Chapter 36 Abdominal and Genitourinary Trauma National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. National EMS Education Standard Competencies Abdominal and Genitourinary Trauma • Recognition and management of: − Blunt versus penetrating mechanisms − Evisceration − Impaled object National EMS Education Standard Competencies • Pathophysiology, assessment, and management of: − Solid and hollow organ injuries − Blunt versus penetrating mechanisms − − − − − − Evisceration Injuries to the external genitalia Vaginal bleeding due to trauma Sexual assault Vascular injury Retroperitoneal injuries Introduction • Abdominal cavity extends from diaphragm to pelvis − Injuries can be life threatening. − Contains several vital organ systems Introduction • Damage from trauma can be decreased by: − Empty bladder − Toned abdominal muscles Introduction • Perform assessment and intervention quickly and cautiously. − Delays can have disastrous consequences. − Blunt abdominal trauma is the leading cause of morbidity and mortality. Introduction • Trauma to the GU system can result from blunt or penetrating trauma − Consider when injuries involve: • Lower rib cage • Abdomen • Pelvis • Upper legs Introduction • Your field account is the only source of information for understanding the events and mechanism that led to trauma. − Critical for injuries that are not apparent Anatomic Regions • Cavity extends from diaphragm to pelvic brim • Divided into three sections: − Anterior abdomen − Flanks − Posterior abdomen Anatomic Regions Anatomic Regions • Quadrant system describes location in abdomen − Four regions • Periumbilical area: around the navel Anatomic Regions • Peritoneum: membrane that lines the cavity • Mesentery: double fold of tissue in abdomen Anatomic Regions • Internally divided into three regions: − Peritoneal space − Retroperitoneal space − Pelvis Anatomic Regions Abdominal Organs and Vital Vessels • Abdomen contains many organs − Solid organs − Hollow organs • Abdomen also contains vital vessels Abdominal Organs and Vital Vessels Abdominal Organs and Vital Vessels Solid Organs • Liver: largest organ in the abdomen − Functions include: • Detoxifying the blood • Processing hemoglobin before it is stored • Regulating blood clotting • Removing bacteria from the bloodstream • Regulating fat Solid Organs • The spleen is highly vascular. − Functions include filtering and storing blood. − If the body needs extra blood, the spleen provides it to the circulatory system. − Detects pathogenic organisms and produces lymphocytes Solid Organs • The pancreas is located under the liver and behind the stomach. − Acinar cells produce and secrete enzymes that aid in digestion. − Secretes insulin from the islets of Langerhans Hollow Organs • The stomach is an intraperitoneal organ. − Concave on its right and convex on its left side • Uppermost part: fundus • Largest part: body • Lower part: antrum Hollow Organs • Three layers of the stomach wall: − Longitudinal muscle − Circular layer − Oblique layer Hollow Organs • Blood is supplied to the stomach from the celiac trunk. − Blood is returned via the portal vein • The stomach contains acid to assist in digestion. Hollow Organs • Small and large intestines − Run from stomach to anus − Digest and absorb water and nutrients • Gallbladder − Saclike organ on the lower surface of the liver − Reservoir for bile Hollow Organs • Duodenum: first part of the small intestine • Pylorus: circumferential muscle at the end of the stomach • Cecum: pouch at junction of small and large intestine Hollow Organs • Colon: large intestine − Absorbs sodium and other ions − Excretes other metallic ions into wastes − The last 20 cm is the rectum. Organs of the Genitourinary System • The abdomen contains organs of the urinary system. − Kidneys filter blood and excrete waste. − Urinary bladder: hollow, muscular sac − Ureters: thick-walled, hollow tubes Organs of the Genitourinary System • The abdomen contains organs of the reproductive system. The female reproductive system Organs of the Genitourinary System The male reproductive system The Diaphragm • Dome-shaped muscle • Separates the thoracic cavity from the abdominal cavity Physiology • Some abdominal trauma can cause shock due to blood loss. − Bleeding may produce few signs and symptoms. Physiology • Organs most frequently injured after blunt trauma include: − Spleen and liver • If a patient has unexplained symptoms of