ABDOMINAL INJURIES Definition of Abdominal Injuries Abdominal injuries account for a large percentage of trauma-related injuries and deaths.

The visceral organs contained within the abdomen can be classified as either hollow or solid.  Damage to a hollow organ can result in acute peritonitis leading to shock within a few hours  Damage to a solid organ can result in lethal hemorrhage. y Abdominal injuries may be classified as either penetrating or blunt. Penetrating abdominal injury  usually the result of gunshot wounds or stab wounds.  The mechanism that caused the penetrating abdominal trauma may cross the diaphragm and enter the chest. The opposite can also occur. Blunt abdominal injury  Usually caused by motor vehicle accidents or falls.  Trauma to the abdomen is frequently associated with extraabdominal injuries (ie, chest, head, and extremity injuries) and severe concomitant trauma to multiple intraperitoneal organs.  Causes more delayed complications, especially if there is injury to liver, spleen, or blood vessels, which can lead to substantial blood loss into the peritoneal cavity. Primary Assessment and Interventions Assess airway, breathing, and circulation. Initiate resuscitation as indicated. Control bleeding, and prepare to treat shock. If there is an impaled object in the abdomen, leave it there.  Stabilize the object in place with bulky dressings along the sides of the object. Subsequent Assessment Obtain a history of the mechanism of the injury, type of weapon, and estimated amount of blood loss.

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 If the patient was stabbed, how long was the blade?  Was the person who stabbed the patient a man or a woman? o Men usually hold a knife underhand and stab/thrust upward. o Women usually will stab/thrust downward with an overhand motion.  If the patient sustained a gunshot wound, attempt to ascertain the type of gun and range at which shot.  Time of onset of symptoms.  Passenger location (driver frequently sustains spleen/liver rupture). Were safety belts worn? Did the airbag deploy? y Inspect the abdomen for obvious signs of injury (penetrating injury, bruises).

Evaluate for signs and symptoms of hemorrhage  frequently accompanies abdominal injury, especially if the liver and spleen have been traumatized. y Note tenderness, rebound tenderness, guarding, rigidity, and spasm.

y Cullen's sign  a slight bluish discoloration around the navel, is a sign of hemoperitoneum. y Pain is a poor indicator of the extent of the abdominal injury.  Rebound tenderness and boardlike rigidity are indicative of a significant intraabdominal injury. y A rectal examination and examination of the perineum should be done on all patients.  The presence of blood may be indicative of trauma. Continually assess vital signs urine output CVP readings hematocrit values, neurologic status. Tachypnea Tachycardia Hypotension may be clues to intra-abdominal bleeding. General Interventions Goals are to control bleeding, maintain blood volume, and prevent infection.

 Press the area of maximal tenderness (let the patient point to the area).  Remove the fingers quickly to check for rebound tenderness o pain at suspected point indicates peritoneal irritation. y Ask about referred pain: Kehr's sign

 pain radiating to the left shoulder may be a sign of blood beneath the left diaphragm  pain in right shoulder can result from laceration of liver. y Look for increasing abdominal distention.

 Measure abdominal girth at umbilical level early in assessment o serves as a baseline from which changes can be determined.

       

y y Auscultate for bowel sounds  a silent abdomen accompanies peritoneal irritation. y Auscultate for loss of dullness over solid organs (liver, spleen)  indicates presence of free air; dullness over regions normally containing gas may indicate presence of blood. y Look for chest injuries, which frequently accompany intra-abdominal injuries.

y Keep the patient quiet and on the stretcher  because movement may fragment or dislodge a clot in a large vessel and produce massive hemorrhage. y Cut the clothing away from the wound.  Do not cut through bullet holes or stab marks. These will be needed by law enforcement authorities as forensic evidence. y Count the number of wounds.

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Look for entrance and exit wounds. If the patient is comatose, immobilize the cervical spine until after cervical films are taken and cleared. Apply compression to external bleeding. Insert two large-bore I.V. lines and infuse Ringer's lactate.

complication (depending on history and nature of wound). y Prepare for peritoneal lavage when there is uncertainty about intraperitoneal bleeding. Prepare for surgery if the patient shows evidence of: unexplained shock unstable vital signs peritoneal irritation bowel protrusion or evisceration significant penetrating injury significant GI bleeding peritoneal air Prepare the patient for diagnostic procedures.

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 If possible, one of the lines should be in a central venous location. y Insert an NG tube to decompress the abdomen.

 This will serve to empty the stomach, relieve gastric distention, and facilitate abdominal assessment.  if blood is found, it may indicate stomach injury or esophageal injury. y Cover protruding abdominal viscera  do not attempt to replace the protruding organs into the abdomen.  Use sterile saline dressings to protect viscera from drying. y y Cover open wounds with dry dressings. Withhold oral fluids to prevent increased peristalsis and vomiting.

Catheterization and urinalysis  as a guide to possible urinary tract injury and to monitor urine output. Type and cross-match and serial hgb and hct levels  their trend reflects presence or absence of bleeding. Complete blood count (CBC)  white blood cell count is generally elevated with trauma. y Cont. Prepare the patient for diagnostic procedures.

Insert an indwelling urethral catheter to ascertain the presence of hematuria and to monitor urine output.  If a fracture of the pelvis is suspected, a catheter should not be placed until the integrity of the urethra is ensured.

Serum amylase elevation  indicates pancreatic injury or perforations of GI tract. Computed tomography (CT) scans  permit detailed evaluation of abdominal and retroperitoneal injuries. Abdominal and chest X-rays  may reveal free air beneath diaphragm, indicating ruptured hollow viscus.

y Pharmacologic interventions  Tetanus prophylaxis.  Broad-spectrum antibiotics because bacterial contamination is a frequent