregular shaped shrapnel and debris
Pressure wave
Compresses and relaxes air-filled organs
Contuses or ruptures organs

Abdominal injury is secondary concern during


blast injury

Pathophysiology of
Abdominal Injury

Pathophysiology of
Abdominal Injury
Injury to the Abdominal Wall
Skin and muscles transmit blunt trauma to
internal structures
Erythema
Swelling and ecchymosis occur over several hours

Penetrating trauma may appear minimal


externally in comparison to internal trauma
Muscle may mask the size of the external wound
Evisceration may be present

Pathophysiology of
Abdominal Injury
Injury to the Abdominal Wall
Trauma to thorax, buttocks, flanks, and back may
penetrate abdomen Lower chest may injure
spleen, liver, stomach, or gallbladder
Diaphragmatic tears:
Herniation of abdominal contents into thorax

Pathophysiology of
Abdominal Injury
Injury to the Hollow Organs
May rupture with compression from blunt forces
May tear due to penetrating trauma
Spillage of contents
Retroperitoneal space
Peritoneal space
Pelvic space

Intestines have a large amount of bacteria:


Leakage can result in sepsis

Manifestations of Blood Loss


Hematochezia, hematemesis, hematuria

Pathophysiology of
Abdominal Injury
Injury to the Solid
Organs
Dense and less
strongly held
together
Prone to contusion
Bleeding
Fracture (rupture)

Unrestricted
hemorrhage if organ
capsule is ruptured

Pathophysiology of
Abdominal Injury
Specific Organs
Spleen
Pain referred to left
shoulder

Pancreas
Pain radiates to back

Kidneys
Pain radiates from flank
to groin and hematuria

Liver
Ligamentum Teres

Pathophysiology of
Abdominal Injury
Injury to the Vascular Structures
Abdominal aorta and vena cava
Prone to direct blunt or penetrating trauma
May be injured in deceleration injuries

Blood accumulates beneath diaphragm


Irritation of muscular structures
Produces referred pain in the shoulder region
Presence of blood in abdomen stimulates vagus nerve
resulting in slowing of heart rate

Blood can isolate in any of the abdominal spaces

Pathophysiology of
Abdominal Injury
Injury to the Mesentery and Bowel
Provides bowel with circulation, innervation, and
attachment
Disrupts blood vessels supplying the bowel
Leads to ischemia, necrosis, or rupture

Blood loss minimal


Peritoneal layers contain hemorrhage

Tear of mesentery may rupture bowel


Penetrating trauma to the lateral abdomen likely
to injure large bowel

Pathophysiology of
Abdominal Injury
Injury to the Peritoneum
Delicate and sensitive lining of anterior abdomen
Peritonitis
Inflammation of the peritoneum due to:
Bacterial irritation
Due to torn bowel or open wound

Chemical irritation
Caustic nature of digestive enzymes
Urine initiates inflammatory response

Blood does not induce peritonitis

Symptoms

Pathophysiology of
Abdominal Injury
Injury to the Pelvis
Serious skeletal injury
Life-threatening hemorrhage
Potential injury to pelvic organs
Ureters
Bladder
Urethra
Female Genitalia
Prostate
Rectum
Anus

Pathophysiology of
Abdominal Injury
Injury During Pregnancy
Trauma is the number one killer of pregnant
females
Penetrating abdominal trauma accounts for 36% of
maternal mortality
Gunshot wounds account for 4070% of penetrating trauma

Blunt trauma due to improperly worn seatbelts


Auto collisions are leading cause of mortality

Pathophysiology of
Abdominal Injury
Changing
dimensions of
uterus:
Protects
abdominal
organs
Endangers
uterus and
fetus

Pathophysiology of
Abdominal Injury
Injury During Pregnancy
Maternal Changes
Increasing size and weight of uterus
Increasing maternal blood volume
Protects mother from hypovolemia
3035% of blood loss necessary before signs of shock

Uterus is thick and muscular


Distributes forces of trauma uniformly to fetus
Reduces chances for injury

Pathophysiology of
Abdominal Injury
Injury During Pregnancy
Risk of uterine and fetal injury increases with the
length of gestation
Penetrating trauma may cause fetal and maternal
blood mixing
Blunt trauma complications
Uterine rupture
Abruptio placentae
Premature rupture of amniotic sac

