CHAPTER 28: ABDOMINAL & GENITOURINARY INJURIES

PATIENT ASSESSMENT & CARE II

EMS 246

Dr.Bushra Bilal

ABDOMINAL CAVITY

• Abdomen is major body cavity extending from diaphragm to pelvis.

Contains organs that make up digestive, urinary, and genitourinary systems.

ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (1 OF 5)

• Abdominal quadrants

Right upper quadrant (RUQ)

Liver

gallbladder,duodenumpancreas

Left upper quadrant (LUQ)

Stomach,

Spleen

Right lower quadrant (RLQ)

Large and small intestine,the appendix

Left lower quadrant (LLQ)

Descending colon ,left half of transverse colon

ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (2 OF 5)

• RLQ is a common location for swelling and inflammation.

• The appendix is a source of infection if it ruptures.

ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (3 OF 5)

A hollow organ is a visceral organ that forms a hollow tube or pouch

Stomach, intestines, ureters, bladderMost of these contain digested food, urine, or bile.

When ruptured or lacerated, contents spill into peritoneal cavity and can cause infections such as peritonitis.

ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (4 OF 5)

Small intestine • Duodenum, jejunum,

and ileum

Large intestine • Cecum, colon, and

rectum

• Intestinal blood supply comes from mesentery.

ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (5 OF 5)

Liver, spleen, pancreas, kidneys• Solid masses of

tissue• Perform chemical

work of the body: enzyme production, blood cleansing, energy production• Because of rich

blood supply, hemorrhage can be severe.

INJURIES TO THE ABDOMEN

• Injuries to the abdomen are considered either open or closed.

CLOSED ABDOMINAL INJURIES (1 OF 2)

• Blunt trauma to abdomen without breaking the skin

– MOIs:• Steering wheel• Bicycle handlebars• Motorcycle collisions• Falls

– Compression • Poorly placed lap belt

– Deceleration• Fast-moving vehicle strikes an immoveable object.

CLOSED ABDOMINAL INJURIES (2 OF 2)

• Signs and symptoms

Pain : Diffuse, may be referred to another body location (such as the Kehr sign)

Blood in peritoneal cavity

Guarding: stiffening of abdominal muscles

Abdominal distention: result of free fluid, blood, or organ contents spilling into peritoneal cavity

Abdominal bruising and discoloration

OPEN ABDOMINAL INJURIES (1 OF 3 )

• Foreign object enters abdomen and opens peritoneal cavity to outside.

Also called penetrating injuries example stab wounds, gunshot wounds

• Injury depends on velocity of object.

OPEN ABDOMINAL INJURIES (2 OF 3)

• Evisceration: bowel protrudes from peritoneum.

• Can be painful and visually shocking

• Do not push down on abdomen.

• Only perform visual assessment.

• Never pull on clothing stuck to or in the wound channel.

Evisceration

OPEN ABDOMINAL INJURIES (3 OF 3)

• Signs and symptoms

Pain

TachycardiaHeart increases pumping action to compensate for

blood loss

Later signs include:• Evidence of shock• Changes in mental status• Distended abdomen

HOLLOW ORGAN INJURIES

• A hollow organ is a visceral organ that forms a hollow tube or pouch, such as the stomach or intestine, or that includes a cavity, like the heart or urinary bladder Often have delayed signs and symptoms

• Spill contents into abdomen. Infection develops.

• Both blunt and penetrating trauma can cause hollow organ injuries

Blunt: causes organ to “pop”

Air in peritoneal cavity causes pain, ischemia and infarction.

SOLID ORGAN INJURIES (1 OF 3)

• Liver is the largest organ in abdomen.

Vascular, can lead to hypoperfusion• Often injured by fractured lower right rib or

penetrating trauma• Kehr sign is common finding with injured liver.• is the occurrence of acute pain in the tip of the

shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated.

• Spleen and pancreas

prone to heavy bleeding

SOLID ORGAN INJURIES (3 OF 3)

• Diaphragm

– When penetrated or ruptured, loops of bowels invade thoracic cavity.• May cause bowel sounds during auscultation of

lungs• dyspnea.

• Kidneys

blood loss

blood in urine (hematuria).

PATIENT ASSESSMENT OF ABDOMINAL INJURIES

• Patient assessment steps

Scene size-up

Primary assessment

History taking

Secondary assessment

Reassessment

SCENE SIZE-UP

• Scene Safety

Standard precautions of gloves and eye protection should be a minimum

Be sure scene is safe for you

PRIMARY ASSESSMENT (1 OF 2)

• Evaluate patient’s ABCs.

• Form a general impression.

– Check for responsiveness using AVPU scale

• Airway and breathing

– Ensure airway is clear and patent.

– Clear airway of vomitus (note the nature)

PRIMARY ASSESSMENT (2 OF 2)

• Circulation

Superficial abdominal injuries usually do not produce significant external bleeding.

