Abdominal Injuries

Abdomen extends from diaphragm to pelvis, containing the digestive, urinary, and genitourinary systems.

Significant trauma can occur from blunt, penetrating, or both types of trauma.

There are 4 quadrants:

• RUQ: Liver, gallbladder, duodenum, pancreas

• LUQ: Stomach and spleen

• LLQ: Descending colon, left transverse colon.

• RLQ: Large and small intestine, appendix; Common location for swelling of inflammation, since the appendix is a source of infection if it ruptures.

Hollow Organs: Stomach, intestines, ureters, bladder; when ruptured/lacerated, contents spill into peritoneal cavity and can cause intense inflammatory reaction/infection like peritonitis.

• Intestinal blood comes from mesentery, connects the small intestine to the abdominal wall, patients with injuries to the mesentery can bleed into the peritoneal cavity.

Solid Organs: Liver, spleen, pancreas, kidneys; perform the chemical work of the body: enzyme production, blood cleansing, energy production; because of rich blood supply, hemorrhage can be severe.

Abdominal injuries are either open or closed, and can involve hollow and/or solid organs.

Closed Abdominal Injuries:

• Blunt trauma to abdomen; MOIs: Motor vehicle crashes, falls, blast injuries, pedestrian vs bicycle, rapid deceleration, compression

  • S/S: Blood in peritoneal cavity produces acute pain in entire abdomen; Abdominal distension is often the result of free fluid, blood, or organ contents spilling into peritoneal cavity; abdominal bruising and discoloration

• Seat belts can cause blunt injuries to abdominal organs, particularly when belt lies too high, and can cause bladder injuries to pregnant patients. Inspect beneath airbag for signs of damage to the steering column.

Open Abdominal Injuries:

• Foreign object enters abdomen and opens peritoneal cavity to the outside. Open wounds can be deceiving, so maintain a high index of suspicion.

• Damage depends on velocity of object

  • Low-velocity injuries: Knives and other edged weapons

  • Medium-velocity injuries: Small caliber handguns and shotguns

  • High-velocity injuries: High-powered rifles and handguns

• High and medium velocity injuries have temporary wound channels, caused by cavitation; cavity forms as pressure wave from projectile transfers to tissues, can produce large amounts of bleeding.

• Low velocity injuries also have the capacity to damage organs, although internal injury may not be apparent. If injury is at or below xiphoid process, assume it has affected the thoracic and peritoneal cavities.

• Evisceration: Bowel protrudes from peritoneum

  • Can be painful and visually shocking, but do not push down on abdomen and only perform a visual assessment. Cut clothing close to wound, and never pull on clothing stuck to or in the wound channel.

Hollow Organ Injuries:

• Often delayed signs and symptoms

• Spill contents into abdomen; infection develops which can take hours or days. Stomach intestines can leak highly toxic and acidic liquids into peritoneal cavity.

• Blunt trauma causes organ to “pop” which releases fluids and air.

• Penetrating trauma causes direct injury.

• If contents of gallbladder and urinary bladder release, it’s damaging.

• Air in peritoneal cavity causes pain, and can cause ischemia and infarction.

Solid Organ Injuries:

• Can bleed significantly and cause rapid blood loss.

• Can be hard to identify from physical exam, and slowly ooze blood into peritoneal cavity.

• Liver is the largest organ in the abdomen. Vascular & can lead to hypoperfusion, often injured by fractured lower right rib or penetrating trauma; referred pain to the right shoulder is a common finding with an injured liver.

• Spleen and pancreas are vascular and prone to heavy bleeding, with the spleen often injured in motor vehicle collisions, steering wheel trauma, falls from heights, bicycle and motorcycle accidents involving handlebars.

• When diaphragm is penetrated or ruptured, loops of bowels invade thoracic cavity, and patient may exhibit dyspnea.

• Kidneys can cause significant blood loss, with a common finding being blood in urine; blood visible in urinary meatus indicates significant trauma to genitourinary system.

