B

PCT2 - Abdominal

Blast Injuries

  • Primary Blast:
    • The initial pressure wave from the explosion.
  • Secondary Blast:
    • Injuries from flying fragments.
  • Tertiary Blast:
    • When the person is propelled through the air due to the explosion's force.
  • Miscellaneous Blasts:
    • Burns and respiratory injuries from hot gases or chemicals.
    • Inhalation of the pressure wind can cause rapid lung expansion and pneumothorax.

Patient Assessment - Altered Mental Status and Abdominal Trauma

  • Scenario:
    • Patient found in an alleyway, unsure of how he got there.
    • Ankle injury, remembers arguing with a friend.
    • Disoriented – doesn't know location, date, or year (unusual for this individual).
  • Concerns:
    • Possible intracranial pressure (ICP).
    • Abdominal guarding and bruising in the right upper quadrant.
  • Right Upper Quadrant Organs:
    • Gallbladder.
    • Liver.
  • Left Upper Quadrant Organs:
    • Stomach.
    • Spleen.
    • Pancreas.
  • Assessment Priority:
    • The ankle injury is of lower priority compared to potential internal injuries.
    • Prioritize ABCs (Airway, Breathing, Circulation), medical history, and Glasgow Coma Scale (GCS).

Internal Bleeding and Abdominal Guarding

  • Signs Indicating Internal Bleeding:
    • Decreased Level of Alertness (LOA).
    • Skin signs.
    • Tachycardia (rapid heart rate).
    • Hypotension (low blood pressure).
    • Abdominal guarding.
  • Abdominal Guarding:
    • Indicates peritonitis, which is inflammation of the lining of the abdomen.
    • Caused by blood or hollow organ contents spilling into the abdominal cavity.
    • Peritonitis is a late finding and can take hours to develop.
  • Blood Loss:
    • Significant blood loss from peritonitis can lead to shock.
    • Signs and symptoms may not appear until 40% or more of blood volume is lost.

Hollow vs. Solid Organs

  • Right Upper Quadrant:
    • Liver (solid organ): bleeds significantly when injured.
    • Gallbladder (hollow organ): expels contents.
  • Left Upper Quadrant:
    • Stomach (hollow organ): expels caustic contents (stomach acid, pH ~1).
    • Spleen (solid organ): fragile and bleeds heavily; often removed (splenectomy) if damaged.

The Spleen

  • Function:
    • Filters blood.
    • Removes old or damaged blood cells.
    • Key immunological organ.
  • Splenectomy:
    • Compromises the patient's immune response, making them more prone to illness.
  • Vascular Nature:
    • Highly vascular and bleeds profusely when injured.
  • Bruising:
    • Bruising along the lateral aspect of the thorax under the arm may indicate spleen injury.

Hemorrhage in Abdominal Trauma

  • Concerns:
    • Major concern due to potential for significant blood loss within the abdominal cavity.
    • Can be internal (blunt trauma) or external (open trauma).
  • Signs and Symptoms:
    • Hypovolemia (decreased blood volume).
    • Tachycardia (increased heart rate).
    • Hypotension (decreased blood pressure).
      • Blood\, Pressure = Heart\, Rate \times Stroke\, Volume
    • Increased respiratory rate.
    • Anxiety and agitation due to decreased blood flow to the brain.
    • Cool, pale, clammy skin.
    • Altered mental status.
  • Decompensating Stages of Shock:
    • Rapid heart rate and decreasing blood pressure indicate decompensation.
    • Requires immediate IV access, rapid transport to the hospital, and notification of the receiving facility.

Injury to Hollow Organs

  • Peritonitis:
    • Spillage of contents from hollow organs irritates surrounding abdominal tissues.
  • Pain Localization:
    • Generalized pain: Patient uses whole hand to indicate pain location, suggesting widespread peritoneal involvement.
    • Localized pain: Patient can point to the specific location with one or two fingers, suggesting confined contamination (e.g., appendicitis).
  • Abdominal Distension
    • May not be evident until significant blood loss (e.g., 3-4 liters in larger individuals; normal blood volume is about 6 liters).

Referred Pain

  • Diaphragmatic Irritation: Abdominal contents near the diaphragm on either side can cause referred pain.
    • Left side (spleen): Non-traumatic pain in the left shoulder tip.
    • Right side (liver, gallbladder): Non-traumatic pain in the right shoulder tip.
  • Explanation: Shared nerve plexus during fetal development results in referred pain patterns.

Notes on Liver

  • The liver is the heaviest organ in the body at around 1.4 kilograms.
  • It filters the body's blood.
  • It filters blood from the hepatic artery (from the heart) and from the intestine.
  • The liver filters and stores nutrients and also delivers oxygen.
  • It holds back nutrients for future cases.
  • The blood flowing into the liver also contains toxins and byproducts.
  • The liver monitors and excretes toxins.
  • It converts something into a product that can't hurt the body or isolates it and whisks it away, channeling it through the kidneys and intestine to be excreted
  • The liver also manufactures things, from various blood plasma proteins that transport fatty acids and help form blood clots to the cholesterol that helps the body create hormones.
  • It also makes vitamin D and substances that help digest it. But one of its most vital products is the bile.
  • It uses cells called cataclytes to convert toxic waste products into Bile.

Notes on Kidneys

  • The kidneys balance the amount of fluid in your body, detect waste in your blood, and know when to release the vitamins, minerals, and hormones you need to stay alive.
  • The body's eight liters of blood pass through the kidneys between twenty and twenty five times each day, meaning that together, these organs filter about 180 liters every twenty four hours.
  • It contains a glomerulus which is a blob like structure and a tubule which is a long stringy structure. The glomerulus works like a sieve, allowing only certain ingredients such as vitamins and minerals to pass into the tubule. Then this vessel's job is to detect whether any of those ingredients are needed in the body. If so, they're reabsorbed in amounts that the body needs so they can circulate in the blood again.
  • The tubules sense compounds the body doesn't need, like urea, leftover from the breakdown of proteins, and redirects them as urine out of the kidneys and through two long sewers called ureters.
  • The kidneys also have the power to activate vitamin D to secrete a hormone called renin that raises blood pressure and another hormone called erythropoietin, which increases red blood cell production.

Notes on Kidney Stones

  • The components of urine contain calcium, sodium, potassium, oxalate, uric acid, and phosphate. If the levels of these particles get too high or if urine becomes too acidic or basic, the particles can clump together and crystallize.
  • Calcium oxalate is the most common type of crystal (80%) to form this way
  • Masses less than five millimeters in diameter will usually pass out of the body on their own.
  • A doctor will often recommend drinking large amounts of water to help speed the process along and maybe taking some painkillers. If the stone is slightly larger, medications like alpha blockers can help by relaxing the muscles in the ureter and making it easier for the stone to get through.
  • Another medication called potassium citrate can help dissolve the stones by creating a less acidic urine.
  • Another option is pulverizing them with sound waves (Extracorporeal shockwave lithotripsy) by using high intensity pulses of focused ultrasonic energy aimed directly at the stone. The pulses create vibrations inside the stone itself, and small bubbles jostle it. These combined forces crush the stone into smaller pieces that can pass out of the body more easily.
  • A rigid tube called a stent can be placed in the ureter to expand it. Optical fibers can deliver laser pulses to break up the stone. Stones can also be surgically removed through an incision in the patient's back or groin.