Abdominal Provincial Reciprocity Attainment Program Abdominal Organs ADUKPIE Types of Abdominal Organs ABDOMINAL ORGANS SOLID ORGANS HOLLOW ORGANS LIVER STOMACH SPLEEN GALL BLADDER PANCREAS SMALL INTESTINE KIDNEYS LARGE INTESTINE OVARIES BLADDER Abdominal Organs RUQ LUQ Liver Spleen Gall Bladder Stomach Kidney Kidney Part of the Pancreas Part of the Liver Large Intestine Kidney Large Intestine Small Intestine Part of the Pancreas Appendix Lt Ureter Large Intestine Large Intestine Rt Ureter Small Intestine Small Intestine Femoral Artery/Vein to Left Leg Femoral Artery/Vein to Rt Leg RLQ LLQ Traumatic Injuries Abdominal Trauma May be difficult to evaluate in the prehospital setting due to: Wide spectrum of potential injuries to multiple organs Physical findings that are sometimes lacking or exaggerated Abdominal Trauma Assessment may be compromised by: Use of alcohol and/or recreational drugs Injury to brain, spinal cord Injury to ribs, spine, pelvis Exercise a high degree of suspicion based on mechanism of injury and kinematics Boundaries of the Abdomen Diaphragm Anterior abdominal wall Pelvic bones Vertebral column Muscles of the abdomen and flanks Surface Anatomy of Abdomen Quadrants Upper - right, left Lower - right, left Xiphoid Symphysis pubis Umbilicus Peritoneal Cavity Also called the “true” abdominal cavity Quadrants Upper - right, left Lower - right, left Contents-liver, spleen, stomach, small intestine, colon, gallbladder, female reproductive organs Pelvic Cavity Surrounded by the pelvic bones Lower part of retroperitoneal space Contents: Rectum Bladder Urethra Iliac vessels In women, internal genitalia Retroperitoneal Space Potential space behind the “true” abdominal cavity Contents (ADUCKPIE): Abdominal aorta Duodenum Ureter Colon Kidneys Pancreas Inferior vena cava Esophagus Mechanisms of Abdominal Injury Blunt trauma Compression or crushing forces Shearing forces Deceleration forces Degree of injury is usually related to: Quantity and duration of force applied Type of abdominal structure injured (fluid filled, gas filled, solid, hollow) Blunt Trauma Motor vehicle collisions Motorcycle collisions Pedestrian injuries Falls Assault Blast injuries Penetrating Trauma Energy imparted to the body Low velocity - knife, ice pick Medium velocity - gunshot wounds, shotgun wounds High velocity - high-power hunting rifles, military weapons Ballistics Trajectory Distance Solid & Hollow Organs Solid Organs Liver Spleen Pancreas Kidneys Adrenals Ovaries (female) Hollow Organs Stomach Intestines Gallbladder Urinary bladder Uterus (female) Solid Organ Injury Liver Largest organ in the abdominal cavity Located in the right upper quadrant of abdomen Commonly injured from trauma to the: Eighth through twelfth ribs on right side of body Upper central part of abdomen Damaged in 19% of blunt ABD trauma 37% of penetrating trauma Liver Suspect liver injury in any patient with: Steering wheel injury Lap belt injury History of epigastric trauma After injury, blood and bile escape into peritoneal cavity Produces signs and symptoms of shock and peritoneal irritation, respectively Spleen Lies in upper left quadrant of abdomen Rich blood supply Slightly protected by organs surrounding it medially and anteriorly and by lower portion of rib cage Most commonly injured organ from blunt trauma (41%) Associated intraabdominal injuries common 40% of patients do not show symptoms Spleen Suspect splenic injury in: Motor vehicle crashes Falls or sport injuries in which there was an impact to lower left chest, flank, or upper left abdomen Kehr’s sign Left upper quadrant pain with radiation to left shoulder Common complaint associated with splenic injury Kidneys Located high on posterior wall of abdominal cavity in retroperitoneal space Held in place by renal fascia Cushioned by a generous layer of adipose tissue Partially enclosed and protected by lower rib cage Kidneys Injuries may involve fracture and laceration Resulting in hemorrhage, urine extravasation, or both Contusions usually are self-limiting Heal with bed rest and forced fluids Fractures and lacerations may require surgical repair Hollow Organ Injury Stomach Not commonly injured after blunt trauma because of its protected location in abdomen Penetrating trauma may cause gastric transection or laceration Patients exhibit signs of peritonitis rapidly from leakage of gastric contents Diagnosis confirmed during surgery unless nasogastric drainage returns blood Colon and Small Intestine Injury is usually the result of penetrating trauma Large and small intestine may also be injured by compression forces High-speed motor vehicle crashes