ABDOMINAL TRAUMA
ABDOMINAL TRAUMA OBJECTIVES
Upon completion of this lecture, the learner should be
able to:
I. Identify the common mechanisms of injury
associated with abdominal trauma.
2. Describe the pathophysiologic changes as a basis
for signs and symptoms.
3. Discuss the nursing assessment of patients with
abdominal trauma.
ABDOMINAL TRAUMA OBJECTIVES
4. Based on the assessment data, identify appropriate
nursing diagnoses and expected outcomes associated
with patients with abdominal trauma.
5. Plan appropriate interventions for patients with
abdominal trauma.
6. Evaluate the effectiveness of nursing interventions
for patients with specific types of abdominal injuries.
INTRODUCTION
Epidemiology :
Abdominal injuries rank third as a cause of
traumatic death preceded by head and chest
injuries.
Mechanisms of Injury and Biomechanics

The abdomen is vulnerable to injury since there is
minimal bony protection for underlying organs.

The retropentoneal location of certain organs and
vascular structures (e.g., vena cava, aorta, pancreas,
and duodenum) these structures are less frequently
injured.

The physical examination of the abdomen may not be
successful in identifying intra-abdominal pathology;
therefore, a description of the mechanism of injury is
important.
Mechanisms of Injury and Biomechanics

The most common mechanism of blunt abdominal injury is a
motor “vehicle crash.Firearms, stabbings, and physical
assaults are associated with penetrating abdominal trauma.

Injuries to the abdomen can result from acceleration,
deceleration, or a combination of both forces.

Crushing forces may compress the duodenum or the pancreas
against the vertebral column.
Mechanisms of Injury and Biomechanics

During energy transfer, abdominal structures attached
by either ligaments or blood vessels may be stressed at
their attachment points

Safety restraint devices, particularly three-point safety
belts, provide significant protection; however, if they
are improperly positioned, they can cause deceleration
injuries to the lower abdomen.
Types of Injuries
Blunt or penetrating abdominal injuries are related to the:
 Type of force applied.
 Tissue density of structure injured (e.g.. fluid-filled, gasfilled, solid, or encapsulated)
The liver and spleen are the most commonly injured organs
from blunt trauma.
Organs of the abdomen are vulnerable to penetrating injury
not only through the anterior abdominal ,but through the
back, flank area, and lower chest.
The liver, small bowel, and stomach are the most commonly
injured organs from penetrating trauma.
Usual Concurrent Injuries

Because of their anatomical location, fractures of the
lower rib cage are often associated with spleen or liver
injuries

The patient with abdominal trauma, particularly
esophageal and gastric injuries, may have associated
chest trauma.

Patients with pelvic fractures frequently have
associated intra-abdominal trauma(bladder laceration).
SIGNS AND SYMPTOMS OF
ABDOMINAL TRAUMA
Signs and symptoms of blood loss.
Abdominal tenderness specific pain
patterns, and absent bowel sounds are
associated with abdominal injury
Blood Loss

Injuries to organs or abdominal blood vessels may lead
to extensive hemorrhage

Some abdominal organs are semi-fixed by ligaments,
such as the mesenteric attachments of the intestines.
When these organs are stressed at their points of
attachment, tears often occur at the point where the
vessels enter the organ.

The spleen and the liver have a rich blood supply and
store blood. Rapid loss of large blood volumes from
their parenchymal or vascular structures can occur.
Blood Loss
Bleeding from organs in the anterior abdomen is
usually confined to that cavity.
Bleeding from structures in the retro peritoneum
lead to hemorrhage in retroperitoneum which
is more difficult to evaluate and diagnose .
Pain


Pain, rigidity, guarding, or spasm, of the
abdominal musculature are classic signs of
intraabdominal pathology.
Rebound tenderness and guarding of the
abdominal muscles are caused by sudden
movement of irritated peritoneal
membranes against the abdominal wall.
Pain

Irritation may be because of the presence of free blood
or gastric contents in the peritoneal cavity.

Manifestations of pancreatic and duodenal injury are
related to hemorrhage in the area and the effect of
active enzymes on their surrounding tissues.

The resultant chemical peritonitis from the enzymes
released into the retroperitoneum and the significant
tissue swelling may not appear as signs and symptoms
for several hours after injury.
Pain

Pain can be referred to other areas of the body. An
example is the referred shoulder pain known as
Kehr’s associated with splenic rupture. The blood
that collects under the diaphragm causes irritation
of the phrenic nerve which innervates the
diaphragm.
Peristalsis
o
Following abdominal injury, bowel sounds are
frequently hypodynamic.
o
Blood in the abdominal cavity, direct bowel
injury, or any number of conditions including
stress may decrease peristaltic activity.
Hepatic Injuries
Injury to the liver range from controlled subcapsular
hematoma and laceration of the parenchyma to severe
vascular injury of the hepatic veins.
The friability of liver tissue ,the extensive blood supply
,and the blood storage capacity cause hepatic injury to
result in profuse hemorrhage.
The trend in blunt hepatic trauma is nonoperative
management of the hemodynamically stable patient.
Hepatic Injuries
The traditional treatment of liver trauma was
exploration and surgical packing but the
nontherapeutic laparotomy rate was as high as
67%, largely because most liver injury
hemorrhage resolves spontaneously before
laparotomy can be performed.
Hepatic Injuries
SIGNS AND SYMPTOMS:
Upper right quadrant pain
Abdominal wall muscle rigidity, spasm. or involuntary
guarding
Rebound tenderness
Hypoactive or absent bowel sounds
Signs of hemorrhage and/or hypovolemic shock
Splenic Injuries
Injury to the spleen is usually associated with blunt
trauma, but may also be associated with
penetrating trauma. Fractures of the left 10th to
12th ribs are associated with underlying damage to
the spleen.
Splenic Injuries
Injury to the spleen usually associated with blunt trauma but
may also be associated with penetrating trauma
Fractures to 10th to 12th ribs are associated with underlying
damage to the spleen
Injury to the spleen range from laceration to the capsule or
non expanding hematoma to ruptured subcapsular
hematoma or parenchymal laceration.
Signs and Symptoms
Signs of hemorrhage or hypovolemic shock
Pain in the left shoulder (Kehr’s sign)
Tenderness in the upper left quadrant
Abdominal wall muscle rigidity, spasm, or
involuntary guarding
ARTICLES
The American Association for the Surgery of Trauma Organ
Injury Severity Scale Liver grading system is as follows:

Grade I - Capsular avulsion; periportal blood tracking;
superficial laceration less than 1-cm deep; subcapsular
hematoma less than 1-cm thickness

Grade II - Laceration 1- to 3-cm deep; subcapsular/central
hematoma 1- to 3-cm diameter

Grade III - Laceration greater than 3-cm deep;
subcapsular/central hematoma greater than 3-cm diameter

Grade IV - Massive central or subcapsular hematoma greater
than 10 cm; lobar tissue maceration or devascularization
ARTICLES

Grade V - Bilobar tissue maceration or devascularization
The grade of hepatic injury does not necessarily correlate with
the rate of nonoperative treatment success. In grade III and
IV liver injuries, a wide range of nonoperative management
successes have been reported. Overall, the nonoperative
success rate in patients with liver trauma has been reported
to be as high as 89-98%.
Meredith JW, Young JS, Bowling J, Roboussin D: Nonoperative
management of blunt hepatic trauma: the exception or the
rule? J Trauma 1994 Apr; 36(4): 529-34; discussion 534-5