Abdominal Trauma C168W013 / Version 1.

1 01 Jan 2010
SECTION I. All Courses Including This Lesson Task(s) Taught(*) or Supported

ADMINISTRATIVE DATA
Course Number Version Course Title

300-68W10

2010

Health Care Specialist

Task Number

Task Title

INDIVIDUAL 081-833-0045 (*) TREAT A CASUALTY WITH AN OPEN ABDOMINAL WOUND

Task Title

Reinforced Task(s)

Task Number

081-833-0046 081-833-0213

TREAT A CASUALTY WITH AN IMPALEMENT PERFORM A TACTICAL CASUALTY ASSESSMENT

Academic Hours

The academic hours required to teach this lesson are as follows:

Resident Hours/Methods

Test Test Review Total Hours: Test Lesson Number

20 mins / Demonstration/Practical Exercise (Hands-on) 25 mins / Lecture 5 mins / Lecture 0 hrs / Study Assignement 0 hrs / Study Assignement 0 hrs 0 hrs 1 hr
Hours Lesson No.

Testing
(to include test review)

N/A
Lesson Title

Prerequisite Lesson(s) Clearance Access Foreign Disclosure Restrictions

Lesson Number

None

Security Level: Unclassified Requirements: There are no clearance or access requirements for the lesson. FD6. This product/publication has been reviewed by the product developers in coordination with the USAMEDDC&S foreign disclosure authority. This product is releasable to students from foreign countries on a case-by-case basis.

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010

References
Number Title Date Additional Information

0-323-03986-3

BUTLER, BOL. 161, AUG 199

ISBN 0-07-065351-8 ISBN 0026-4075

PHTLS: Prehospital 01 Jan 2007 Trauma Life Support, 6th Edition Tactical Combat Casualty Care in Special Operations, Supplement to "military Medicine" Emergency Medicine, Tintinalli, McGraw Hill Tactical Combat Casualty Care in Special Operations Supplement to Military Medicine Butler, Vol. 161, August 1996

Student Study Assignments Instructor Requirements Additional Support Personnel Requirements Equipment Required for Instruction

None

One 68W Instructor per specified group

Stu Ratio

Name

Qty

Man Hours

None
Id Name Stu Ratio Instr Ratio

Spt

Qty

Exp

6510-00-201-7425 DRESSING, FIRST AID, FIELD 6510-00-926-8884 ADHESIVE TAPE, SURGICAL 6510-00-935-5823 BANDAGE, ELASTIC 7010-01-454-5951 Laptop/Notebook Computer (w/case & Windows OS) 8105-00-104-9788 BAG PLASTIC CLEAR 10 X 15 IN 250S COMPUTER-INSTRUCTOR COMPUTER (CPU) WITH KEYBOARD, INSTRUCTOR USE ONLY MONITOR-INSTRUCTOR COMPUTER MONITOR PROJECTOR-INSTRUCTOR OVERHEAD PROJECTOR WITH COMPUTER INTERFACE SCREEN-INSTRUCTOR SCREEN PROJECTOR, INSTRUCTOR USE VCR-INSTRUCTOR VCR, CLASSROOM SUPPORT ITEM * Before Id indicates a TADSS

1:1 1:4 1:10 1:1

No No No No

0 0 0 0

Yes Yes Yes No

1:222 1:60

No No

0 0

Yes No

1:60 1:30

No No

0 0

No No

1:30 1:60

No No

0 0

No No

Materials Required

Instructor Materials: Student Materials:

Student Handout LP C168W013

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 The AMEDD Virtual Library: https://medlinet.amedd.army.mil/
Classroom, Training Area, and Range Requirements Ammunition Requirements Instructional Guidance

CLASSROOM, L1, 1881.81SF, 60PN (68W)

Id

Name

Exp

Stu Ratio

Instr Ratio

Spt Qty

None NOTE: Before presenting this lesson, instructors must thoroughly prepare by studying this lesson and identified reference material.

