01

I NTRODUCTION

Abdominal Injury is an injury to the

abdomen and its content.
Most Frequently Injured Intra-abdominal
Structures

1.Spleen
2.Liver
3.Kidneys
Blunt Injury
1 2 Penetrating
abdominal injury
 Types of Abdominal Injuries

➢ Blunt abdominal trauma is

Blunt Injury rarely an isolated event.
➢ Patients with abdominal
injuries can lose large amount
of blood.
➢ Hemorrhage is the usual
proximate cause of death.
 Types of Abdominal Injuries

Mechanism A.Motor vehicle collisions

of Blunt B.Contact sports
Injury C.Fall
D.Physical abuse
 Types of Abdominal Injuries
• Penetrating may be single injury or may be
associated with multiple injuries.
Penetrating
• Abdominal wall is penetrated and open wound is
Abdominal present
Injury • Penetrating object may be knife, bullets, or gunshot

• Stab wounds most commonly produce an intestinal

injury.
• A large number of stabs do not penetrate the
peritoneal cavity so; they may not even require
surgery and are associated with a low mortality
rate.
 I NTRODUCTION
Penetrating Abdominal Injury

• The majority of abdominal gunshot wounds are

more severe because these are associated with
significant damage to the intra-abdominal
organs & vessels necessitating emergent
operative intervention.
 Pathophysiology
➢Abdominal trauma can be life-threatening because
abdominal organs, especially those in the retroperitoneal
space, can bleed profusely, and the space can hold a great
deal of blood.
➢Solid abdominal organs, such as the liver and kidneys,
bleed profusely when cut or torn, as do major blood
vessels such as the aorta and vena cava.
 Pathophysiology

➢ Hollow organs such as the stomach, while not as likely to

result in shock from profuse bleeding, present a serious
risk of infection, especially if such an injury is not treated

promptly.
 Pathophysiology
➢ Gastrointestinal organs such as the bowel can spill their
contents into the abdominal cavity. Hemorrhage and
systemic infection are the main causes of deaths that result
from abdominal trauma.
➢ One or more of the intra-abdominal organs may be
injured in abdominal trauma. The characteristics of the
injury are determined in part by which organ or organs are
injured.
 Signs and Symptoms of Abdominal Injuries

01 • Altered level of consciousness 02 • Tachypnea

(S&S of hypovolemic
• Cold clammy skin

manifestations
03
04 • Delayed capillary refill

General
shock)
05 • Tachycardia 06 • Hypotension

07 • Narrowed pulse pressure

08 • Decreased CVP

08 • Decreased UOP
 Specific Manifestations

Inspection
• Bruises, Abrasions, Open wounds, and Distension, Rectal bleeding, and
testicular swelling
Palpation
• Rebound tenderness and pain, Guarding /Rigidity, Masses, Pelvic
instability, and High-riding prostate
Auscultation
• Decreased or absent bowel sounds
Specific Manifestations
 NB
➢Immediate determination of specific structures that have
been injured is not essential. The most important management
decision is whether the patient requires immediate surgery, care is
focused on:
✓Basic stabilization.
✓Frequent reassessment.
✓Diagnostic testing.
 Assessment & Management of Abdominal Injury

1. Airway & Breathing

2. Circulation.
Assessment

3. Disability

4. Exposure & Environmental control

 1. Airway & Breathing

• Assess and secure airway

oCheck response
oLook for chest movement and listen to breath
sounds over 10 seconds
oLook for indicators of airway obstruction
 If airway is compromised

oSecure airway and maintain breathing

oHead tilt, chin lift or jaw thrust
oInsert airway and start ventilation
oCover wound
oNeedle thoracotomy
oInsert chest tube
 2. Circulation

• Assess circulation" Responsiveness, pulse, skin

color, skin temperature, capillary refill time,
bleeding"
• Obtain a minimum of 2 IV lines
• Send for blood group & cross match
• Administer warm lactated Ringer or NS
 2. Circulation

• Administer blood and blood products as

needed
• Prepare for Pericardiocentesis and thoracotomy
• Prepare for immediate laparotomy if there is
excessive bleeding, penetration into the
peritoneum or both.
• Stabilize penetrating object if present
 3. Disability

• Assess LOC, Pupils size& RBS.

