Abdominal Trauma
Temple College
EMS Professions
1
The Abdomen


Everything between diaphragm and
pelvis
Injury, illness very difficult to assess
because of large variety of structures
2
Abdominal Anatomy


Abdomen divided into four quadrants by
body mid-line, horizontal plane through
umbilicus
Organs can be located by quadrant
3
Abdominal Anatomy

Right Upper Quadrant
– Liver
– Gall Bladder
– Right Kidney
– Ascending Colon
– Transverse Colon
4
Abdominal Anatomy

Left Upper Quadrant
– Spleen
– Stomach
– Pancreas
– Left Kidney
– Transverse Colon
– Descending Colon
5
Abdominal Anatomy

Right Lower Quadrant
– Ascending Colon
– Appendix
– Right Ovary (female)
– Right Fallopian Tube (female)
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Abdominal Anatomy
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Left Lower Quadrant
– Descending Colon
– Sigmoid colon
– Left Ovary (female)
– Left Fallopian Tube (female)
7
Abdominal Anatomy

Periumbilical area
– Located around (peri) the navel (umbilicus)
– Small bowel lies in all quadrants in
periumbilical area
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Suprapubic area
– Located just above pubic bone
– Urinary bladder, uterus lie in this area
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Abdominal Cavity


Peritoneum = abdominal cavity lining
Divides abdomen into two spaces
– Peritoneal cavity
– Retroperitoneal space
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Abdominal Anatomy

Peritoneal
–
–
–
–
–
Spleen
Liver
Stomach
Gall bladder
Bowel

Retroperitoneal
–
–
–
–
–
–
–
Pancreas
Kidney
Ureter
Inferior vena cava
Abdominal aorta
Urinary bladder
Reproductive organs
Disease, injury of retroperitoneal organs
often causes back pain
10
Abdominal Anatomy

Organs can be classified as:
– Hollow
– Solid
– Major vascular
11
Solid Organs




Liver
Spleen
Kidney
Pancreas
When solid organs are
injured, they bleed heavily
and cause shock
12
Solid Organs

Liver
– Largest abdominal organ
– Most frequently injured
– Fractures of ribs 8-12 on right side
– Bleeding can be either:
• Slow, contained under capsule
• Free into peritoneal cavity
13
Solid Organs

Spleen
– Frequently injured with trauma ribs 9-11 on
left side
– Bleeds easily
– Capsule around spleen tends to slow
development of shock
– Rapid shock onset when capsule ruptures
14
Solid Organs

Pancreas
– Lies across lumbar spine
– Sudden deceleration produces straddle
injury
– Very little hemorrhage
– Leakage of enzymes digests structures in
retroperitoneal space, causes volume loss,
shock
15
Hollow Organs




Stomach
Gall bladder
Large, small intestines
Ureters, urinary bladder
Rupture causes content
spillage, inflammation of
peritoneum
16
Hollow Organs

Stomach
– Acid, enzymes
– Immediate peritonitis
– Pain, tenderness, guarding, rigidity
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Hollow Organs

Colon
– Spillage of bacteria
– May take 6 hrs to develop peritonitis

Small Bowel
– Fewer bacteria
– May take 24-48 hours to develop peritonitis
18
Major Vascular Structures



Aorta
Inferior vena cava
Major branches
Injury can cause severe
blood loss ; exsanguination
(bleeding out)
19
Abdominal Trauma


Most survive to reach hospital
Most common factors leading to death
– Failure to adequately evaluate
– Delayed resuscitation
– Inadequate volume
– Inadequate diagnosis
– Delayed surgery
20
High Index of Suspicion
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Mechanism
Trauma to lower chest, back, flank,
buttocks, and perineum
Hypovolemic shock with no readily
identifiable cause
Diffusely tender abdomen
Pain in uninjured shoulder
21
Mechanism

Look for signs of injury
– Bruises
– Tire marks
– Obvious open injuries


Assume any abdominal injury is serious
until proven otherwise!
Injury above umbilicus also involves
chest until proven otherwise
22
Unexplained Shock



Assess vital signs; skin color,
temperature; capillary refill
Tachycardia; restlessness; cool, moist
skin
In trauma, signs of shock suggest
abdominal injury if no other obvious
causes present
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Signs of Injured Abdomen