Demonstrations - All demonstrations will be delivered by way of the "wholepart-whole" technique. The instructor demonstrates the skill three times, in a row, to students, before students practice the directed task: 1. Whole. The instructor demonstrates the entire skill from beginning to end, while briefly naming each action or step. If possible, the skill should be performed under the condition specified in standard. 2. Part. The instructor demonstrates the skill again step-by-step, explaining each part in detail. It is important that the instructor select proper size "bites" of the skill. If the information is too specific, the learner can be overloaded with detail. Too broad and the learner may not be able to make the connection from step to step. 3. Whole. The instructor demonstrates the entire skill from beginning to end without interruption, and usually, without commentary. If possible, as the skill would normally be completed "on the job".
Proponent Lesson Plan Approvals
Name Rank Position Date

Walker, Barbara Hansen, Meredith

GS-12 YC-02

ISS Chief, Curriculum Development

15 Dec 2009 15 Dec 2009

SECTION II.

INTRODUCTION

Method of Instruction: Lecture Instructor to Student Ratio is: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction
Motivator

Abdominal injuries are difficult to evaluate in the Medical Treatment Facility (MTF) and even more so in the field. Immediate surgical intervention is needed for penetrating abdominal injuries; blunt injuries may be more subtle in their presentation, but may be just as deadly. Whether the result of penetrating or blunt trauma, abdominal injuries present two life threatening dangers: infection and hemorrhage. Casualties may require surgical intervention to ultimately save their life.
NOTE: Inform the students of the following Terminal Learning Objective requirements. At the completion of this lesson, you [the student] will:

Terminal Learning

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010

Objective Action: Conditions:

Treat an abdominal injury Given a casualty with suspected abdominal injury in a combat environment IAW Prehospital Trauma Life Support Chapter 11 and 21.

Standards:

Safety Requirements Risk Assessment Level Environmental Considerations

None Low

NOTE: It is the responsibility of all Soldiers and DA civilians to protect the environment from damage.

None
Evaluation

Students will be given a one (1) hour comprehensive written examination to include management of abdominal injuries.

Instructional Lead-In

Uncontrolled hemorrhage has immediate consequences to life, thus you must be alert to the danger of early shock in abdominal injury casualties. Infection can be just as fatal, but with prompt recognition of abdominal injury and rapid evacuation of the casualty, field intervention will not be required. In this lesson, you will gain an understanding of the anatomy of the abdomen and the types of injuries you may encounter. You will learn the principles of abdominal injury assessment and casualty stabilization.
PRESENTATION

SECTION III.

1.

Learning Step / Activity 1. Anatomy and Physiology of the Abdomen - Review Method of Instruction: Instructor to Student Ratio: Time of Instruction: Media: Study Assignment 1:60 0 hrs Large Group Instruction

NOTE TO STUDENTS: This information will not be covered in class. It is provided to you as a reference only. a. Boundaries (1) The abdominal cavity is below (inferior to) the diaphragm. (2) Anterior abdominal wall. (3) Pelvic bones. (4) Spinal column.

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (5) Muscles of the abdomen and flanks. b. Quadrants (1) Right upper quadrant (RUQ). (a) Liver. (b) Gallbladder. (c) Head of the pancreas (retroperitoneal). (d) Part of colon (hepatic flexure and part of transverse colon). (e) Small intestine (a portion of). (f) Abdominal aorta (along the line separating RUQ from LUQ). (e) Right kidney (retroperitoneal). (f) Right renal artery. (2) Left upper quadrant (LUQ). (a) Stomach. (b) Spleen. (c) Tail of the pancreas (peritoneal). (d) Part of colon (splenic flexure and portion of the transverse colon). (e) Small intestine (a portion of). (f) Abdominal aorta (along line separating RUQ from LUQ). (g) Left kidney (retroperitoneal). (h) Left renal artery. (3) Right lower quadrant (RLQ). (a) Part of colon (ascending colon including cecum). (b) Appendix (attached to cecum). (c) Small intestine (a portion of). (d) Part of the bladder and uterus; right fallopian tube, right ovary. (e) Right iliac artery. (4) Left lower quadrant (LLQ). (a) Small intestine (a portion of).

