Abdominal InjuriesFirst Aid and Treatment Options

Anas Bahnassi PhD

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Anas Bahnassi PhD CDM CDE 2

Introduction:

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Anatomy and major abdominal trauma

Blunt abdominal trauma may push the abdominal content upward and cause rupture of the diaphragm.

Abdominal trauma is a major component of traumatic injury and can be deadly.

Blunt trauma can occur during falls, motor vehicle accidents, or severe blows to the abdomen.

Introduction:

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Physiology review

• The liver is a vascular solid organ in the right upper quadrant, protected by the lower ribs, than may be lacerated by blunt trauma.

• The resultant bleeding can be massive.

Gallbladder injury is unusual but may release bile into the abdominal cavity causing a severe peritoneal reaction.

Introduction:

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Physiology review

• The spleen is a highly vascular organ located behind the stomach and protected by the lower ribs on the left side of the body.

• The spleen is the most commonly injured organ in blunt abdominal trauma and it can bleed profusely when injured.

Fractures of lower ribs on the left side along with hypotension should raise suspicion of spleen injury.

Introduction:

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Physiology review

Abdominal injuries can significantly delay intestinal emptying.Bowels rupture is most frequently associated to penetrating injuries.

Injuries that break bowel wall spill the intestinal contents into the peritoneal cavity causing peritoneal irritation with diffuse abdominal pain, tenderness and ilus as the commonest findings

Introduction:

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Physiology review

The urinary bladder is vulnerable to injury when the pelvis is fractured.The pancreas, duodenum, kidneys, ureters, aorta and inferior cava are retroperitoneal structures. Injuries to them are difficult to detect for retroperitoneal bleeding does produce neither abdominal distension nor peritoneal reaction.

The pancreas. Seriously injury to the pancreas is not common in accidents. Damage can be seen in cases of kicking injuries, abdominal gunshot wounds. When injured can bleed profusely and release digestive juices into the abdomen

Types of Abdominal Trauma

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Most commonly, symptoms and signs of blunt abdominal trauma are subtle and the diagnosis of intra-abdominal injury uncertain therefore is important to assess adequately the mechanisms of injury.

Suspect intraabdominal injury whenever penetrating trauma to the chest, abdomen, back or buttocks has occurred.Shotgun wounds may cause abdominal devastating injuries.Sharp instruments wounds cause local tissue disruption.

Primary Survey

• Airway– Ensure an adequate airway since vomiting may compromised the

airway in abdominal trauma. (See indications for endotrachealintubation).

• Breathing– Auscultate the chest for breath sounds. Impairment of breathing and

presence of bowel sounds may indicate rupture of the diaphragm.

– If there is an inadequate oxygenation, oxygen should be delivered at a high flow rate.

– If adequate ventilation or oxygenation cannot be provided by other means, bag-mask ventilation followed by pharyngeal or tracheal intubation should be used.

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Primary Survey

• Circulation– Look for signs of hypotension or shock.

– Hypotension and left upper quadrant trauma is suggestive of ruptured spleen.

– Maintain a high index of suspicion for intra-abdominal or retroperitoneal bleeding if the patient has unexplained hypotension or shock. This is an indication for peritoneal lavage, exploratory laparatomy or focused abdominal sonography for trauma. Computed tomography is only recommended for the evaluation of hemodynamically stable patients.

– Begin treatment for hypotension or shock if present.

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Primary Survey

• Disability– Assess the level of responsiveness with the AVPU scale

– Check pupil size and reflection to light.

• Exposure/Monitoring– Undress the patient for further examination.

– Monitor BP, HR, EGC, temperature, etc…

– Obtain arterial blood gases to evaluate the adequacy of ventilatoryfunction and the severity of tissue perfusion.

– Perform frequent monitoring of vital signs.

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Secondary Survey

• Perform a detailed head to toe survey and obtain as detail a medical history of the patient as possible.

• Chest:

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Check for broken ribs than may indicate abdominal organs injury.

Fractures of the 7th -9th ribs on the right or the left side may be associated to liver injury or spleen injury.

Secondary Survey

• Abdomen

– Altered level of consciousness due to trauma

– intoxicated patients

confounding factors in the accuracy of abdominal assessment.

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Secondary Survey

• Abdomen

– Levels of abdominal pain and reaction to palpation are unreliable (often masked by other major injuries.)

– Peritoneal irritation signs produced by blood loss or spillage of bowel content may not develop for one to four hours.

– Distention is a late and unreliable sing.

– Bruises may take several hours to develop.

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Secondary Survey

• Abdomen

– Fractures of the lower ribs, vertebral fractures, transverse process fractures are often associated with renal injuries.

– Renal vessel lacerations may cause intensive blood loss into the retroperitoneal space.

– Major renal trauma causes gross hematuria.

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Secondary Survey

• Abdomen

– Palpate for a rigid, distended abdomen or involuntary guarding, which may indicates significant intraabdominal injury.

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Abdominal evisceration does not take precedence over the ABCD approach of the primary survey.

Management

• Cover any exposed abdominal viscera with sterile saline-soaked packs do not attempt to reduce the viscera into the abdomen

• Do not remove any impaled foreign matter. Stabilize impaled objects with bulky dressings that are bandaged in place.

• Assess the pelvis for associated fractures by pressing over the anterior iliac crest to detect instability.

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Pelvis Fracture

• A fractured pelvis may produce a blood loss up to 3 L

• Examine the anus and vagina to confirm their integrity. Rectal bleeding may be suggestive of trauma to the colon. Pelvic fractures may disrupt the vaginal wall.

• Look for lacerations, haematoma, active bleeding, scrotal contusions or haematomas than may indicate testicular rupture.

• Look for associated urinary bladder or urethral injury.

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Pelvis Fracture

• Pelvic fractures are often associated with bladder injuries and gross haematuria.

• Extravagation of blood or urine may cause perineal or genital swelling.

• High rising prostate or an absent prostate indicates posterior urethral injury.

• Other signs or urethral injury include pelvic fracture, perineal haematoma, blood at the urethral meatus, inability to urinate.

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Pelvis Fracture – Management.

• Fluid resuscitation

• Determine if open or closed fracture

• Determine associated perineal /GU injuries

• Determine need for transfer

• Splint pelvic fracture

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Pelvis Fracture – Management.

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Management

• Extremities

– Liver or spleen injury may cause referred right shoulder pain or referred left shoulder pain respectively that may be enhanced by Trendelenburg position.

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Management

• Other Considerations

– Insert a nasogastric tube to drain and decompress the stomach.

– Insert a urinary catheter to monitor urine output if no contraindications exist (meatal bleeding, scrotal haematoma or prostate malposition)

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Clinical Pharmacy VI:First Aid

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Anas Bahnassi PhD CDM CDE