Assessment of Abdominal Injuries can be difficult, since causes of injury may be apparent but resulting tissue damage may not be; patient may be overwhelmed with more painful injuries, and some injuries develop and worsen over time.

Assessment:

• Standard scene-size up

• Primary assessment:

  • quickly form general impression and not LOC, severe external hemorrhage must be addressed before airway or breathing. Treat signs and symptoms of shock aggressively, and patients with abdominal injuries should be evaluated at the highest level of trauma center available.

• History Taking:

  • Investigate chief complaint and MOI, movement of body or abdominal organs irritates peritoneum, causing pain. SAMPLE & OPQRST; ask for nausea, vomiting, or diarrhea, and ask about appearance of any bowel movements and urinary output.

• Secondary Assessment:

  • May not have time to do in field

  • Inspect for bleeding, remove or loosen clothes to expose injuries, patient should remain in position of comfort, examine entire abdomen.

  • DCAP-BTLS

  • Inspect and palpate for deformities, look for presence of contusions, abrasions, puncture wounds, penetrating injuries, burns

  • Palpate for tenderness and attempt to localize to specific quadrant of abdomen

  • Swelling may indicate significant intra-abdominal injury

  • Palpate the quadrant farthest away from quadrant exhibiting signs of injury and pain, since it allows you to investigate possibility of pain radiating

  • Perform full-body scan and if life threat is found, stop and treat it.

  • Inspect and palpate kidney area for tenderness, bruising, swelling or other trauma signs.

  • Many abdominal emergencies can cause a rapid pulse and low blood pressure. Record of vital signs will help identify changes in condition.

Assessment of an Isolated Abdominal Injury

• Visually inspect abdomen for penetrating wounds, if entrance is found check for corresponding exit wound, and do not remove impaled object.

Reassessment:

• Repeat the primary assessment and reassess vital signs.

• Reassess interventions and treatment.

• Communication and documentation; outline the patient’s MOI, injuries, and relevant vital signs

Emergency Medical Care of Abdominal Injuries

• For closed abdominal injuries: monitor and evaluate for progression into shock, patient may experience nausea and vomiting, administer oxygen to patients who are unconscious or in shock. Assist ventilations if necessary. Consider calling ALS for gastric tube placement.

• For open abdominal injuries: patients with penetrating injuries generally have obvious wounds, external bleeding, maintain a high index of suspicion for serious unseen blood loss. If penetrating object is still in place, apply stabilizing bandage around it.

• For evisceration, never try to replace a protruding organ, keep them moist and warm, cover with moistened, sterile dressings; secure the dressing with bandage, and secure bandage with tape.

Anatomy of the Genitourinary System

• Controls reproductive functions and waste discharge; organs of the genitourinary system are located in the abdomen, male genitalia lie outside pelvic cavity, while female genitalia are within.

Injuries of the Genitourinary System:

• Kidney injuries are not uncommon but rarely occur in isolation; they lie in a well-protected area, so a forceful blow or penetrating injury are often involved.

  • Suspect kidney damage if patient has evidence of any of the following: Abrasion, laceration, contusion on the flank. Penetrating wound in region of flank or upper abdomen. Fractures on either side of lower rib cage or of lower thoracic or upper lumbar vertebrae. A hematoma in the flank region.

• Urinary Bladder injuries may result in rupture, where urine spills into surrounding tissues. Blunt injuries to lower abdomen or pelvis can rupture urinary bladder. In males, sudden deceleration can shear the bladder from the urethra. In later trimesters of pregnancy, bladder injuries increase.

• External male genitalia injuries are usually soft tissue wounds, painful and of great concern for the patient. They’re rarely life threatening and should not be given priority over more severe wounds unless severe bleeding is present. Pain may be referred to the lower abdomen.

• Internal female genitalia injuries involve the uterus, ovaries, fallopian tubes are rarely damaged. Exception is pregnant uterus, where it enlarges substantially and rises out of pelvis. Injuries can be serious, also keep fetus in mind.