Internal bleeding can be profound specially trauma to liver, kidneys and spleen.

• Transport decision

Abdominal injuries generally indicate a quick transport to the hospital.

HISTORY TAKING

• Investigate chief complaint, focus on MOI

• SAMPLE history

If patient is not responsive, obtain history from family or friends.

Ask if there is nausea, vomiting, diarrhea and appearance of any bowel and urinary output.

SECONDARY ASSESSMENT

Physical examinations Inspect for bleeding.Evaluate the bowel sounds.

Hypoactive = cannot hear soundsHyperactive = lots of gurgling and gas moving about

Use DCAP-BTLSPerform full-body scan to identify injuries, beginning

with head

• Vital signsMany abdominal emergencies can cause a rapid pulse

and low blood pressure.

REASSESSMENT

• Repeat the primary assessment and reassess vital signs.

• Interventions

Manage airway and breathing problems.

Provide spinal stabilization, treatment for shock

Cover wounds

• Communication and documentation

Communicate all relevant information to staff at receiving hospital.

EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (1 OF 4)

• Closed abdominal injuries• Patient requires immediate transport.• Apply high-flow oxygen.• Treat for shock.

Patient with blunt abdominal injury should be log rolled to a supine position on a backboard.

Monitor vital signs

EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (2 OF 4)

• Open abdominal injuries

Patients with penetrating injuries

Inspect patient’s back and sides for exit wound.

Apply dry, sterile dressing to all open wounds.

If penetrating object is still in place, apply stabilizing bandage around it.

EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (3 OF 4)

Evisceration: Severe lacerations of abdominal wall may result in internal organs or fat protruding through wound.

EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (4 OF 4)

• Open abdominal injuries (cont’d)

Never try to replace a protruding organ.• Keep the organs moist and warm.• Cover with moistened, sterile gauze or occlusive

dressing.• Secure dressing with bandage.• Secure bandage with tape.

ANATOMY OF THE GENITOURINARY SYSTEM (1 OF 3)

• Controls reproductive functions and waste discharge

Male genitalia lie outside pelvic cavity.• Except prostate gland and seminal vesicles

Female genitalia lie within pelvic cavity.• Except vulva, clitoris, labia

ANATOMY OF THE GENITOURINARY SYSTEM (2 of 3)

Anatomy of the Genitourinary System (3 of 3)

INJURIES OF THE GENITOURINARY SYSTEM (1 OF 4)

Kidney injuries

Suspect kidney damage if:

• Abrasion, laceration, contusion in the flank

• Penetrating wound in region of flank or upper abdomen

• Fractures on either side of lower rib cage

• A hematoma in the flank region

INJURIES OF THE GENITOURINARY SYSTEM (2 OF 4)

• Urinary bladder injuries

• Blunt injuries to lower abdomen or pelvis can rupture urinary bladder.

• In later trimesters of pregnancy, bladder injuries increase.

INJURIES OF THE GENITOURINARY SYSTEM (3 OF 4)

• External male genitalia injuries

– Soft-tissue wounds, painful but not life threatening.

• Female genitalia injuries• Uterus, ovaries, fallopian tubes are rarely damaged, the

exception is pregnant uterusUterus enlarges substantially and rises out of pelvisAlso keep fetus in mind.In last trimester of pregnancy, uterus is large and may

obstruct vena cava.

INJURIES OF THE GENITOURINARY SYSTEM (4 OF 4)

External female genitalia• Very rich nerve supply• Consider sexual assault and pregnancy.• If there is external bleeding, a sterile absorbent

sanitary pad may be applied to the labia.• Do not insert anything into the vagina.

PATIENT ASSESSMENT OF THE GENITOURINARY SYSTEM (1 OF 2)

• Potential for patient embarrassment

Maintain a professional presence.

Provide privacy .

Have EMT of same gender perform assessment.

Look for blood on patient’s undergarments.

PATIENT ASSESSMENT OF THE GENITOURINARY SYSTEM (2 OF 2)

• Patient assessment steps

Scene size-up

Primary assessment

History taking

Secondary assessment

Reassessment

SCENE SIZE-UP

• Scene safety

Assess the scene for hazards and violence.

• Mechanism of injury/nature of illness

Look for indicators of MOI.• Patient may avoid the discussion to avoid undergoing

a physical exam.• Patient may also provide an MOI that seems less

embarrassing than the actual MOI.

PRIMARY ASSESSMENT (1 OF 2)

• Form a general impression.

Important indicators will alert you to the seriousness of the condition.• Is the patient awake and interacting?• Are there any life threats?• What color is the patient’s skin?• Is he or she responding appropriately or

inappropriately?

PRIMARY ASSESSMENT (2 OF 2)

• Airway and breathing Ensure the patient has a clear and patent airway.

• Circulation Genitourinary system can be a significant source of bleeding. Assess pulse rate and quality. Determine skin condition, color, and temp. Check capillary refill time.

