Abdominal Trauma

1. Abdominal Trauma Natalie Wynn RN, BSN Valley Hospital Medical Center Emergency Room

2. Objectives • Types of abdominal trauma. • List the major organs of the abdominal cavity and relate them to theiranatomical 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. Abdominal organs http://www.webmd.com/digestive-disorders/picture-of-the-abdomen

4. Blunt Abdominal Trauma Common causes of injury • Motor vehicle accidents • Motor vehicle versus pedestrian • Fall from heights • Blast injuries • Physical assault • Blunt abdominal injuries result from compression, shearing or deceleration forces.

5. Grey Turner’s Sign,Cullen’s Sign http://clancyclark.blogspot.com/2012/06/grey-turner-s-sign.html

6. Blunt Abdominal Trauma • Solid organ injuries including liver, spleen, kidneys, pancreas • Rupture of hollow viscus including small and large intestine, stomach, esophagus, and bladder • Vascular injuries • Bony fractures of pelvis

7. Hollow versus Solid Organs • Hollow organs – stomach, small bowel, large bowel, gallbladder, bile ducts, fallopian tubes, ureters and urinary bladder. • Solid organs – liver, spleen, kidneys, adrenals, pancreas, ovaries and uterus.

8. 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

9. Hollow Organ Injuries: Mechanism of Injury • Seat belts cause compression, which can result in rupture of small bowel or large bowel. – Large bowel injuries have a high morbidity and mortality rate due to fecal contamination and probability of sepsis. •Diagnostic peritoneal lavage (DPL) can show presence of bile, feces or food. • Deceleration injuries may lead to shearing, tearing or avulsion of the small bowel. • Majority of hollow organ injury is related to penetrating trauma.

10. 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.

11. Eviceration of Bowel

12. 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!

13. 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

14. 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

15. Active splenic hemorrhage This is an 18 year old boy involved in a motor vehicle crash, incurred blunt trauma to the abdomen. Intraoperatively, they noted two liters of blood in his peritoneal cavity, and a splenectomy was performed.

16. 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

17. Liver Laceration http://www.trauma.org/index.php/main/image/154/

18. 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

19. Penetrating Abdominal Trauma • Mechanism of wounding and organ damage • Stab wounds with knife or other instruments • Gunshot wounds • Explosive injury with shrapnel or secondary projectiles

20. Impaled Five Foot Iron Bar two inches in diameter This 22 year old male was impaled by an iron bar while do road work. The bar entered at the level of the epigastrium and exited through the left posterior thoracic wall.Under general anesthesia a left thoracotomy was done. The surgery was successful.

21. Penetrating Abdominal Knife wound http://www.trauma.org/index.php/main/images_keyword/stab/ Treatment, stabilize device and pack so that it cannot cause further damage.

22. Penetrating Abdominal Trauma • The most common organs injures with a stabbing are: the liver, small bowel, diaphragm, large bowel, and vascular structures. • The extent of the internal injury should never be based on the appearance of the external injury!!! • Abdominal trauma manifestations can be subtle.

23. Abdominal Trauma-Assessment • A - Airway • B - Breathing • C - Circulation • D - Disability (neurological status) • E - Expose (take patient’s clothes off) • F - Full set of vital signs • G - Give comfort measures • H - History head to toe assessment • I - Inspect posterior surfaces

24. Assessing Abdominal Trauma • Inspection (look) • Swelling, bruising, lacerations or abrasions • Auscultate (listen) • Bowel sounds: are there any and where are they? • Palpate (feel) • Subcutaneous emphysema; soft, rigid or distended abdomen; palpable masses; stable pelvis; flank tenderness; anal sphincter-presence or absence of tone • Percuss (tap) • For hyperresonance which indicates air. Dullness which indicates fluid accumulation.

25. 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.

26. 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

27. 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

28. 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/

29. Diagnosing Trauma • Classic signs and symptoms • Pain, guarding, rigid abdomen • Chemical peritonitis: 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

30. 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

31. Diagnosing Trauma • Diagnostic exams continued • Focused Assessment Sonography for Trauma • Rapid, accurate, inexpensive, noninvasive and can be repeated multiple times • Patient should be placed in the supine position for exam • 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

32. 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

33. Bibliography • TNCC: Trauma Nursing Core Course (6th ed.). (2007). Park Ridge, Ill.: Emergency Nurses Association.