Deceleration injuries associated with wearing personal restraints Bacterial contamination common problem with these injuries Retroperitoneal Organ Injury May occur because of blunt or penetrating trauma to the: Anterior abdomen Posterior abdomen (particularly the flank area) or Thoracic spine Ureters Hollow organs Rarely injured in blunt trauma because of their flexible structure Injury usually occurs from penetrating abdominal or flank wounds (stab wounds, firearm injuries) Pancreas Solid organ that lies in the peritoneal space Blunt injury usually occurs from a crushing injury of the pancreas between the spine and a steering wheel, handlebar, or blunt weapon Most pancreatic injuries are due to penetrating trauma Duodenum Lies across the lumbar spine Seldom injured due to its location in the retroperitoneal area, near pancreas May be crushed or lacerated when great force of blunt trauma or penetrating injury occurs Usually associated with concurrent pancreatic trauma Pelvic Organ Injury Usually results from motor vehicle crashes that produce pelvic fractures Less frequent causes: Penetrating trauma Straddle-type injuries from falls Pedestrian accidents Some sexual acts Urinary Bladder Hollow organ May be ruptured by blunt or penetrating trauma or pelvic fracture Rupture more likely if bladder is distended at time of injury Suspect bladder injury in inebriated patients subjected to lower abdominal trauma Vascular Structure Injury Intraabdominal arterial and venous injuries may be life-threatening Injury usually occurs from penetrating trauma May also occur from compression or deceleration forces applied to abdomen Usually presents as hypovolemia Occasionally associated with a palpable abdominal mass Vascular Structure Injury Major vessels most frequently injured: Aorta Inferior vena cava Renal, mesenteric, and iliac arteries and veins Pelvic Fractures Disruption of the pelvis may occur from: Motorcycle crashes Pedestrian-vehicle collisions Direct crushing injury to the pelvis Falls from heights greater than 12 feet Blunt or penetrating injury may result in: Fracture Severe hemorrhage Associated injury to urinary bladder and urethra Pelvic injury Most common injured organs are the urinary bladder and urethra Mortality rate 6.4 – 19% Structural damage to the pelvis Room to empty large quantity of blood (shock) Inability to urinate Gross hematuria suspect bladder Blood at the meatus, suspect urethral damage Pelvic Fractures Suspicion of pelvic injury should be based on: Mechanism of injury Presence of tenderness on palpation of iliac crests Force may be direct or indirect Assessment findings Management Evisceration Protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall Common finding with stab wounds May be seen to a lesser degree with gunshot wounds Do not replace organs back into abdomen Protect organs from further damage Cover with sterile saline moistened dressing Transport Focused History and Physical Head injury and/ or intoxicants (drugs/alcohol) mask signs and symptoms Hemoperitoneum (solid organ/vascular injuries) Adult abdomen will accommodate 1.5 liters with no abdominal distention Often present even with normal abdominal exam Unexplained shock Shock out of proportion to known injuries Peritonitis – S/S Pain (subjective symptom from patient) Tenderness (objective sign with percussion/palpation) Guarding/rigidity Distention (late finding) Abrasions Ecchymosis Visible wounds Mechanism of injury Unexplained shock Critical Findings Rapid assessment and transport Detailed assessment On-going assessment Noncritical Findings Focused history and physical examination Other interventions and transport considerations Comprehensive Assessment Vital signs Inspection Auscultation Percussion Palpation Comprehensive Assessment Absence of signs and symptoms does not rule out abdominal injuries Not necessary to determine definitively if abdominal injuries are present Remember to examine the back Differential diagnosis Continued management Management/Treatment Plan Surgical intervention only effective therapy Rapid evaluation Initiation of shock resuscitation Rapid packaging and transport to nearest appropriate facility Facility must have immediate surgical capability Rapid transport Defeated if hospital cannot provide immediate surgical intervention Crystalloid fluid replacement en route to hospital Indications for Rapid Transport Critical findings Surgical intervention required to control hemorrhage and/ or contamination High index of suspicion for abdominal injury Unexplained shock Physical signs of abdominal injury Indications for Rapid Transport Hemorrhage continues until