Abdominal Trauma

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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.

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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/233
10/s_jrc25002f1.png
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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.

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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.

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Gastric injuries

• Gastric tear

http//www.ispub.com/journal/the-internet-journal-
of-gastroenterology/volume-7-number-2/isolated-gas
tric-tear-due-to-blunt-abdominal-trauma.html
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Esophageal Injuries

• Signs and symptoms
• Pain in chest, shoulder and neck
• Subcutaneous emphysema
• Crackling sensation felt when palpating patients
  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

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Large and Small Bowel Injuries

• Perforated intestines secondary to trauma

http//www.openabdomen.org/diseases/trauma.cfm
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Large and Small Bowel Injuries

• Rupture and partial evisceration of bowel

http//atlas-emergency-medicine.org.ua/ch.7.htm
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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/se
vere-intraabdominal-trauma-in-illegal-abortion-a-c
ase-report.html
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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

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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/se
vere-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

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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

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Hepatic Injuries

• Subcapsular hematoma

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Hepatic Injuries

• Liver laceration

http//www.trauma.org/index.php/main/image/154/
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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

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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

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Splenic Injuries

• Laceration of the spleen

http//www.trauma.org/index.php/main/image/156/
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Splenic Injuries

• Signs and symptoms
• Left upper quadrant tenderness
• Pain in left shoulder while lying flat (Kehrs
  sign)
• Signs of hypovolemia or hemorrhage
• Abdominal rigidity, spasm or guarding

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Splenic Injuries

• Splenic hematoma with laceration

http//www.learningradiology.com/archives03/COW20
068-Splenic20laceration/spleniclaccorrect.htm
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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 Turners sign
• Normally does not develop for 6-12 hours after
  injury

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Renal Injuries
http//www.surgical-tutor.org.uk/default-home.htm?
core/trauma/renal_trauma.htmright
http//www.trauma.org/index.php/main/image/172/pri
nt/print
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Renal Injuries

• Grey Turners Sign

http//clancyclark.blogspot.com/2012/06/grey-turne
r-s-sign.html
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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
  cavityaverage human body contains 4-7 liters
• Stabilize with a sheet or belt wrapped
  circumferentially around hips at level of greater
  trochanter

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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

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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 patients
  status, vital signs, physical assessmentmake
  sure your patient is not deteriorating.

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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

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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 availableif 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

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Stabilizing Impaled Objects
http//www.medskills.eu/index.php/dropbox/en/Body/
level3/topic8/null/1434/
http//www.moondragon.org/health/disorders/specifi
cwoundtreatment.html
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Stabilizing Impaled Objects
http//members.tripod.com/cynthia_gray/emsphotos/i
njuries.html
http//www.medskills.eu/index.php/wiki/en/body/med
ical20fundamentals/critical20trauma20patients/a
bdominal20trauma/
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Diagnosing Trauma

• Classic signs and symptoms
• Pain, guarding, rigid abdomen
• Chemical peritonities pancreatic injury
• Kehrs 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

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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 positiveassume 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

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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

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Diagnosing Trauma

• Laboratory Tests
• Hematocrit and Hemoglobin levels
• Is a blood transfusion needed? Have levels
  changed from patients 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

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Bibliography

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