Pathophysiology of
Abdominal Injury
Injury to Pediatric Patients
Children have poorly developed abdominal
musculature and smaller diameter
Rib cage more cartilaginous
Transmits injury to organs beneath easier

Increased incidence of injury to


Liver
Kidney
Spleen

Shock
Compensate well for blood loss
May not show signs and symptoms until 50% of blood is
lost

Assessment of the Abdominal


Injury Patient

Assessment of the Abdominal


Injury Patient
Scene Size-up
Must evaluate MOI to
assess seriousness of
injury
Identify strength and
direction of forces
Develop a mental list of
possible organs involved

If auto crash
Determine if seatbelts
used properly
Interior signs of impact

Mark C. Ide

Assessment of the Abdominal


Injury Patient
Scene Size-up
Auto Crash Injury Patterns
Frontal impact
Compress abdomen
Liver, spleen, and rupture of hollow organs

Right impact
Liver, ascending colon, and pelvis

Left impact
Spleen, descending colon and pelvis

Children and pedestrians


Abdominal injuries common

Gunshot Wounds
Type and caliber of weapon
Check whether assailant still on scene

Assessment of the Abdominal


Injury Patient
Initial Assessment
Level of consciousness
Drug or alcohol use
May mask injury

As you evaluate airway, breathing, and circulation,


be observant for any associated signs and
symptoms of hypovolemia.

Assessment of the Abdominal


Injury Patient
Rapid Trauma Assessment
Rapid and Full Trauma Assessment
Closely examine regions with a high index of
suspicion
Expose and Examine for DCAP-BTLS
If suspected pelvic injury, DO NOT test pelvis
Palpate entire abdomen
Evaluate for entrance and exit wounds

OPQRST Assessment
Characteristics of pain
Tenderness versus rebound tenderness

SAMPLE History
Vital Assessment

Assessment of the Abdominal


Injury Patient
Considerations with Pregnant Patients
Be observant for
Signs of shock
Signs may not develop until 30% of blood volume lost
Body begins shunting blood from GI/GU to primary organs

Supine hypotensive syndrome


Premature contractions
Vaginal hemorrhage
Uterine rupture versus abruptio placentae

Assessment of the Abdominal


Injury Patient
Ongoing Assessment
Trend vital signs
Every 5 minutes for critical patients

Evaluate for
Progressive peritonitis
Progressive hemorrhage
BP and capillary refill
Pulse rate and pulse oximetry
Mental status
Skin condition
Ineffective aggressive fluid resuscitation

Management of the Abdominal


Injury Patient

Management of the Abdominal


Injury Patient
General Management
Position patient
Position of comfort unless spinal injury
Flex knees or left lateral recumbent

General shock care


PASG application
Specific injury care
Impaled objects or eviscerations

Management of the Abdominal


Injury Patient
Fluid Resuscitation
Large-bore IV with isotonic solution
Large-bore IV for use if patients BP drops below
80 mmHg
Fluid challenge 250 mL or 20 mL/kg
Limit to 3 L

Titrate to systolic blood pressure of 80 mmHg

Management of the Abdominal


Injury Patient
Cover any exposed
abdominal organs
with a dressing
moistened with
sterile saline
Stabilize any
impaled objects

Management of the Abdominal


Injury Patient PASG
Contraindications
Concurrent
penetrating chest
trauma
Abdomen inflation
contraindicated in
pregnancy
Inflate legs only

Indications
Evisceration
If SBP <60 mmHg

Intra-abdominal
bleeding
Shock

Incremental inflation
titrated to BP and
Pulse

Management of the Abdominal


Injury Patient
Management of the Pregnant Patient
Positioning:
Left lateral recumbent
If on backboard tilt backboard
Facilitates venous return

Oxygenation:
High-flow O2
Consider PPV by BVM if hypoxia ensues

Maintain high index of suspicion for intraabdominal bleeding


Consider IV and PASG

Summary
Introduction to Abdominal Injury
Abdominal Anatomy and Physiology
Pathophysiology of Abdominal Injury
Assessment of the Abdominal Injury Patient
Management of the Abdominal Injury Patient