CHAPTER 28: ABDOMINAL & GENITOURINARY INJURIES

PATIENT ASSESSMENT & CARE IIEMS 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)Livergallbladder,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 pouchStomach, intestines, ureters, bladder

Most 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 PainTachycardia

Heart 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 injuriesBlunt: 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 pancreasprone 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 stepsScene size-upPrimary assessmentHistory takingSecondary assessmentReassessment

SCENE SIZE-UP

• Scene SafetyStandard precautions of gloves and eye protection should

be a minimumBe 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)

• CirculationSuperficial abdominal injuries usually do not produce

significant external bleeding. Internal bleeding can be profound specially trauma to

liver, kidneys and spleen.

• Transport decisionAbdominal 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 signs

Many 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 shockCover wounds

• Communication and documentationCommunicate 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 injuriesPatients 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.

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?