• Transport decision

HISTORY TAKING

• Investigate chief complaint.

Common associated complaints are:• Nausea and vomiting, Diarrhea• Blood in urine• Vomiting blood• Abnormal bowel and bladder habits

• SAMPLE history

Ask about pain, output especially blood in urine allergies, past medical history, last intake of food and fluid.

SECONDARY ASSESSMENT

• Physical examinations

Look for DCAP-BTLS.

Identify wounds and control bleeding.

Start with a full-body scan for significant trauma.

• Vital signs

Obtain the patient’s vital signsTachycardia; tachypnea; low blood pressure; weak

pulse; and cool, moist, pale skin indicate hypoperfusion.

REASSESSMENT

• Interventions

Provide oxygen and maintain airway.

Control bleeding and treat for shock.

• Communication and documentation

Communicate all concerns to hospital staff.

Describe and document all injuries and treatments given.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (1 OF 7)

• Kidney injuriesSigns of shockBlood in urine (hematuria)

– Treat for shock, transport promptly, monitor vital signs en route.

• Urinary bladder injury• Blood at urethral opening• Signs of trauma to lower abdomen, pelvis, perineum

– In presence of shock, transport promptly and• Monitor vital signs en route.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (2 OF 7)

• External male genitalia

– General rules for treatment:• Make patient comfortable.• Use sterile, moist compresses to cover areas stripped

of skin.• Apply direct pressure with dry, sterile gauze dressings

to control bleeding.• Never move or manipulate foreign objects in urethra.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (3 OF 7)

Laceration of head of penis • Associated with heavy bleeding• Apply local pressure with sterile dressing.

Skin of shaft or foreskin caught in zipper• If small segment of zipper is involved, try to unzip.• If long segment of zipper is involved, cut the zipper

out of the pants with heavy scissors.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (4 OF 7)

Urethral injuries • Straddle injuries, pelvic fractures, and 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.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (5 OF 7)

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; use local pressure for bleeding.

Direct blows to scrotum can result in rupture of a testicle or accumulation of blood around testes.• Apply ice to scrotal area.

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (6 OF 7)

• Female genitalia

Treat lacerations and avulsions with moist, sterile compresses.• Use local pressure to control bleeding.

Do not pack dressings into vagina.

Leave any foreign bodies in place after stabilizing with bandages

EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (7 OF 7)

• Rectal bleeding

Possible causes include sexual assault, hemorrhoids, colitis, ulcers.

Acute rectal bleeding should never be passed off as something minor.

SEXUAL ASSAULT (1 OF 2)

• Sexual assault and rape are common.

• Victims are generally women.

• Do not examine genitalia unless obvious bleeding requires application of dressing.

• Follow appropriate procedures and protocol.

Shield patient from curious onlookers.

Document patient’s history, assessment, treatment, and response to treatment

SEXUAL ASSAULT (2 OF 2)

Follow crime scene policy of your EMS system.

Advise patient not to wash, douche, urinate, or defecate until after examination.

If oral penetration occurred, advise patient not to eat, drink, brush the teeth, or use mouthwash until after examination.

Handle patient’s clothes as little as possible.

Make sure EMT caring for patient is same gender as patient whenever possible.

SUMMARY

• Abdominal injuries are categorized as either open (penetrating trauma) or closed (blunt force trauma).

• Blunt force trauma that causes closed injuries results from an object striking the body without breaking the skin, such as being hit with a baseball bat or when the patient’s body strikes the steering wheel during a motor vehicle crash.

• Penetrating trauma is often a result of a gunshot wound or stab wound. Other MOIs such as a fall on an object can also cause penetrating trauma to the abdomen.

SUMMARY

• Always maintain a high index of suspicion for serious intra-abdominal injury in the trauma patient, particularly in the patient who exhibits signs of shock.

• Assess the abdomen for signs of bruising, rigidity, penetrating injuries, and pain.

• Never remove an impaled object from the abdominal region. Secure it in place with a large bulky dressing and provide prompt transport.

• Be prepared to treat the patient for shock. Place the patient in the modified shock position, keep the patient warm, and provide high-flow oxygen.

SUMMARY

• Never replace an organ that protrudes from an open injury to the abdomen (evisceration). Instead, keep the organ moist and warm. Cover the injury site with a large sterile, moist, bulky dressing.

• Injury to the external genitalia of male and female patients is very painful but not usually life threatening.

• In the case of sexual assault or rape, treat for shock if necessary, and record all the facts in detail. Follow any crime scene policy established by your system to protect the scene and any potential evidence. Advise the patient not to wash, douche, or void until after a physician has examined him or her.

UNIT ASSESSMENT

• List three signs and symptoms associated with abdominal injuries

• What is the displacement of abdominal organs outside of the body called?

 

 • What findings would suggest damage to the kidneys?