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Abdominal TraumaPrehospital Trauma Life Support
Intro
´ Unrecognized ABD injury is one of the most common causes of preventable death in trauma patients.
´ Usually die due to significant blood loss
´ Always rule out internal abdominal hemorrhage in all unexplained shocks
´ ABD is a poor historian so don’t exclude abd trauma if no acute symptoms in the abd.
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Anatomy
´ Abd contains all of the major organs of digestive, endocrine and urological systems.
´ Major vessels found in the abdcavity.
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External Genitalia
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Pathophysiology
´ Non Traumatic´ Anorexia
´ Vomiting´ Nausea´ Retching´ Constipation
´ Diarrhea´ ABD Pain´ GI Bleeding
´ Dysphagia ´ GERD´ Hiatal hernia´ Pyloric obstruction
´ Intestinal obstruction
´ Gastritis
´ Peptic Ulcer
´ Gastric Ulcer
´ Malabsorption syndromes
´ Inflammatory bowel disease
´ Ulcerative Colitis
´ Crohn Disease
´ Diverticular Disease
´ Appendicitis
´ Liver disease
´ Gallstones
´ Pancreatitis
´ Cancers
´ Traumatic´ Penetrating trauma
´ Blunt trauma
´ Impaled Objects
´ Evisceration
´ Obstetrical Trauma
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General Assessment´ Mechanism of Injury
´ Blunt? Penetrating?
´ History´ SAMPLE´ Collision Specific:
´ Type, position of patient, ejection?
´ Vehicle speed´ Extent of vehicle damage
´ Seat belts? ´ Penetrating
´ Type of weapon´ Number of penetrations
´ Distance from gun (if shooting)´ Blood on scene
Physical Examination
´ Inspection´ Examine for soft-tissue injuries, distension, symmetry, bruising, evisceration,
impaled objects, tire marks, etc.
´ Palpation´ Typically start right to left, or from area of less injury
´ Voluntary guarding: patients reaction to pain
´ Involuntary guarding: rigidity or spasm and remains without provocation
´ Rebound tenderness: pain when pressure released indicates peritonitis
´ Deep palpation to identify organs not necessary when trauma present
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´ Auscultation´ Not all that useful in a trauma
´ If you hear bowel sounds when auscultating the chest good indicator that the diaphragm is ruptured
´ Percussion´ Does indicate fluid but may not be crucial finding if already assessed by other
means
´ Defiantly can be useful if not sure
´ Tympanic or dull sounds may indicate liquid
´ Percussing kidney can indicate injury with pain
Systematic Approach
´ Inspect the abdomen´ Auscultate (if appropriate) (consider vascular auscultation)´ Palpate starting from the right quadrant to the left if no visible issues´ McBurney’s Point´ Murphy’s Sign´ Examine for Spleenic Enlargement´ Inspect genitalia ´ Palpate genitalia only if indicated ´ Palpate femoral pulses´ Percuss kidney landmarks
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Other assessment parameters
´ Don’t forget your basic principles ´ Scene size up
´ Primary
´ ABCDE
´ Secondary
´ Focused or complete
´ SAMPLE
´ Vitals
´ Ongoing Care
Field Ultrasounds
´ New technique in emergency care to find damage to tissues, vessels, free fluid, etc.
´ Need lots of expertise in reading u/s to be effective
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Impaled Objects
´ Standard management
´ Do not remove the object´ Stabilize the object and control bleeding from around the injury site
´ Do not palpate or percuss the organs as further damage can occur.
Evisceration
´ Organ penetrating through open wound
´ Treatment is to protect the protruding segment´ Never replace the organs
´ Apply a clean, sterile dressing saturated in NaCl
´ Continue to re-saturate the dressing as it dries
´ Wet dressings may also be covered by an occlusive dressing
´ Keep patient calm
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Internal Bleed
´ Stabilize vital signs
´ Consider IV ´ Careful consideration: IV increases blood volume, but can also
affect the ability to form a clot at the location of the bleed.
´ Trendelenburg position?´ Goal is to maintain systolic pressure >90 as long as no
indicator of TBI
Obstetrical
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Genitourinary Injuries
´ Blood in the urine or visible blood loss from the genitals is the usual sign
´ Pelvic fractures can cause lacerations to urinary bladder and walls of the vagina
´ Trauma can occur from many MOI
´ Most injuries are ‘external’
´ Bleeding controlled with direct pressure
´ Never insert dressings into the vagina, just external ´ Amputations managed like any other amputation