• Initiate or maintain spinal immobilization
 4. Exposure & Environmental control

• Inspect carefully the anterior, lateral, and

posterior abdomen for wounds and other
concomitant major injuries in other body
sites.
 Management
• Identify the mechanism of injury, time since the injury, and
estimated external blood.
• Determine past medical history.
• Place an orogastric or nasogastric tube (for stomach
decompression)
• Insert an indwelling urinary (Foley) catheter (for monitoring
output)
• Cover open abdominal wounds with sterile saline dressings.
Avoid allowing exposed viscera to dry.
 Management of Exposed Abdominal Organs

• Obtain blood sample for arterial blood gases, complete

blood count (CBC),
• Prothrombin time (PT), partial thromboplastin time (PTT),
electrolytes, blood urea nitrogen (BUN), creatinine, blood
type and cross match, and amylase.
• Obtain urine sample for analysis for microscopic blood, free
hemoglobin, and myoglobin (to determine possible renal
damage and prevent acute tubular necrosis
 Management of Exposed Abdominal Organs

• Facilitate diagnostic studies such as chest, abdominal,

and pelvic radiography.
• Peritoneal lavage is an excellent tool for determining
intra-abdominal bleeding.
• Prepare for surgical intervention if indicated.
Important Consideration for the Pregnant Patient

Blunt abdominal injury Penetrating abdominal injuries

It produces placental It produce variable

abruption frequently degrees of damage to
& may cause uterine the uterus, placenta &
rupture fetus

The pregnant uterus is protective; most women who

sustain penetrating trauma to the gravid uterus will not
have other intra-abdominal injuries.
 Important Consideration for the Pregnant Patient

• Fetal survival is highly dependent on maternal

survival. Therefore resuscitative effort must always
focus on the mother
• The uterus should be shielded with a lead apron as much
as possible during radiological procedures.
 Important Consideration for the Pregnant Patient

• After 20 weeks of gestation, whenever possible, elevate the

women’s right hip, tilt the backboard to the left, or
manually displace the uterus to promote venous return to
the right heart because the combined weight of the fetus,
placenta, & amniotic fluid is sufficient to compress the
abdominal vena cava & produce obstructive hypovolemia
when the patient is spine.
Important Consideration for the Pregnant Patient
Diagnostic Procedures for Patient with
Expected Abdominal Trauma:

01 02 03
Focused
Diagnostic
abdominal
Peritoneal CT scan
sonography
Lavage
for trauma,
(DPL)
(FAST)
 Focused abdominal sonography for
trauma, (FAST):

➢ It is performed by placing an ultrasound probe over

various areas on the abdomen to determine if free fluid is
located in those areas.
➢ If the results of FAST are
positive and the patient is
hemodynamically unstable, an exploratory laparotomy is
performed.
 Focused abdominal sonography for
trauma, (FAST):
➢ The areas evaluated are the Morison’s pouch(area between
your liver and your right kidney) in the right upper quadrant,

the pericardial sac, the splenorenal region in the left upper

quadrant,
and the
pelvis
(Douglas ’
pouch).
Focused abdominal sonography for
trauma, (FAST):
 Diagnostic Peritoneal Lavage (DPL)

➢ Is a quick diagnostic procedure that is used during the

resuscitation phase of care in hemodynamically unstable trauma
patients to diagnose intra-abdominal bleeding.
❖ Other indications for use may include:
o Blunt abdominal injury with:
▪ Altered mental status ▪ Spinal cord injury
▪ Unexplained hypotension, ▪ Distracting injuries (e.g.,
orthopedic fractures,chest
decreased hematocrit, shock
trauma)
▪ Equivocal results of abdominal
▪ Penetrating abdominal trauma
examination (if exploration is not indicated).
 Positive Results of DPL

✓ 10-20 ML gross blood on initial aspirate

✓ Greater than 100,000 red blood cells/mm3
✓ Greater than 500 white blood cells/mm3
✓ Elevated amylase level
✓ Presence of bile, bacteria, or fecal matter
 Positive Results of DPL

➢ There are several contraindications to

performing a DPL.
➢ These include morbid obesity, third-trimester pregnancy,
advanced cirrhosis, a history of coagulopathy ,and a history of
multiple abdominal surgeries.
➢ There is an increased risk of omental laceration and visceral or
vascular perforation if DPL is performed in patients with these
findings.
 Diagnostic Procedures for Patient
with Expected Abdominal Trauma:

✓ A chest x-ray (to determine gross abnormalities

as well as any organ displacement), and
✓ An abdominal CT scan.
 Hemodynamic instability systolic BP< 90mHg with a positive FAST

Evidence of peritonitis (tenderness on palpation,

involuntary guarding and percussion tenderness).

Traumatic diaphragmatic injury with herniation.

Severe solid organ injury (e.g. kidney and spleen)

Infarction due to post traumatic occlusion of the blood supply.
Mesenteric tear/s.
Unexplained moderate to large amounts of
intraperitoneal free fluid (200-≥500mls).
Failed non-operative management.
 Specific Abdominal Injury
✓ The most commonly injured organ in blunt &
penetrating trauma to the lower thorax.
Spleen ✓ It is associated with ribs fracture (9-11) and
Injuries injuries of the upper outer quadrant of the
abdomen".
✓ Spleen lacerations or rupture can cause massive
hemorrhage because it receives 200 ml /min
 Signs & Symptoms
✓ Left upper quadrant pain & tenderness; pain
referred to the left shoulder (Kehr’s sign) is
Spleen indicative of diaphragmatic irritation)
Injuries ✓ Signs & symptoms of peritoneal irritation
✓ Signs & symptoms of hypovolemic shock
Diagnostic Studies
Abdominal ultrasound, Computed
tomography scans (CT).
 Therapeutic Interventions
Hemodynamically Stable Patient
❑ Admit for close observation

Spleen ❑ Obtain blood sample for serial hematocrit tests

❑ Facilitate repeated CT scans.
Injuries
Hemodynamically Unstable Patient
❑ Prepare for surgical intervention (splenectomy).
❑ Administer a pneumovax vaccination to reduce the
incidence of future infection and sepsis
 Specific Abdominal Injury
✓ The second most commonly injured organ in blunt
trauma.
Liver ✓ It is a major source of potential hemorrhage. It is highly

Injuries vascular it receives 100 to 400 ml /min.

