Abdominal trauma

Anatomy
• Abdominal cavity extend from diaphragm ( the 5th ribs line of mammary gland)
to the pelvic
• The abdominal content found in
1. peritoneal cavity : covered by peritoneum and mesenteris
2. retroperitoneal cavity : covered by peritoneum
3. pelvic cavity
• the abdominal is covered by serous smooth membrane called peritoneum
• mesenteris: sheet over the peritoneal and carry blood vessels
Solid organ anatomy
Liver
• vascular organ in the upper right quadrant and extend transversely a cross the
midline, located between ribs 6-10
• liver considered large vascular capacity and always contain 500ml of blood
• friable to rupture and lacerate
• the circulation through hepatic artery, portal vein and blood flow is equal 30%
• function of the liver
1. secretary gland
2. release bile to emulsification food and absorb fatty acid
3. filter blood
Spleen
• located at the left upper quadrant under diaphragm and lateral to stomach at
level of ribs 9-11
• high vascularity and cover by peritoneum sheet
• spleen function
1. blood filter
2. reservoir of 200 ml of blood
Kidney
• found in retroperitoneal space at level of T12-L3
• right kidney slightly lower than left due to liver in the right area
• move when expiration and inspiration because it is not fixed with abdominal wall
• kidney surround by capsules of fatty tissue and facia to maintain position
Pancreas
• is a gland tissue covered by retroperitoneal sheet
• function of pancreas:
1. exocrine organ: produce fluid contain enzymes,
bicarbonate, electrolyte and absorb nutrient
2. secret insulin and glucagon
Hollow organs
• include stomach, small bowel, large bowel and bladder
• located in upper left quadrant between liver and spleen at level of ribs 7-9 and
contain acid gastric solution
Roles: injury above the umbilicus it is include chest trauma or injury
Mechanism of injury
• injury of the abdominal result from acceleration and deceleration or
combination of the forces
• lap belt cause hallow organ injury
• blunt injury
• firearm and stabbing
• physical assault

Type of injury:
• blunt or penetrate injury but the severity depend on
1. type of force applied
2. tissue density of structure injury
• liver and spleen is the most organ injured in blunt trauma

Usual current injury

• fracture of the ribs associated with liver and spleen injury
• esophageal and stomach injury associated with chest trauma
• pelvic fracture associated with intra-abdominal trauma as bladder laceration
Pathophysiology of abdominal trauma
Blood loss
• liver and spleen rich of blood supply and considered a store of blood so rapid loss
of blood from there the parenchyma or vascular tissue structure can occurs
• the consistency of the tissue in liver and spleen make tissue difficult to
homeostasis
• bleeding in the retroperitoneal cavity difficult to evaluated and diagnosis

Pain
• pain , rigidity, guarding, spasm of the abdominal are classic songs of intra-
abdominal pathology
• rebound tenderness and guarding of the abdominal muscles are caused by
sudden movement and irritant of peritoneal membrane against abdominal wall
• the irritant caused presence of blood or gastric content on the peritoneal cavity
• pancreatic and duodenal injury cause hemorrhage and effect of active enzymes
of the surround tissue which lead to chemical peritonitis of the retroperitoneal
area
• sings and symptoms of pancreatic and duodenal injury is
1. diffused abdominal tenderness
2. pain radiating in epigastric area to the back
• Kehr's sings : abdominal pain and radiating to shoulder pain associated with
splenic rupture or spleen ulceration
• Irritant of phrenic nerve and diaphragm pain with radiated pain of sub-scapular
pain produced by collect of blood under diaphragm
• Abdominal pain with Radiated pain in testicles caused by duodenal ulcer or
injury

Peristalsis
• The bowel sound become hypodynamic due to blood collection in abdominal
cavity or direct injury of bowel or stress
• Hypoactive bowel sound associated with tenderness and guarding
Liver injury
• Frequent injury because of size, location, tissue density and vascularity
• The severity of hepatic injury range from controlled sup-scapular hematoma
and laceration of the parenchyma to vascular injury of hepatic vein, hepatic cava
and hepatic avulsion
• Liver injury need surgical control of bleeding
• Non operative management of hepatic injury depend on rigid criteria include:
1. homodynamic stability
2. absence of peritoneal sings ( neurological shock)
3. degree of free peritoneal blood
4. need more than 2 units of hepatic blood transfusion
5. CT (computed tomography)
• Sings and symptoms of hepatic injury
 Upper right quadrant pain
 Abdomen wall muscles rigidity. Spasm and involuntary
guarding
 Rebound tenderness
 Hypoactive or absent bowel sound
 Sings of hypovolemic shock