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (b) Part of colon (sigmoid/descending colon). (c) Part of the bladder and uterus, left fallopian tube, left ovary. (d) Left iliac artery. c. Abdominal Organ Physiology (1) Liver. (a) Stores about 10% of total blood volume (TBV). (b) Metabolizes carbohydrates (sugars), fat and protein. (c) Stores vitamins and iron. (d) Forms various blood clotting factors. (e) Detoxifies/excretes and metabolizes many different drugs. (f) Forms bile which breaks down fat for digestion and serves as a means for excreting certain waste products from the blood. (2) Gallbladder. (a) Stores bile formed by the liver. (b) Empties bile into first part of small intestine (duodenum) when there is high fat content in a meal. (c) If stones form in the gallbladder, they may obstruct the drainage system (bile duct) to the small intestine. (3) Pancreas. (a) Produces and secretes digestive juices into the first part of the small intestine (duodenum) via the pancreatic duct. (b) Produces and secretes hormones (insulin and glucagon) into the blood that will regulate the blood sugar (glucose) level. 1) Insulin: Promotes glucose entry into most cells of the body, decreasing blood glucose levels in the blood. 2) Glucagon: Increases the release of glucose from the liver into the circulating body fluids, increasing blood glucose levels in the blood. (4) Small intestine. (a) Absorption of carbohydrates (sugars) proteins and fats. (b) Absorption of ions (sodium, chloride, bicarbonate, calcium, iron, potassium). (c) Absorption of water (that accompanies the ions being absorbed). Most water however, is absorbed in the colon (large intestine).

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (d) Absorption of proteins and fat. (5) Colon (large intestine). (a) Absorption of water and electrolytes (up to 5 to 7 liters per day). (b) Storage of fecal matter until it can be expelled. (6) Stomach. (a) Stores large quantities of food until it can be converted into a soupy mixture (chyme) and then emptied into the duodenum (first portion of small intestine). (b) Secretes digestive juices and enzymes. (c) Poor at absorption except for highly lipid-soluble substances like alcohol and some medications such as aspirin. (7) Spleen. (a) An organ of the lymphatic system: contains the largest amount of lymphatic tissue in the body. (b) Stores Red Blood Cells (RBCs) and platelets. Removes RBC and platelets that are worn out or defective. (c) Carries out immune functions and has cells involved in fighting infections. (d) Highly vascular organ that, if injured, may result in massive hemorrhaging. NOTE: The spleen may become inflamed and enlarged in patients with infectious mononucleosis (Mono). As a result these patients should be advised to avoid contact sports for up to 6 weeks after diagnosis due to the remote possibility of splenic rupture. (8) Kidneys. (a) Excrete most of the end products of bodily metabolism through filtration of blood and formation of urine. (b) Regulates the water, electrolytes and acid-base content of the blood. 2. Learning Step / Activity 2. Assessment of Abdominal Trauma Lecture 1:60 10 mins Large Group Instruction

Method of Instruction: Instructor to Student Ratio: Time of Instruction: Media: a. Abdominal Trauma (1) Solid and Vascular Organs (a) Liver, spleen, aorta, vena cava

(b) Bleeding into the abdominal cavity when injured (c) Blood loss into the peritoneal cavity, regardless of the source will contribute to hypovolemic shock. A casualty's entire circulating volume can be lost into the abdominal cavity.