shock, suspect abdominal trauma. Physiology • Hollow organs are more resilient. − More likely to be injured and burst when full • May cause toxins to be released into the abdominal cavity • Spillage can cause peritonitis. Physiology • Two types of peritonitis: − Chemical peritonitis • May have sudden onset − Bacterial peritonitis • May develop over several hours • Also classified as: − Primary • Infection travels from blood or lymph nodes into peritoneum. − Secondary • Infection travels from GI or biliary tract into the peritoneum. Mechanism of Injury • Trauma is the leading cause of death in patients ages 1 to 44 years. − About 80% of all significant traumas involve the abdomen. Blunt Trauma • Can cause compression and crushing injuries • Results from compression or deceleration forces • Leads to a closed abdominal injury Blunt Trauma • Common MOI—Shearing − Caused by rapid deceleration • Organs continue forward motion, causing tear − Signs of abdominal bleeding may include: • Referred shoulder pain • Unexplained hypotension • Multiple traumas present Blunt Trauma • Common MOI—Crushing − Abdominal contents are crushed between: • Anterior abdominal wall, and • Spinal column − Results from direct strikes or falling objects Blunt Trauma • Common MOI—Compression − Results from direct blow or external compression from a fixed object − Forces will deform hollow organs. • Can rupture the small intestine or diaphragm Penetrating Trauma • Results from low-velocity gunshot or stab wounds • Causes an open abdominal injury • Gunshot wounds cause more injury than stab wounds. Penetrating Trauma • Damage is a function of energy imparted. − Kinetic energy = Mass/2 × Velocity2 − Velocity delivered is divided into three levels: • Low velocity (< 200 ft per second) • Medium velocity (200–2,000 ft per second) • High-velocity (> 2,000 ft per second) Penetrating Trauma • Contributors to the extent of injury include: − Trajectory or direction the projectile traveled − Distance the projectile traveled − Profile of the bullet Motor-Vehicle Crashes • Five typical patterns of impact − Frontal − Lateral − Rear − Rotational − Rollover Motor-Vehicle Crashes • Consider transporting the patient if one of the following is present: − Ejection from vehicle − High-speed crash − Death of passenger − Falls greater than 15′, or three times patient’s height − Pedestrian crash − Motorcycle crash − Unrestrained occupants − Penetrating wounds to head, chest, or abdomen Motor-Vehicle Crashes • Seat belts can cause blunt trauma to the abdominal organs. Motorcycle Falls or Crashes • No structural protection exists. − Protection: protective devices worn by driver • Helmets do not protect for severe cervical injury. − Consider transport to a trauma center with: • Crashes at speeds greater than 20 mph • Separation of rider and motorcycle Falls from Heights • Body’s position or orientation determine types of injuries and survivability. • Forces can be dissipated by: − Surface the person has fallen − Degree to which surface can deform under force Falls from Heights • A fall produces acceleration at 9.8 m/sec2. − Height plus stopping distance predict magnitude of forces. • Transport patients to a trauma center if falls are greater than 20 ft. Blast Injuries • Generated fragments can travel at velocities of 4,500 fps • Injuries may be from four mechanisms: • Primary blast • Secondary blast • Tertiary blast • Quaternary blast General Pathophysiology • Hemorrhage is a concern with abdominal trauma. − Estimation of blood volume lost is difficult. − Signs and symptoms depend on: • Volume of blood lost • Rate of loss General Pathophysiology • Increased hypovolemia results in agitation and confusion. − The heart increases rate and stroke volume. • Increased hypoperfusion leads to ischemia and heart failure. General Pathophysiology • Injuries can result in organ spillage into the abdominal cavity. − Will eventually result in localized pain • Localized if contamination is confined • Generalized if entire peritoneal cavity is involved Patient Assessment • During evaluation, look for evidence of hemorrhage or spillage of bowel contents. − Have a high index of suspicion. − Provide tissue perfusion and oxygen delivery. Patient Assessment • Evaluation must be systematic. − − − − − Bruising Road rash Localized swelling Lacerations Distention or pain © Dr. P. Marazzi/Photo Researchers, Inc. • Examine for: Patient Assessment • Look for