Division 3

Trauma Emergencies

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 Chapter 26
Abdominal Trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 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

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Introduction to Abdominal
Injury
One of body’s 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
Seatbelt usage
Proper application
Airbags

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Abdominal Anatomy and
Physiology (1 of 2)
Boundaries
– Superior: Diaphragm
– Inferior: Pelvis
– Posterior: Vertebral column and posterior
and inferior ribs
– Lateral: Muscles of the flank
– Anterior: Abdominal muscles

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Abdominal Anatomy and
Physiology (2 of 2)
Three Specific Spaces
– Peritoneal Space
Organs covered by abdominal (peritoneal)
lining
– Retroperitoneal Space
Organs posterior to the peritoneal lining
– Pelvic Space
Organs contained within pelvis

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 Bledsoe et al., Essentials of Paramedic Care: Division 1II
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Organs by Abdominal Quadrant
Liver, Gallbladder,
U Stomach (Small Part)
p Small and Large Intestine
p Head of Pancreas
e Upper Part of Kidney
r
Small and Large Intestine
L Lower part of Kidney
o Half of Bladder, Appendix,
w Female Reproductive
e Organs
r
Right
Stomach,
Tail of Pancreas
Tail of Liver
Small and Large Intestine
Upper Part of Kidney
Small and Large Intestine
Lower part of Kidney
Half of Bladder, Female
Reproductive Organs
Left
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 Hollow and Solid
Abdominal Organs
Solid Hollow
– Liver – Stomach
– Spleen – Small intestine
– Pancreas – Large intestine
– Kidneys – Gall bladder
– Ovaries – Bladder
– Uterus

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Major Abdominal Structures
Digestive Tract Urinary System
– AKA: Alimentary canal – Kidneys
– Structures – Ureter
Stomach – Urinary Bladder
Small Intestine – Urethra
Large Intestine
Rectum
Immune System
– Spleen
Accessory Organs
– Liver
Genitals
– Ovaries
– Gallbladder
– Fallopian tubes
– Pancreas
– Uterus
– Vagina

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 Bledsoe et al., Essentials of Paramedic Care: Division 1II
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Digestive Tract
Function
– Churn material to be digested
– Excrete digestive juices
– Absorb nutrients and water
Components
– Stomach
Food mixed with HCl and enzymes to form chyme
– Small bowel
Food moved through bowel by peristalsis
Duodenum
Jejunum
Ileum
– Large bowel (Colon)
– Rectum
– Anus

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Accessory Organs (1 of 3)
Liver
– Located in upper right quadrant
– 2.5% of total body weight
– Receives 25% of cardiac output and has 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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Accessory Organs (2 of 3)
Gallbladder
– Small hollow organ located behind and beneath
liver
– Receives bile
Waste product from reprocessing of RBCs
Used to digest fatty foods (emulsification)
Pancreas
– Produces endocrine hormones and exocrine
enzymes
Glucagon
Insulin
Digestive enzymes that return the chyme pH to normal
and break down proteins

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Abdominal Anatomy and Physiology
Accessory Organs (3 of 3)
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

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Abdominal Anatomy and Physiology
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
– Ureters
– Urinary bladder
Can contain as much as 500 mL of urine
– Urethra

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 Bledsoe et al., Essentials of Paramedic Care: Division 1II
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 Abdominal Anatomy and
Physiology
Genitalia
– Female sexual organs
Represent an open passage to the interior of the
abdominal cavity
Components
Ovaries
Fallopian tubes
Uterus
Vagina
– Male sexual organs
External to the abdomen
Components
Testes
Penis

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 Bledsoe et al., Essentials of Paramedic Care: Division 1II
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Pregnant Uterus (1 of 2)
Uterus and contents grow rapidly after
conception and until delivery
1st Trimester (0–12 weeks)
– Well protected
2nd Trimester (12–24 weeks)
– Uterus displaces organs upward
3rd Trimester (24 weeks to term)
– Fills entire abdominal cavity
– Displaces diaphragm upward
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Abdominal Anatomy and Physiology
Pregnant Uterus (2 of 2)
Effects on Maternal Physiology
– Increases circulatory blood volume by 45%
Greater volume but fewer RBCs
Results in relative anemia
– Cardiac output increases by 40%
– Heart rate increases by 15 bpm
– Compresses the vena cava in 3rd trimester
Reduces venous return
Supine hypotensive syndrome

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 Bledsoe et al., Essentials of Paramedic Care: Division 1II
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Anatomy and Physiology
Vasculature (1 of 2)
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

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Abdominal Anatomy and Physiology
Vasculature (2 of 2)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abdominal Arteries

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Abdominal Anatomy and Physiology
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
– Double fold of peritoneum
– Supports and suspends small bowel from posterior
abdominal wall
– Omentum
Additional fold
Insulates and protects anterior surface of abdomen

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Retroperitoneal Structures
Kidneys
Duodenum
Pancreas
Urinary Bladder
Posterior portions of ascending and
descending colon
Rectum
Major vascular structures

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Reflections of the Peritoneum

Bledsoe et al., Essentials of Paramedic Care: Division 1II

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Pathophysiology of Abdominal Injury
Mechanism of Injury (1 of 3)
Penetrating Trauma
– Energy transmitted to surrounding tissue
– Projectile cavitation, pitch, and yaw
– 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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury
Mechanism of Injury (2 of 3)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal Injury
Mechanism of Injury (3 of 3)
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.