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (2) Hollow Organs (a) Intestine, gallbladder, urinary bladder (b) Spill contents into the peritoneal cavity and retroperitoneal space (c) Release of digestive acids, enzymes, bacteria and partially digested food (chyme) into the peritoneal cavity causes peritonitis and sepsis. 1) Peritonitis - Inflammation of the peritoneum or lining of the abdominal cavity. 2) Sepsis - massive systemic infection that includes hypotension, decreased urine output and altered mental status (See Shock Lesson). (d) Bleeding from an intestinal injury is typically minor, unless larger vessels of the mesentery are damaged. (3) The Diaphragm - During maximum expiration (exhale) extends, superiorly to the 4th intercostal space anteriorly, to the 6th intercostal space laterally and to the 8th intercostal space posteriorly. Consequently, a wound that started out in the abdomen may end up in the chest or the other way around. (4) Penetrating Trauma (a) Mentally visualize the path of all penetrating trauma of the abdomen and thorax. (Penetrating abdominal wounds should never be probed with fingers or instruments.) (b) Trauma to the thorax or abdomen may continue into a different cavity depending on the position of the diaphragm on impact. (c) Penetrating wounds to the flanks and/or buttocks may involve organs of the abdominal cavity. Penetrating trauma in the gluteal area is frequently associated with significant intraabdominal trauma in up to 50% of the cases. (d) In penetrating trauma, the casualty may not initially appear to be in shock unless the object or projectile penetrates a major vessel or organ. (5) Blunt Trauma (a) Possesses a greater threat to life. (b) Difficult to diagnose. Objective evidence of blunt trauma may not appear on the casualty for hours. Mechanism of injury and pain may be the only signs to an underlying injury. (c) Compression injuries - organs are crushed between solid objects (d) Shearing injuries - Tearing forces exerted against the supporting ligaments of solid organs and vessels. Deceleration injuries are common and restraining devices (seat belts) may cause injuries themselves. b. Kinematics (1) Mechanism of injury and a high index of suspicion play an important role in identifying possible life threatening abdominal injuries.

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (a) 15% of stab wounds (low energy) require surgical intervention. (b) 85% of gunshot wounds (medium and high energy) require surgical intervention. Fragmentation wounds are the most common cause of penetrating injuries in combat. (c) The following are key indicators of establishing a high index of suspicion for abdominal injuries: 1) Obvious signs of trauma 2) Signs of hypovolemic shock without obvious cause 3) Degree of shock greater than would be expected by other injuries 4) Presence of peritoneal signs 5) Mechanism of injury (d) The primary factor in assessing abdominal trauma is not the accurate diagnosis of the injury, but rather the determination that an abdominal injury does exist. The major cause of morbidity and mortality in abdominal trauma is the delay in determining if an injury exists and the resulting delay in treatment. c. History (1) Position of the vehicle, extent of vehicle damage and position of casualty within the vehicle. (2) Was there an explosion that threw the victim against immobile objects or transmitted blast pressure to organs inside the abdomen? (Keep in mind that due to overpressure, hollow organs can rupture with no apparent external injury. Look for ruptured eardrums.) (3) Type of weapon used and casualty distance from weapon. Fragmentation wounds. (4) Was safety equipment used? Vehicle seat belts, helmets, body armor. d. Physical Examination (1) The most reliable indicator of intraabdominal bleeding is the presence of hypovolemic shock from an unexplained source. (2) Look for signs and symptoms of compensated, and later decompensated, shock (See Shock Lesson). (3) Auscultation - time should not be wasted auscultating the abdomen in a combat environment. Regardless of your findings, casualty treatment before reaching the medic treatment facility (MTF) will not change. (4) Inspection for soft tissue injuries and distention. (a) Soft tissue injuries due to blunt trauma may not be apparent for hours after the injury. (b) An adult peritoneal cavity can hold up to 1.5 liters of fluid before evidence of distention is apparent. (5) Palpation

