Abdominal Trauma

Tim Diklat IRD RSSA 09

The Abdomen
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Everything between diaphragm and pelvis Injury, illness very difficult to assess because of large variety of structures

Abdominal Anatomy
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Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus Organs can be located by quadrant

True Abdomen

Abdominal Anatomy
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Right Upper Quadrant

Liver Gall Bladder Right Kidney Ascending Colon Transverse Colon

Abdominal Anatomy
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Left Upper Quadrant

Spleen Stomach Pancreas Left Kidney Transverse Colon Descending Colon
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Abdominal Anatomy
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Right Lower Quadrant

Ascending Colon Appendix Right Ovary (female) Right Fallopian Tube (female)

Abdominal Anatomy
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Left Lower Quadrant

Descending Colon Sigmoid colon Left Ovary (female) Left Fallopian Tube (female)

Abdominal Anatomy
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Periumbilical area
Located around (peri) the navel (umbilicus) Small bowel lies in all quadrants in periumbilical area

Suprapubic area
Located just above pubic bone Urinary bladder, uterus lie in this area
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Abdominal Cavity
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Peritoneum = abdominal cavity lining Divides abdomen into two spaces

Peritoneal cavity Retroperitoneal space

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THORACIC ABDOMEN

Retroperitoneal Abdomen

Abdominal Anatomy
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Peritoneal
Spleen Liver Stomach Gall bladder Bowel

Retroperitoneal
Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs

Disease, injury of retroperitoneal organs often causes back pain

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Abdominal Anatomy
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Organs can be classified as:

Hollow Solid Major vascular

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Solid Organs
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Liver Spleen Kidney Pancreas

When solid organs are injured, they bleed heavily and cause shock
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Solid Organs
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Liver
Largest abdominal organ Most frequently injured Fractures of ribs 8-12 on right side Bleeding can be either:
Slow, contained under capsule Free into peritoneal cavity

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Solid Organs
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Spleen
Frequently injured with trauma ribs 9-11 on left side Bleeds easily Capsule around spleen tends to slow development of shock Rapid shock onset when capsule ruptures

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Solid Organs
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Pancreas
Lies across lumbar spine Sudden deceleration produces straddle injury Very little hemorrhage Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock
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Hollow Organs
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Stomach Gall bladder Large, small intestines Ureters, urinary bladder

Rupture causes content spillage, inflammation of peritoneum

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Hollow Organs
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Stomach
Acid, enzymes Immediate peritonitis Pain, tenderness, guarding, rigidity

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Hollow Organs
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Colon
Spillage of bacteria May take 6 hrs to develop peritonitis

Small Bowel
Fewer bacteria May take 24-48 hours to develop peritonitis

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Major Vascular Structures

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Aorta Inferior vena cava Major branches

Injury can cause severe blood loss ; exsanguination (bleeding out)

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Abdominal Trauma
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Most survive to reach hospital Most common factors leading to death

Failure to adequately evaluate Delayed resuscitation Inadequate volume Inadequate diagnosis Delayed surgery
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High Index of Suspicion

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Mechanism Trauma to lower chest, back, flank, buttocks, and perineum Hypovolemic shock with no readily identifiable cause Diffusely tender abdomen Pain in uninjured shoulder

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Mechanism
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Look for signs of injury

Bruises Tire marks Obvious open injuries

Assume any abdominal injury is serious until proven otherwise! Injury above umbilicus also involves chest until proven otherwise

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Unexplained Shock
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Assess vital signs; skin color, temperature; capillary refill Tachycardia; restlessness; cool, moist skin In trauma, signs of shock suggest abdominal injury if no other obvious causes present
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Signs of Injured Abdomen

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Diffuse tenderness Pain

Pain referred to shoulder = Organ under diaphragm involved (?spleen) Pain referred to back = Retroperitoneal organ involved (?kidney)

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Abdominal Rigidity
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NOT reliable Bleeding may not cause rigidity if free hemoglobin absent Bleeding in retroperitoneal space may not cause rigidity

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Abdominal Trauma Management

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Less important to diagnose exact injury Treat clinical findings Management same regardless of specific organ(s) injured

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Abdominal Trauma Management

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Airway C-Spine if mechanism indicates High flow O2 Assist ventilations if needed Give nothing by mouth MAST may be helpful in slowing intraabdominal bleeding with shock
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Impaled Object
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Leave in place
Shorten if necessary for transport Leave part of object exposed

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Evisceration
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With large laceration abdominal contents may spill out Do NOT try to replace

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Evisceration
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Cover exposed organs with saline moistened multi-trauma dressing Do NOT use 4 x 4s Cover first dressing with second DRY dressing or aluminum foil

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QUESTIONS?