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (1 of 12)
Injury to the Abdominal Wall
– Skin and muscles transmit blunt trauma to internal
structures.
Typically only show erythema.
Visible 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.
– 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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (2 of 12)
Injury to the Hollow Organs
– May rupture with compression from blunt forces
– May tear due to penetrating trauma
– Spillage of contents into:
Retroperitoneal space
Peritoneal space
Pelvic space
– Intestines have a large amount of bacteria:
Leakage can result in sepsis
– Manifestations of Blood Loss
Hematochezia: blood in stool
Hematemesis: blood in emesis
Hematuria: blood in the urine

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (3 of 12)
Injury to the Solid Organs
– Dense and less strongly held together
– Prone to contusion
Bleeding
Fracture (rupture)
– Unrestricted hemorrhage if organ capsule is
ruptured
– Specific Organs
Spleen: pain referred to left shoulder
Pancreas: pain radiates to back
Kidneys: pain radiates from flank to groin and hematuria
Liver: pain referred to the right shoulder

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (4 of 12)
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
Greater volume of blood can be lost
Presence of blood in abdomen stimulates vagus nerve
resulting in slowing of heart rate
– Blood can isolate in any of the abdominal
spaces.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (5 of 12)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (6 of 12)
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
Progression
Slight tenderness at location of injury
Rebound tenderness
Guarding
Rigid, board-like feel

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (7 of 12)
Injury to the Pelvis
– Serious skeletal injury
Life-threatening hemorrhage
Potential injury to pelvic organs
Ureters
Bladder
Urethra
Female genitalia
Prostate
Rectum
Anus

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (8 of 12)
Injury During Pregnancy
– Trauma is the number one killer of pregnant
females.
Penetrating abdominal trauma accounts for 36% of
maternal mortality.
GSW account for 40–70% of penetrating trauma.
Blunt trauma due to improperly worn seatbelts.
Auto collisions are leading cause of mortality.
– Changing dimensions of uterus:
Protects abdominal organs.
Endangers uterus and fetus.

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (9 of 12)

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (10 of 12)
Injury During Pregnancy
– Maternal Changes
Increasing size and weight of uterus
Compresses inferior vena cava
Reduces venous return to heart
Increasing maternal blood volume
Protects mother from hypovolemia
30–35% of blood loss necessary before signs of
shock
Uterus is thick and muscular
Distributes forces of trauma uniformly to fetus
Reduces chances for injury

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (11 of 12)
Injury During Pregnancy
– Risk of uterine and fetal injury increases with the
length of gestation.
Greatest risk during 3rd trimester
– Penetrating trauma may cause fetal and
maternal blood mixing.
– Blunt trauma complications:
Uterine rupture
Abruptio placentae
Premature rupture of amniotic sac

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of Abdominal
Injury (12 of 12)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (1 of 6)
Scene Size-up
– Must evaluate MOI to assess seriousness of
injury
– Identify strength and direction of forces
Velocity of impact
Focus observations and palpation on that site
Develop a mental list of possible organs involved
– If auto crash
Determine if seatbelts used properly
Interior signs of impact
Steering wheel and dashboard deformity

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (2 of 6)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (3 of 6)
Initial Assessment
– LOC
– Drug or alcohol use
– Evaluate ABCs and immediate threats

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (4 of 6)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (5 of 6)
Considerations with Pregnant Patients
– Be observant for
Signs of shock
PRETREAT: 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
Uterus development
Abnormal asymmetry

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the Abdominal
Injury Patient (6 of 6)
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

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal
Injury Patient (1 of 2)
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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal
Injury Patient (2 of 2)
Fluid Resuscitation
– Large-bore IV with isotonic solution
Consider 2 bolus if pulse does not slow
– Large-bore IV lock for use if patient’s BP
drops below 80 mmHg
– Fluid challenge 250 mL or 20 mL/kg
Limit to 3 L
– Titrate to SBP of 80 mmHg

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Evisceration Care

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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Management of the Abdominal
Injury Patient – PASG
Contraindications Indications
– Concurrent – Evisceration
penetrating chest If SBP <60 mmHg
trauma – Intra-abdominal
– Abdomen inflation bleeding
contraindicated in – Shock
pregnancy
Inflate legs only
Incremental
inflation titrated to
BP and Pulse

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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 intra-
abdominal bleeding.
Consider IV and PASG.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
 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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