• External Female genitalia injuries involve the vulva, clitoris, major and minor labia, all are very rich in nerve supply. Consider sexual assault and pregnancy. If external bleeding, sterile absorbent sanitary pad may be applied to the labia. Do NOT insert anything into the vagina.

Patient Assessment of the Genitourinary System

• Potential for patient embarrassment, so be professional and provide presence, have EMT of same gender perform assessment.

Scene Size Up (For Genitourinary)

• Standard scene safety, but patient may avoid discussion to avoid undergoing physical exam, and they may provide MOI that seems less embarrassing than actual MOI.

Primary Assessment (Genitourinary)

• Typical quick scan, life-threatening hemorrhage must be addressed immediately.

• Assist ventilations with BVM is needed, consider advanced airway if patient is unresponsive.

• Assess pulse rate and quality, treat for shock.

• Transport to a trauma center.

History Taking (Genitourinary)

• Common associated complaints are: Nausea and vomiting, diarrhea, blood in urine, vomiting blood, abnormal bowel and bladder habits.

• SAMPLE and OPQRST

• Ask patient about output, especially blood in urine. Allergies, last intake, events leading to injury.

Secondary Assessment (Genitourinary)

• Can be awkward to assess and treat, focus on specific region of body when isolated injury is present. DCAP-BTLS. Identify wounds and control bleeding, obtain vitals and reassess frequently.

Reassessment (Genitourinary)

• Repeat primary assessment and vital signs. Adjust interventions as needed.

Emergency Medical Care of Genitourinary Injuries:

• Kidney injuries may not be obvious, you will see signs of shock and blood in urine. Treat for shock, transport promptly, and monitor vital signs en route.

• For urinary bladder injury, suspect if you see blood at urethral opening, signs of trauma to lower abdomen, pelvis, or perineum. In presence of shock or associated injuries, transport promptly and monitor vitals en route.

• External male genitalia:

  • make patient comfortable, use sterile, moist compresses to cover areas of stripped skin; apply direct pressure with dry, sterile gauze dressings to control bleeding

  • Never move or manipulate foreign objects in urethra.

  • Identify and take avulsed parts in bag to hospital with patient. In cases of amputation of penile shaft, managing blood loss is the top priority using local pressure with sterile dressing. If you can locate the amputated part surgical reconstruction is possible.

  • When erect penis is bent sharply, shaft can be severely damaged.

  • Laceration of head of penis is associated with heavy bleeding, so apply local pressure with sterile dressing. Skin of shaft or foreskin caught in zipper, try to unzip if small segment of zipper is involve, if large segment then cut zipper out of pants.

  • Urethral injuries are not uncommon; straddle injuries, pelvic fractures, penetrating wounds of the perineum. Important to know if patient can urinate and if there is blood in urine. Foreign bodies protruding from urethra will have to be surgically removed.

  • Avulsion of the skin of the scrotum may damage scrotal contents, preserve avulsed skin in a moist sterile dressing. Wrap scrotal contents or perineal area with a sterile moist compress. Direct blows to scrotum can result in rupture of a testicle or accumulation of blood around testes, so apply ice to scrotal area.

• Female Genitalia:

  • Treat lacerations and avulsions with moist sterile compresses. Use local pressure to control bleeding, and hold dressings in place with diaper-type bandage. Do NOT pack dressings into vagina.

  • Leave any foreign bodies in place after stabilizing with bandages, injuries are painful but not life threatening.

• Rectal bleeding is a common complaint, possible causes include sexual assault, rectal foreign bodies, hemorrhoids, colitis, ulcers.

Sexual Assault:

• SA and rape is common, generally women but sometimes men and children. Often little to do beyond providing compassion and transport. May need treatment for shock.

• Do not examine genitalia unless obvious bleeding requires application of dressing, and follow appropriate procedures and protocol. Document.

• Follow crime scene policy, and advise patient not to do anything until after examination. No washing, using bathroom, cleaning mouth, and handle clothes as little as possible.

• Make sure EMT caring for patient is same gender if possible.