shock not proportional to external evidence. • Abdominal organs are susceptible to significant bleeding. − Can be fatal Patient Assessment • When assessing a genitourinary injury: − Provide privacy for the patient. − Look for blood on the undergarments. − Only inspect the external genitalia if: • The patient reports pain. • There are external signs of injury. Scene Size-Up • Scene safety is priority. • Penetrating or blunt trauma is caused by an external force. − Situation may be dangerous to the paramedic. Primary Assessment • Form a general impression. − Note the manner in which the patient is lying. • Body or abdominal movement irritates inflamed peritoneum. • Patient may also present with guarding. Primary Assessment • Airway and breathing − Keep airway clear of vomitus. • Note the nature of the vomitus. − Assess for adequate breathing. • Supplemental oxygen with a nonrebreathing mask may be necessary. Primary Assessment • Circulation − Superficial abdominal injuries usually don’t produce external bleeding. − To determine stage of shock, evaluate: • Pulse and skin color • Temperature • Condition Primary Assessment • Circulation (cont’d) − When caring for genitourinary emergency, remember the system is very vascular. − To determine the presence of shock: • Assess pulse rate and quality. • Determine skin condition, color, and temperature. • Check capillary refill time. Primary Assessment • Circulation (cont’d) − Closed injuries do not have visible signs of bleeding. − If the patient is visibly bleeding, control it. − Consider the MOI, and expose that body part. Primary Assessment • Transport decision − Abdominal injuries call for short on-scene time. − Patients should be evaluated at the highest trauma center available. Primary Assessment • Transport decision (cont’d) − Patients with a genitourinary system injury should be taken to a trauma center. − Treatment may require a specialist. History Taking • Obtain the following with blunt trauma caused by a motor-vehicle crash: − Types of vehicles − Speed of travel − How vehicles collided − Other information: • Use of seat belts • Air bag deployment • Patient’s position History Taking • If a patient has stab wounds, determine: • In a gunshot case, determine: − Type of knife − Angle of entry − Type of gun − Number of shots − Number of wounds − Estimated distance Secondary Assessment • Inspect the abdomen. − May involve ecchymosis, abrasions, lacerations − Note blood from vagina or rectum. − Peritonitis could result in decreased or absent abdominal sounds. Secondary Assessment • Perform palpation and percussion. − Start with the quadrant furthest from injury. • Note whether the patient has hematuria. − Dark brown: bleeding in upper urinary tract − Bright red: bleeding in lower portion of tract Secondary Assessment • Determine if the patient is pregnant. − Risk of massive blood loss is increased − Management should start with the ABCs. − Tilt patients at least 15° to the left to prevent vena cava syndrome. Secondary Assessment • New technologies include: − Portable ultrasound machines − Telemedicine • Misconception: patients without pain or abnormal vital signs are unlikely to have serious injuries. Secondary Assessment • Abdominal trauma may include: − Abdominal evisceration − Injury to the diaphragm • Signs of rupture may include: − Abdominal pain − Abdominal sounds in the chest − Sunken abdomen Secondary Assessment • Examine the patient’s neck and chest. • Assess the patient’s pain. − Somatic pain: sharp and localized − Visceral pain: deep aching with cramping Secondary Assessment • Perform a thorough full-body exam. − Conduct en route. − Assess the same structures as the rapid exam but more methodically. Reassessment • Field documentation should include: − Seat belt use − Location, intensity, quality of pain − Nausea or vomiting − Contour of abdomen − Ecchymosis or open areas on soft-tissue − Rebound tenderness, guarding, rigidity, spasm, localized pain Reassessment • Field documentation should include (cont’d): − Changes in LOC and vital signs − Other injuries found − Alcohol, narcotics, analgesic − Results of assessment Emergency Medical Care • Ensure an open airway. • Establish IV access. • Apply pressure dressings if necessary. • Apply a: − Cardiac monitor − Pulse oximetry − Capnography • Transport to a hospital or trauma center. Emergency Medical Care • Administering pain medication is controversial. − Consult with