TRAUMA ABDOMEN

Anatomy of the Abdomen

Divided into three regions:
1. the intrathoracic abdomen
The thoracic portion of the abdomen is
located underneath a thin sheet of muscle called
the diaphragm and is enclosed by the lower ribs
2. the true abdomen (Organ in abdomen)

3. the retroperitoneal abdomen

Blunt Abdominal Trauma

Definition:
Blunt abdominal trauma is defined as injury
due to a direct blunt force. Such injuries can crush
solid (liver, spleen) and hollow (bowel, stomach)
organs against the vertebral spine or pelvis causing
significant damage. In patients with abdominal pain
due to trauma, intraperitoneal injury can be difficult
to exclude even when imaging and FAST ultrasound
are negative.
Causes
1. Blows or crush injuries by animals
2. Direct impact from road traffic accident
3. Acceleration / deceleration
4. Fall from height
5. Sports
6. Explosion
7. Assaults
 Signs and symptoms
• History
o Abdominal pain
o Vomiting
o Kehr's Sign: Left shoulder pain with splenic injury
o Right shoulder pain with liver injury
• Exam
o Tenderness
Abdominal distension
o Seat belt sign (bruising in the shape of where seat belt goes across
chest and abdomen)
■ Consider lumbar fracture; 20% associated with abdominal injury
o Cullen sign (periumbilical bruising)
■Suggests retroperitoneal or intra-abdominal bleed
o Grey Turner sign (flank or groin bruising)
■ Suggests retroperitoneal hemorrhage
o Peritonitis: rigid, severe abdominal tenderness with percussion
• Bedside tests: FAST ultrasound can identify intraperitoneal fluid
 General Pathophysiology
• Hemorrhage is a concern with abdominal
trauma.
– Estimation of blood volume lost is difficult.
– Signs and symptoms depend on:
• Volume of blood lost
• Rate of loss
 General Pathophysiology
• Increased hypovolemia results in agitation and
confusion.
– The heart increases rate and stroke volume.
• Increased hypoperfusion leads to ischemia and heart
failure.
 General Pathophysiology
• Injuries can result in organ spillage into the
abdominal cavity.
– Will eventually result in localized pain
• Localized if contamination is confined
• Generalized if entire peritoneal cavity is involved
 Patient Assessment
• During evaluation, look for evidence of
hemorrhage or spillage of bowel contents.
– Have a high index of suspicion.
– Provide tissue perfusion and oxygen delivery.
 Patient Assessment
• Evaluation must be
systematic.
• Examine for:
– Bruising
– Road rash
– Localized swelling

© Dr. P. Marazzi/Photo Researchers, Inc.

