Prehospital Trauma Life Support

Lesson

Abdominal Trauma & Trauma in Pregnancy

Developed by the

National Association of Emergency Medical Technicians

In cooperation with

The Committee on Trauma, American College of Surgeons

This slide presentation is intended for use only in approved PHTLS courses.

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Abdominal Trauma & Trauma in Pregnancy

Abdominal Trauma

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Lesson 7 Abdominal Trauma Objectives

Associate blunt and penetrating abdominal trauma with anatomy, physiology and pathophysiology. Use mechanism of injury and index of suspicion when assessing, treating and prioritizing abdominal trauma. Identify the appropriate assessment and management of abdominal trauma, and the limitations of each.
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Abdominal Trauma
Abdominal trauma often goes unrecognized.

Second leading cause of trauma death.

Extent of damage difficult to determine. Massive blood loss can lead to shock and death.
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Abdominal Assessment
Keys:

Anatomy - to identify structures that may be damaged. Mechanism. Index of suspicion. Observation for wounds, guarding, positioning. Palpation for rigidity, tenderness, and masses.

Tools:

Pitfall: Auscultation is a tool, but not recommended in the prehospital setting.

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Penetrating Trauma
Your patient is the victim of multiple

gunshot wounds to the abdomen.

Pitfall: Injury significance missed due to a lack of attention to kinematics.

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Anatomy
How can you use anatomy to evaluate this patient?

Organ location.
Solid versus hollow.

Bleeding versus peritonitis.

Associated chest injury.

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Frontal Impact
You are dispatched to a one-vehicle MVC with one occupant. The scene is safe.

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Blunt Trauma
Your patient is the victim of an MVC. Her van struck a pole head on. Moderate damage to the van. She was wearing a seatbelt, and it was positioned over the soft part of her abdomen.

A - Airway clear. B - Breathing rapid and shallow. C - Skin cool and diaphoretic, weak radials, rapid heart rate. D - Confused and anxious. E - Bruising to left clavicle area and abdomen above the iliac crest. Abdomen is soft and nontender.

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Mechanism of Injury
Is the patient in this scenario critical or non-critical?

What was the speed?

What type of impact occurred?

What do you see inside the car? What internal organs might be involved? Are there signs and symptoms of shock?

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Index of Suspicion
Reliable indicators for index of suspicion:

Mechanism of injury.

Unexplained indicators of shock.

Outward signs of trauma. Level of shock greater than explained by other injuries.
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Index of Suspicion Pitfalls

Blood in the abdomen may not always cause abdominal pain or tenderness. In most cases, retroperitoneal injuries are initially asymptomatic.

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Mechanism of Injury
Which of these should increase your index of suspicion that this patient might be seriously injured?

A - Airway clear. B - Breathing 18 & labored; lungs clear & equal. C - Skin cool & dry; radial pulse 110. D - Anxious, intoxicated.

E - Bruising to right thorax and hip; abdomen soft, non-tender.

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Other Assessment Findings

You respond to a patient involved in a fight. Hes been hit in the back and flank with a heavy piece of pipe. He has no complaints of abdominal pain. Scene is safe. What injuries would you suspect?

Injuries to the back may involve retroperitoneal structures like the kidneys, aorta, and vena cava. They often present with back pain rather than abdominal complaints and findings.
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Evisceration & Impaled Objects

You respond to a patient stabbed in the abdomen. A piece of bowel is eviscerated and the knife is still impaled. How would you manage this patient?

Cover the bowel with moist sterile dressings. Why? Stabilize the knife in place. Do not remove impaled objects. PASG contraindicated.
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Pelvic Fractures
You respond to a rollover MVC. The patients pelvis was crushed when the small tractor he was driving rolled over.

What is significant about this injury?

Blood loss is usually significant and occurs retroperitoneal.

Can the PASG be used to stabilize fractures and control bleeding?

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Abdominal Trauma Management

Rapid evaluation.

Shock therapy.
Pneumatic antishock garment. Rapid transport to the appropriate facility with surgical intervention immediately available. IV therapy en route.
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Abdominal Trauma & Trauma in Pregnancy

Trauma in Pregnancy

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Lesson 7 Trauma in Pregnancy Objectives

Identify the implications of the anatomical and physiological changes of pregnancy for the trauma patient. Identify the appropriate assessment, management and priorities for the pregnant patient.

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Normal Changes with Pregnancy

Increased heart rate of 15 - 20 bpm.

Decreased blood pressure.

Increased cardiac output. Increased blood volume.

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Normal Pregnancy Changes

Increased size of uterus.

Decreased peristalsis.
Loosening of ligaments.

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Trauma in Pregnancy
You respond to the scene of a car that struck a guardrail at 60 mph and is resting upright in a ditch. The patient is a 24 y/o female who is 26 weeks (6.5 months)

pregnant. There is moderate damage to

the car. She was wearing a seatbelt. Given the mechanism, what are the priorities for this patient?
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Findings
A - Clear. B - Breathing: 20 bpm, slightly labored and shallow; lungs clear. C - Pulse 114. Skin warm and dry. D - Anxious. E - No obvious injury noted. Vitals: BP 92/56.
Are these changes due to trauma or pregnancy?
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Resuscitation of the baby

depends on aggressive
resuscitation of the mother.

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Trauma in Pregnancy
You are dispatched to the scene of a 23 y/o female who is 32 weeks pregnant. She was pushed down a flight of stairs, and is found lying on her back. A - Airway clear. B - Breathing 18 per minute, slightly labored. Clear breath sounds. C - Very weak radial pulse of 120. No external hemorrhage. D - Responsive to verbal stimuli. E - Contusion to right temporal region of head. Vitals: BP 86/54. Secondary survey negative except for head contusion.
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Discussion

How would you manage this patient?

What condition mimics a head injury?
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Abdominal Trauma Summary

The cornerstone of assessing and managing the pregnant and nonpregnant abdominal trauma patient is maintaining a high index of suspicion.

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