medical direction en route. Evisceration • Protrusion of abdominal organs through a wound − Apply a sterile dressing over the evisceration. − Transport to the closest hospital. Evisceration • Strangulation of the bowel causes decreased blood flow to the protruding part. • Patients may feel more comfortable with knees bent. − Encourage not to cough or bear down. Impaled Objects • Stabilize the object. • Transport patient in the position found. − Intervene early. © Custom Medical Stock Photo • Significant infection may develop. Pathophysiology of Specific Injuries • Abdominal trauma can be life threatening. − May bleed profusely − May produce peritonitis and systemic infection Injuries to Solid Abdominal Organs • Liver injuries − Suspect with: • Right-sided chest and abdominal trauma • Fractures to the 7th and 9th ribs − Suspect laceration when penetration involves: • Right upper abdomen • Right lower chest Injuries to Solid Abdominal Organs • Spleen injuries − Ruptured spleens have been reported in cases where contact was minor. • If ruptured, blood spills into the peritoneum. Injuries to Solid Abdominal Organs • Spleen injuries (cont’d) − Suspect spleen lacerations if: • 9th through 10th ribs are fractured • Left upper quadrant tenderness • Hypotension • Tachycardia • Left shoulder pain appears 1 to 2 hours after injury Injuries to Solid Abdominal Organs • Pancreas injuries − High-energy forces are needed to damage − Patients present with vague upper and midabdominal pain radiating into the back. Injuries to Solid Abdominal Organs • Diaphragm injuries − Signs and symptoms: ventilatory compromise − Injuries are not isolated. − May result from blunt and penetrating trauma Injuries to Hollow Intraperitoneal Organs • Injuries to the small and large intestines − Most common from penetrating trauma − Rupture causes peritonitis. − Stomach rupture causes: • Rapid burning epigastric pain • Rigidity • Rebound tenderness Injuries to Hollow Intraperitoneal Organs • Stomach injuries − Commonly result from penetrating trauma − Trauma results in the spilling of acidic material. − Antacid medications may delay symptoms. Retroperitoneal Injuries • Injuries to this area do not present with signs and symptoms of peritonitis. − Occasionally bleeding can lead to: • Grey Turner sign • Cullen sign Vascular Injuries • Penetrating trauma is the major cause. • Often masked by other injuries • Significance depends on: − How many vessels were injured − length of time since the injury Duodenal Injuries • Rupture may occur in high-speed deceleration injuries. − Contents spill into the retroperitoneum. − Contamination causes abdominal pain or fever. • Close proximity to other organs Kidney Injuries • Generally caused by large forces • Suspect injury with: − Fractures of the 11th and 12th ribs − Flank tenderness Kidney Injuries • Rupture presents with: − Pain on inspiration − Gross hematuria • Penetrating renal trauma occurs with wounds in the abdomen or lower chest. Ureter Injuries • Difficult to identify • Rarely lead to an immediate life-threatening condition Bladder and Urethra Injuries • Associated with other significant injuries • May result in bladder rupture or laceration − Based on severity of mechanism and degree of bladder distention • Usually associated with pelvic injuries Bladder and Urethra Injuries • Rupture is associated with a high mortality rate. − Trauma often causes damage to other organs or vascular structures. − Urine may spill into the abdominal cavity. Assessment of Specific Injuries • Signs may not develop until a significant amount of blood is lost. − Bleeding can cause tenderness or distention. • Liver injuries result in blood and bile into the peritoneal cavity. Assessment of Specific Injuries • Signs/symptoms of splenic rupture are nonspecific. − Only Kehr sign may be present. Assessment of Specific Injuries • Pancreatic injuries have subtle or absent signs. − Suspect after localized blow to the midabdomen − Patients report vague upper and midabdomenal pain radiating to the back. Assessment of Specific Injuries • Findings of vascular injures depends on whether or not the bleeding is contained. • Blunt renal trauma may present as flank pain and hematuria. Assessment of Specific Injuries • Suspect bladder injury if: − Trauma to the lower abdomen or pelvis − Inability to urinate − Blood in the penile opening − Tenderness on palpation of suprapubic region • Signs and symptoms