– Lacerations
– Distention or pain
 Patient Assessment
• Look for shock not proportional to external
evidence.
• Abdominal organs are susceptible to
significant bleeding.
– Can be fatal
 Patient Assessment
• When assessing a genitourinary injury:
– Provide privacy for the patient.
– Look for blood on the undergarments.
– Only inspect the external genitalia if:
• The patient reports pain.
• There are external signs of injury.
 Scene Size-Up
• Scene safety is priority.
• Penetrating or blunt trauma is caused by an
external force.
– Situation may be dangerous to the paramedic.
 Primary Assessment
• Form a general impression.
– Note the manner in which the patient is lying.
• Body or abdominal movement irritates inflamed
peritoneum.
• Patient may also present with guarding.
 Primary Assessment
• Airway and breathing
– Keep airway clear of vomitus.
• Note the nature of the vomitus.
– Assess for adequate breathing.
• Supplemental oxygen with a nonrebreathing mask may
be necessary.
 Primary Assessment
• Circulation
– Superficial abdominal injuries usually don’t
produce external bleeding.
– To determine stage of shock, evaluate:
• Pulse and skin color
• Temperature
• Condition
 Primary Assessment
• Circulation (cont’d)
– When caring for genitourinary emergency,
remember the system is very vascular.
– To determine the presence of shock:
• Assess pulse rate and quality.
• Determine skin condition, color, and temperature.
• Check capillary refill time.
 Primary Assessment
• Circulation (cont’d)
– Closed injuries do not have visible signs of
bleeding.
– If the patient is visibly bleeding, control it.
– Consider the MOI, and expose that body part.
 Primary Assessment
• Transport decision
– Abdominal injuries call for short on-scene time.
– Patients should be evaluated at the highest
trauma center available.
 Primary Assessment
• Transport decision (cont’d)
– Patients with a genitourinary system injury should
be taken to a trauma center.
– Treatment may require a specialist.
 Secondary Assessment
• Inspect the abdomen.
– May involve ecchymosis, abrasions, lacerations
– Note blood from vagina or rectum.
– Peritonitis could result in decreased or absent
abdominal sounds.
 Secondary Assessment
• Perform palpation and percussion.
– Start with the quadrant furthest from injury.
• Note whether the patient has hematuria.
– Dark brown: bleeding in upper urinary tract
– Bright red: bleeding in lower portion of tract
 Secondary Assessment
• Determine if the patient is pregnant.
– Risk of massive blood loss is increased
– Management should start with the ABCs.
– Tilt patients at least 15° to the left to prevent vena
cava syndrome.
 Secondary Assessment
• New technologies include:
– Portable ultrasound machines
– Telemedicine
• Misconception: patients without pain or
abnormal vital signs are unlikely to have
serious injuries.
 Secondary Assessment
• Abdominal trauma • Signs of rupture may
may include: include:
– Abdominal – Abdominal pain
evisceration – Abdominal sounds in
– Injury to the the chest
diaphragm – Sunken abdomen
 Secondary Assessment
• Examine the patient’s neck and chest.
• Assess the patient’s pain.
– Somatic pain: sharp and localized
– Visceral pain: deep aching with cramping
 Secondary Assessment
• Perform a thorough full-body exam.
– Conduct en route.
– Assess the same structures as the rapid exam but
more methodically.
 Reassessment
• Field documentation should include:
– Seat belt use
– Location, intensity, quality of pain
– Nausea or vomiting
– Contour of abdomen
– Ecchymosis or open areas on soft-tissue
– Rebound tenderness, guarding, rigidity, spasm,
localized pain
 Reassessment
• Field documentation should include (cont’d):
– Changes in LOC and vital signs
– Other injuries found
– Alcohol, narcotics, analgesic
– Results of assessment
 Emergency Medical Care
• Ensure an open • Apply a:
airway. – Cardiac monitor
– Pulse oximetry
• Establish IV access.
– Capnography
• Apply pressure
• Transport to a hospital
dressings if necessary.
or trauma center.
 Nursing Assessment
• Airway
• Abdominal injuries
• Respiratory effort – Rate, Depth
• Symmetrical Chest Wall Movement?
• Contour of abdomen
• Bleeding Perinuem?

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 Nursing Assessment
• Cullen’s Sign
– Bluish sign at umbilicus
– Indicative of bleeding in the
peritonuem

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 Nursing Assessment

• Grey Turner’s Sign

– Bruising on the flanks
indicating a
retroperitoneal bleed

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 Nursing Assessment
• Auscultation
– Bowel sounds in all 4 quadrants
• Percussion
– Hyperresonance – Air
– Dullness - Fluid
• Palpation
– All 4 quadrants
– Pelvis for instability
– Anal sphincter for tone

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 Nursing Assessment

• Diagnostic Procedures
– X-Rays
– Labs – CBC, Pregnancy, Coags, UA, Stool for blood,
– CT
– FAST Exam
– Angiography
– Cystogram

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 Nursing Assessment
• Focused Assessment with Sonography for
Trauma (FAST) Exam
– Used to diagnose free blood in the peritoneum after
blunt trauma
– Looks at 4 areas for free fluid
• Perihepatic
• Perislpenic
• Pelvis
• Pericardium

• 94% effective
• Test takes 4-5 minutes

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FAST: Technical Considerations
Probe placement?
1. RUQ: Morrison’s Pouch
2. LUQ: Splenorenal
3. Pelvis: Pelvic cul-de-sac
1. Transverse
2. Longitudinal
4. Subxiphoid/Subcostal: Pericardium

 Remember: Probe almost ALWAYS

facing either patient’s right or patient’s
head

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 Nursing Interventions
• Maintain Patent airway
• 2 large bore IVs
• IVF or Blood Volume
• Pain Meds
• Foley
• NG
• Cover open wounds

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 Nursing Interventions
• Antibiotics
• Psychosocial support
• Stabilize impaled objects
• Surgical intervention
• Monitor urinary output
• Serial vital signs

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