Splenic injury
• Usually associated with blunt trauma but may caused by penetrate trauma
• Result from fracture of left ribs(10-12) which cause underlying damage include
spleen
• Injury of spleen ranged from laceration of the capsules or non-expanding
hematoma to rupture of sub-scapular hematoma and parenchyma laceration
• The most serious problem of spleen is fracture of spleen or vascular tear which
produce excessive blood loss and ischemia
• Mild spleen injury include hypovolemic shock class 1 and 2 and need to rest and
blood transfusion
• Sings and symptoms of splenic injury
 Sings of hemorrhage and hypovolemic shock
 Kehr's sings : pain in the left shoulder
 Tenderness in the left upper quadrant
 Abdominal muscles wall rigidity, spasm and involuntary
guarding
 Hollow organ injury
• Caused by blunt injury and penetrate injury
• The most common organ injured is small bowel specify of the area which fixed
or looped
• Hollow organ injury caused by deceleration forces lead to shearing, evulsions,
and tearing
• Inappropriate apply lab seat belt cause compression and rupture of small bowel
and colon
• Sings and symptoms of hollow organ injury
 Peritoneal irritation
 Abdominal muscles rigidity, spasm and involuntary
guarding
 Pain and rebound tenderness
 Evisceration of small bowel and stomach
 Diagnostic peritoneal lavage (DPL) observe bile, feces, food
fibers

Renal injury
• Most common caused by blunt trauma suspected when posterior ribs and
lumber vertebral column fracture
• Renal parenchyma can damage by shearing or compression forces cause
laceration and contusion
• More deep laceration cause more serious bleeding
• Laceration of renal artery lead to rupture of the kidney and the hypovolemia
occurred
• Kidney rupture lead seriously to ischemia and tubular necrosis
• Sings and symptoms of renal injury
 Ecchymosis over the flank
 Flank and abdominal tenderness during palpation
 Microscopic hematuria ( if no hematuria not indicate there
is no renal injury)

Bladder and urethral injury

• Mostly by blunt trauma and associated with pelvic fracture
• Depend on the location of symphysis pubis and bladder (the bladder is above or
under symphysis pubis ( full bladder and distended or empty)
• Normally bladder lie below the level of symphysis pubis when empty , in this case
trauma case rupture of the bladder and the urine become a leak into
surrounding pelvic, vulva and scrotum
• If the bladder distended found above the level of symphysis pubis the trauma
cause rupture or perforation and the urine leak into the abdominal cavity
• Urethral trauma most in male than female because it is long and less protection
• In female anterior pelvic fracture cause urethral injury
• In male the injury of penile portion cause by straddle trauma
• In male pelvic fracture case prostate injury and lead to incontinence and
impotence.
• Sings and symptoms of renal injury
 Suprapubic pain
 Urge but inability to urine
 Microscopic hematuria
 Blood in urethral meatus and scrotum
 Rebound tenderness
 Abdominal wall rigidity, spasm and involuntary guarding
 Displacement of prostate gland