are nonspecific. Assessment of Specific Injuries • Signs of peritoneal irritation may indicate intraperitoneal bladder rupture. • Ultrasound may be used in the field. Management of Specific Injuries • Maintain a high index of suspicion. • Management of solid organ injuries includes: − Providing rapid transport − Monitoring vital signs Management of Specific Injuries • Care of bladder and urethra injuries: − Secure the airway. − Address breathing issues. − Support the circulatory system. − Immobilize the spine if necessary. Pathophysiology of Injuries to the Male Genitalia • Injuries to the testicle or scrotal sac − Loss of fertility is the major concern. − Blunt trauma is caused by motor vehicle crashes, physical assaults, sports injuries − Penetrating trauma is caused by stabbings, gunshots, blasts, or animal bites Pathophysiology of Injuries to the Male Genitalia • Penis injuries − Priapism can have nontraumatic causes. − A fractured penis may occur if erect and: • Impacted against partner’s pubic symphysis • Bent too far via self-manipulation Assessment of Injuries to the Male Genitalia • Contusions result in painful hematomas. • Rupture and torsion are difficult to identify. • Intrascrotal bleeding does not require much force. Assessment of Injuries to the Male Genitalia • Penile fracture may present as pain and a large hematoma. • When penetrating trauma occurs: − Control hemorrhage. − Assess the patient for other injuries. Management of Injuries to the Male Genitalia • Treat with attention to hemorrhage or evisceration. − Apply gentle compression and ice packs. − Provide pain relief and emotional support. Management of Injuries to the Male Genitalia • If Fournier gangrene occurs, provide prompt transport to the hospital. • Attempt to recover an amputated penis. • If an object is placed around the penis or testicles, do not attempt removal. Pathophysiology of Injuries to the Female Genitalia • Blunt trauma may result from: − Motor vehicle crashes − Saddle type injuries • Penetrating trauma may result from: − Stabbings to the lower pelvis − Gunshot wounds Assessment of Injuries to the Female Genitalia • Signs of trauma may include: − Hematomas and ecchymosis − Bleeding from the vagina − Tenderness on palpation of the lower pelvis Management of Injuries to the Female Genitalia • Use compression for external hemorrhage. • Administer replacement fluids if hypotensive. • Do not attempt to remove any object that is stuck in the vaginal canal. Summary • Unrecognized abdominal trauma is the leading cause of unexpected death in trauma patients. • The abdomen contains many vital organs and structures. • The quadrant system is generally used to describe a location in the abdomen. • The peritoneum is a membrane that lines the abdominal cavity. Abdominal trauma can lead to peritonitis. Summary • The retroperitoneal space is the area behind the peritoneum. • When a patient has experienced trauma to the chest or abdomen, you should suspect that he or she also has additional internal abdominal injuries. • Injury to the abdomen may be slow to develop, and can be fatal. Summary • Solid organs have a large blood supply and can easily be crushed by blunt trauma. • Injury to hollow organs can cause the release of toxins into the abdominal cavity, causing major peritonitis. • At least two thirds of all abdominal injuries involve blunt trauma. • Penetrating trauma causes open abdominal injury. Summary • During assessment, note the manner in which the patient is lying. Prioritize the ABCs. • Assessment should never delay patient care and transport! • Try to obtain as many details about an injury as possible. • Peritonitis can take hours to days to develop. Summary • Generally, management of patients with abdominal trauma is straightforward: − Ensure a secure airway. − Establish intravenous access and fluid replacement. − Minimize hemorrhaging with pressure dressings. − Apply a cardiac monitor and oxygen therapy, and then transport. Summary • Pelvic fractures can result in damage to the major vascular structures. • Because of the forces required to break the pelvis, if the patient has a pelvic fracture, suspect multisystem trauma. Credits • Chapter opener: © Mark C. Ide • Backgrounds: Green–Jones & Bartlett Learning; Purple–Jones & Bartlett Learning. Courtesy of MIEMSS; Blue–Courtesy of Rhonda Beck; Red–© Margo Harrison/ShutterStock, Inc. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.