Diffuse tenderness
Pain
– Pain referred to shoulder = Organ under
diaphragm involved (?spleen)
– Pain referred to back = Retroperitoneal
organ involved (?kidney)
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Abdominal Rigidity

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NOT reliable
Bleeding may not cause rigidity if free
hemoglobin absent
Bleeding in retroperitoneal space may
not cause rigidity
25
Abdominal Trauma Management

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Less important to diagnose exact injury
Treat clinical findings
Management same regardless of
specific organ(s) injured
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Abdominal Trauma Management
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
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Airway
C-Spine if mechanism indicates
High flow O2
Assist ventilations if needed
Give nothing by mouth
MAST may be helpful in slowing
intraabdominal bleeding with shock
27
Impaled Object

Leave in place
– Shorten if necessary for transport
– Leave part of object exposed
28
Evisceration


With large laceration abdominal
contents may spill out
Do NOT try to replace
29
Evisceration



Cover exposed organs with saline
moistened multi-trauma dressing
Do NOT use 4 x 4s
Cover first dressing with second DRY
dressing or aluminum foil
30
Genitourinary Trauma
31
Urinary System
Kidney
Ureter
Urinary Bladder
Urethra
32
Kidney Trauma

50% of all GU trauma
33
Kidney Trauma

Penetrating
– GSW
– Stab wound

Rare, usually associated with trauma to
other abdominal organs
34
Kidney Trauma

Blunt
– Direct blow to back, flank, upper abdomen
• Suspect with fractures of 10th - 12th ribs or T12,
L1, L2
– Acceleration/Deceleration
• Shearing of renal artery/vein
35
Kidney Trauma

Signs and Symptoms
– Gross Hematuria
• 80% of cases
• Absence does NOT exclude renal injury
– Localized flank/abdominal pain
– Palpable mass
36
Kidney Trauma

Signs and Symptoms
– Tenderness: Lower ribs, upper L-spine,
flank
– Pain: groin, shoulder, back, flank
37
Ureter Trauma



Less than 2% of GU trauma
Usually secondary to penetrating
trauma
Indicator
– Wound to lower back with urine escaping
38
Urinary Bladder Trauma

Mechanisms
– Blunt injury to lower abdomen
– Seat belts
– Pelvic fracture
– Penetrating trauma to lower abdomen or
perineum (pelvic floor)
39
Extraperitoneal Bladder Rupture

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Urine in umbilicus, anterior thighs, scrotum,
inguinal canals, perineum
Dysuria
Hematuria
Suprapubic tenderness
Swelling, redness secondary to tissue
damage from urine
40
Intraperitoneal Bladder Rupture

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Urgency to void
Inability to void
Shock
Abdominal distension
41
Urethral Trauma

Mechanisms
– Sudden decelerations
(bladder shears off urethra)
– Straddle injuries
42
Urethral Trauma

Signs and Symptoms
– Blood at external meatus
– Perineal bruising (butterfly bruise)
– Scrotal hematoma
43
Reproductive System Trauma

Can occur to both external and internal
reproductive systems
– External
• More common
• Pain, extensive bleeding
– Internal
• Rarely injured
44
Reproductive System Trauma
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Treat like blunt or penetrating soft tissue
injuries elsewhere on body
45
Male Genitalia Trauma
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Usually NOT life-threatening
Very painful
Great source of concern to patient
46
Male Genitalia Trauma

Avulsion of skin of penis, scrotum
– Cover with a moist, sterile dressing

Complete amputation of penis
– Treat as any amputated part
47
Male Genitalia Trauma

Blunt trauma to penis, scrotum
– Apply ice pack

Urethral foreign bodies
– Do NOT remove

Penis entrapped in zipper
– If 1 or 2 teeth involved, try to unzip
– If more involved, cut zipper out of trousers,
transport
48
Female Genitalia Trauma

Internal
– Rarely injured

External
– Can cause pain, extensive bleeding
– Usually not life-threatening

Treat with compresses, pressure
49
Sexual Assault
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Avoid examining genitalia unless
obvious bleeding present
Ask patient to NOT wash, douche,
urinate, defecate
Ask patient NOT to change clothes
Record history, but avoid extensive
questioning about incident
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