Physical assessment
• Ask patient about use of tap belt and shoulder belt
• Ask patient about feeling to urination
Inspection
• Observe the counter of the abdomen
• Inspect for gun shot or stabbing and describe by size, appearance, location and
number (not need to identify the inlet and exit point)
• Inspect peritoneal from hematoma, blood drainage from urethral meatus and
vaginal or rectal bleeding
• Inspect the flank, chest, abdomen and back from ecchymosis:
 Ecchymosis in left upper area indicate of soft tissue or
splenic injury
 Ecchymosis in umbilicus area indicate of intra-peritoneum
bleeding
 Ecchymosis on in the area of flank indicate of
retroperitoneal bleeding
Auscultation
• Absent of bowel sound in the four quadrant indicate of visceral injury
• Auscultate the chest to observe if there is bowel sound or not as indication of
diaphragm rupture
Percussion
• Hyper resonance on the abdominal area indicate of air filled
• Dullness sound in the abdominal area indicate of accumulation of blood or fluid
Palpation
• Start with area not injured and move in all four quadrant each quadrant
separate
• Palpate to find guarding, rigidity, spasm and localized pain and to detect
presence of rebound tenderness
• Palpate pelvic bone to identify any possible dislocation or fracture
• Palpate flank for tenderness
• Palpate anal sphincter to determine anal tone
• The abdominal guarding, spasm, rigidity, rebound tenderness not found in
patient with abdominal trauma and in case of:
1. competing of other pain from another injury
2. retroperitoneal hematoma
3. spinal cord injury
4. ingested of alcohol and narcotic drugs
5. decrease level of consciousness
Laboratory test
• serum amylase
• Liver function and kidney function
• Urine analysis
• Test of pregnancy

Diagnostic procedure
• CT: to identify slid organ laceration or injury with normal blood pressure, Also
used to identify small amount of air or blood in the abdomen
• Intravenous pyelogram (IVP): used contrast media : if found into surround
tissue indicate of distribution of integrity of the kidney, urethra and bladder
• Flat, lateral, and upright radiography to identify:
1. foreign body
2. path of penetrate object
3. visualized air in the abdomen as indicate of GI disturbances
• ultrasound (sonogram): to determine homo-peritoneum and fluid accumulation
which associated with hypotension but it is affected by air in the subcutaneous
tissue
• cystogram, urethrogram, angiography

DPL diagnostic peritoneal lavage

• method used to detect intra-abdominal bleeding for peritoneal area but not used
for retroperitoneal
• prefer after urine catheter and NG tube insertion to avoid inadvertent puncture
• peritoneal catheter inserted below the umbilicus introduced by small incision
• withdrawal of gross blood from catheter consider positive finding
• if blood not aspirate infused R\L or normal saline in the catheter and allow the
fluid to out depend on gravity
• analyze for presence of RBC, WBC, feces, bile, amylase and food particle
• early DPL is important with patient in severe abdominal injury associated with
hypotension and unreliable patient responses
• advantages of DPL rapid procedure, the accuracy 98% and used for all patient
• disadvantages: invasive procedure, not detect retroperitoneal injury
• contraindication of DPL
1. when patient has already abdominal surgery
2. patient with pervious abdominal surgery and increase
potential of adhesion
3. when patient with cirrhoses
 4. patient extremely obese which increase the difficulty of the
procedure
5. patient with know coagulopathy

Nursing diagnosis

1. fluid volume deficit R\T hemorrhage, evisceration and disruption

of integrity
2. decrease cardiac output R\T decrease venous return and acute
bleeding
3. altered tissue perfusion R\T hypovolemia and interruption on
venous arterial system

Nursing intervention
• elevate the extremities
• control of bleeding, used sterile moist dressing for evisceration
• insert 2 cannula and infused R\L, normal saline and blood
• prepare for definitive care
• consider PASG if patient with hypotension to decrease intra-abdominal bleeding
• initiate CPR
Increase risk of infection R\T invasive procedure and contamination of
peritoneal cavity of blood, urine, feces, bile and gastric content
Nursing intervention
• maintain aseptic technique
• close open wound
• monitor vital sings especially temperature
• check wound drainage
• obtain blood culture and blood sample
• administer antibiotic
• prepare for definitive care

Altered urinary elimination R\T urethral and renal trauma

• inset urinary catheter unless contraindication to minimize urine leakage into
abdomen and support tissue
• is patient with urethral meatus bleeding consider catheter insertion in
suprapubic area (cyctofix)
• urine analysis after insert catheter: discarded the firs urine out from catheter
because may include blood produced by injury during insertion the catheter then
take other specimen

Pain R\T blunt or penetrating injury and invasive procedure

• administer analgesic
• touch and position
• family presence
Indication of insert NG tube:
1. decompress the stomach and decrease aspiration incidence
2. prevent vegal stimulation and bradycardia
3. minimize gastric content leakage and decrease contamination of
the abdomen cavity
4. test the gastric content of presence of blood