✓ The liver can be damaged because of it is anterior
location, large size, denseness & relatively unprotected
status.
✓ It can be associated with injuries to right 8-12 rib scan
cause hepatic laceration
 Signs & Symptoms

✓ Pain Right upper quadrant pain referred to

right shoulder
Liver
✓ Signs of shock
Injuries
✓ Signs of peritoneal irritation
 Therapeutic Interventions
Laceration & Rupture
❑ Prepare for surgical intervention (laparotomy).
❑ In the case of uncontrollable hemorrhage, the liver is
Liver packed. After packing the abdomen may be closed or

Injuries simply covered and left open.

❑ An additional surgical procedure is required within the
next few days to remove the packing and repair the
laceration. Large liver injuries also need postoperative
drainage of bile and blood with closed suction drains.
 Therapeutic Interventions
Nursing Care Includes:
❑ The replacement of blood products while monitoring
the hematocrit and coagulation studies.
Liver
❑ Assessment of the character and amount of tube
Injuries drainage, along with fluid balance, also is essential.
❑ Assessment of the patient for potential complications of
liver injury include hepatic or perihepatic abscess,
biliary obstruction or leak, sepsis, ARDS, and DIC.
 Specific Abdominal Injury

Kidneys • Kidneys may be contused or lacerated;

contusion is a generally self-limiting
Injuries
condition.
 Signs & Symptoms

✓ Flank or abdominal tenderness,

Ecchymosis over the flank area (Grey
kidneys
Turner’s Sign)
Injuries
✓ Palpable mass
✓ Hematuria, frank on microscopic
✓ Hemorrhage & urine, extravasation (renal
lacerations).
 Diagnostic Studies

Kidneys Diagnostic Studies

Intravenous pyelogram,
Injuries Urine analysis (hematuria), &
CT scan.
 Therapeutic Interventions

Contusions
kidneys ❑ Bed rest- Observation.
Injuries ❑ Increase fluid intake.
Laceration
❑ Surgical repair or nephrectomy
 Specific Abdominal Injury

• The bladder can be lacerated, ruptured, or

contused, most often as the consequence of
Bladder
Injuries blunt trauma (usually because of a full
bladder at the time of injury).
• Bladder injuries frequently are associated
with pelvic fractures.
 Signs & Symptoms
✓ Gross hematuria is typically noted with bladder
rupture.
Bladder ✓ Presence of blood at the urethral meatus, a scrotal
Injuries hematoma, or a displaced prostate gland requires
examination for urethral injuries with a CT scan
or conventional cystography before the insertion
of a urinary catheter.
 Signs & Symptoms
✓ A bladder injury can cause intraperitoneal or
extraperitoneal urine extravasation.

Bladder ✓ Extraperitoneal extravasation ,usually associated with

pelvic fractures, can often be managed with urinary
Injuries
catheter drainage.
✓ Intraperitoneal extravasation (associated with a high-
force injury), however ,requires surgery. This injury has a
high mortality rate because of associated injuries that
occur secondary to the force involved.
 Signs & Symptoms
✓ A suprapubic cystostomy tube may be placed.
✓ Complications are infrequent, but infection due to the

Bladder urinary catheter or sepsis from extravasation of infected

urine can occur.
Injuries
✓ Patients may complain of an inability to void or of
shoulder pain (caused by urine extravasation into the
peritoneal space).
 Specific Abdominal Injury

• It is seen primarily in penetrating trauma.

• Blunt trauma accounts for approximately
Pancreas
30% of cases.
Injuries
• The most common cause of blunt trauma to
the pancreas is a direct blow to the
epigastric region, such as a kick by a horse
or a fall against bicycle handle bars.
 Signs & Symptoms
✓ Patient may be asymptomatic days to months

✓ Epigastric pain; pain in mid-abdominal region (if

Pancreas present)
✓ Nausea & vomiting,
Injuries
✓ Abdominal distention
✓ Altered vital signs
✓ Pancreatic fistula, abscess, hemorrhage, may occur later after
injury.
✓ Serial serum amylase (results may be normal at the time of injury
and elevated after days).
 Therapeutic Interventions

Blunt Trauma
Pancreas ❑Admit for close observation.
Injuries Penetrating Injuries
❑Prepare for immediate surgical interventions