controlled in OR Survival determined by length of time from injury to definitive surgical control of hemorrhage Any delay in the field negatively impacts this time period ABD and Renal Disease Hiatal Hernia Herniation of the stomach through the diaphragmatic opening S/S Chest pain (especially when lying down) Difficulty swallowing Reflux Burping Possible hemorrhage May see signs of shock if severe Hiatal Hernia Treatment ABC’s Position of comfort O2 Rule out ischemia Treat for shock if applicable Transport Inguinal Hernia Herniation of intestine into inguinal canal S/S Pain and/or discomfort Mass may increase with strenuous activity N/V Treatment ABC’s O2 Position of comfort Umbilical Hernia Herniation of intestines or fluids into the umbilicus S/S: May increase with crying, strains or is upright Usually no pain associated with tightening Treatment: ABC’s Pt comfort O2 if necessary Bowel Obstruction Blockage of the intestines due to tumor, feces, adhesions or hernias S/S: N/V Distention Pain (Crampy and intermittent) Diarrhea (early)/Constipation (Late) Fever (late) Absent bowel sounds (late) BAD Breath Signs of shock Bowel Obstruction Treatment: ABC’s O2 Position of comfort IV ALS ? (May need gravol or pain relief) Diverticulitis Inflammation of the diverticula S/S: Maybe asymptomatic Abdominal pain (usually LLQ) Febrile N/V Cramps Chills Constipation/diarrhea Bright red blood Signs of shock Diverticulitis Treatment: ABC’s Position of comfort Treat for shock IV ? ALS ? (Pain, N/V) Intussusception Telescoping of intestine onto itself (commonly at the small/large intestine juncture), usually in infants S/S: Sudden onset of ABD pain N/V (with feces) Distention Febrile Possible bleeding Intussusception Treatment: ABC’s O2 Position of comfort ALS ? Adhesions Scar tissue forming between two surfaces of the body, usually in the intestines, as a result of surgery or traumatic insult S/S: If severe N/V Pain Fever Change in bowel habits Reflux Weakness of esophageal sphincter allowing gastric contents to enter esophagus S/S: Heartburn Burning sensation Burping N/V etc IBS Spastic colon S/S: Stress Change in bowel habits ABD pain or cramping Excessive gas Decrease in appetite Acute Appendicitis Inflammation of the appendix S/S: Sever pain (periumbilical moving to LRQ) Febrile Loss of appetite Rebound tenderness If ruptured Signs of shock Colitis Inflammation of the large intestine S/S: Diarrhea Loss of appetite Rectal bleeding Signs of shock if severe Chrone’s Disease Chronic inflammatory disease causing ulcerations in the small intestines (but may affect large and other regions of the tract) S/S: Diarrhea ABD pain N/V Anorexia Dependant on area and amount of damage Acute Peritonitis Acute inflammation of the peritoneum S/S: ABD pain Tenderness Guarding Is severe signs of shock Anorexia & Bulemia Eating disorders usually connect to the psychology of the patient S/S: Obsession with weight loss May be purging, using laxatives, diuretics… Dehydration Signs of shock (metabolic and hypovolemia) Acute Pancreatitis Inflammation of the pancreas due to stones, necrosis, infections… S/S: Severe epigastric pain N/V If severe Infection Hemorrhage Complications to other organs Acites Renal Calculi Kidney stones S/S: Abdominal pain starting in back and radiating to groin Infection Hematurea Severe may show signs of sepsis Hepatitis Inflammation of the liver S/S: Fatigue Anorexia General malaise N/V Photophobia Muscle and joint pain Dark urine RUQ pain Clay colored stools Jaundice Hepatic Failure Liver failure due to disease or insult S/S: Jaundice Fatigue Edema Metabolic changes (expect EKG changes) Hepatomegaly Febrile Severe may show shock Cirrhosis Necrosis of the liver cells S/S: Fatigue Anorexia GI bleed Ascites Jaundice Signs of shock (late) Cholecystitis Inflammation of the gall bladder S/S: URQ pain radiating to the right shoulder History of gall stones Febrile Fatty food intolerance N/V Severe may be shocky Renal Failure Kidney failure S/S: Oliguria leading to anurea Edema Acidosis Metabolic changes Leading to MOF May see LOC changes N/V….. Pelvic Inflammatory Disease Inflammation of the female pelvic organs S/S: ABD pain with rebound Guarding Febrile Pain with intercourse Changes in menstruation Painful urination Testicular Torsion Twisting of spermatic cord depleting supply of blood S/S: Swelling SEVERE PAIN N/V Hematuria Glomerulonephritis Inflammation of the glomerulus S/S: N/V Edema Decrease in output (may be absent) Hypertension Nephrotic Syndrome Increase in permeability of nephrons S/S: Proteinuria Edema Swelling of the scrotum Distention May see signs of shock Flank Pain N/V