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (a) For combat related abdominal injuries, light palpation of each quadrant to assess for tenderness and rigidity is all that is required. Pain or rigidity in any quadrant of a combat casualty requires surgical exploration. NOTE: Deep or aggressive palpation should be avoided because it may dislodge blood clots, promote existing hemorrhage and increase spillage of contents of the GI tract. (b) Note any voluntary guarding (casualty seems to tense up) and involuntary guarding (spasms of the abdominal wall muscles that remain even when the casualty is distracted). (c) Palpate the pelvis for instability in three steps 1) Press posteriorly on the iliac crest 2) Press inward on the iliac crest 3) Press posteriorly on the symphysis pubis. NOTE: Any combat casualty with a penetrating wound from the nipple line to the buttock needs a routine surgical evaluation unless rigidity or tenderness is identified, they need surgical evaluation immediately. NOTE: Explain what type of physical exam should be completed on a combat casualty with an abdominal injury. Why must the type of exam be changed when compared to the examination you learned during the Limited Primary Care module? For combat related abdominal injuries, light palpation of each quadrant to assess for tenderness and rigidity is all that is required. Pain or rigidity in any quadrant of a combat casualty requires surgical exploration. Deep or aggressive palpation should be avoided because it may dislodge blood clots, promote existing hemorrhage and increase spillage of contents of the GI tract. The most reliable indicator or intraabdominal bleeding is? The presence of hypovolemic shock from an unexplained source. Why are soft tissue injuries not a good indication of intraabdonimal bleeding? They may not be apparent for hours after the injury. 3. Learning Step / Activity 3. Management of Abdominal Trauma Method of Instruction: Instructor to Student Ratio: Time of Instruction: Media: a. Casualty Management (1) Once an abdominal injury is identified the casualty should be evacuated to a MTF as soon as possible. (a) Evacuating a casualty to a MTF that does not have surgical capabilities defeats the purpose of rapid evacuation. These casualties should be categorized for evacuation as urgent surgical. (b) Position the casualty for transport with knees bent, when possible. (2) Manage conditions associated with hemorrhage, airway, breathing and circulation. Lecture 1:60 10 mins Large Group Instruction

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Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 (3) Establish vascular access with a saline lock. (4) Follow fluid resuscitation protocols (See Shock Lesson) for combat casualties suffering from hemorrhagic shock. The medic must achieve a delicate balance of maintaining profusion to the vital organs without restoring a normal blood pressure that will increase internal bleeding. (5) Provide antibiotics (oral or IV depending on availability and the condition of the casualty). b. Special Considerations (1) Impaled objects (a) Do not move or remove impaled objects, that job is for the surgeon. (b) Stabilize the object either manually or mechanically with built up bulky dressing. (c) Apply direct pressure with the flat of the hand to control bleeding around the edges of the wound, if necessary. (d) Palpation of the abdomen should NOT be conducted. (2) Evisceration (a) Efforts should focus on protecting the protruding segment. 1) A small plastic bag can be used in conjunction with an abdominal bandage. 2) Wrap the plastic bag around the intestines and cover with an abdominal dressing. (b) Apply moist dressings to the segment and a larger dry bandage, when possible, to protect the casualty from hypothermia. Intestines that dry out usually do not recover and must be removed. (c) If wound is large and you can put abdominal contents back into the hole in the abdomen, do so and cover with abdominal bandage. (d) Any action that increases intraabdominal pressure such as crying, screaming, coughing, and bearing down can force more of the organs outward. (3) Pregnancy (a) Until about the 12th week, the uterus remains protected by the pelvis. Injury to the uterus can include rupture, penetration, abrupto placentae and premature rupture of the membranes. The placenta and uterus are highly vascular and can result in profound hemorrhage. Additionally, hemorrhage can be concealed for a period of time within the uterus. (b) Vaginal bleeding secondary to trauma should be evacuated expeditiously (c) Physiologic Changes 1) By the third trimester the mother's heart beat increases 15 to 20 beats a min. 2) By the 36 week of pregnancy, the mother's blood volume has increased by about 50%. Because of increases in cardiac output and blood volume, a pregnant casualty may lose 30% to 35% of total blood volume BEFORE showing signs of hypovolemia.
th

11

Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 3) Systolic and diastolic blood pressure drop 5 to 15 mm Hg during the second trimester, but will return to normal by term. 4) Ask the casualty about complications of pregnancy that may complicate your assessment and management. (d) Treatment and transport of a pregnant casualty is similar to that of any other casualty. 1) Manage any condition associated with airway, breathing and circulation. Aggressive resuscitation and transport of the mother is the way best to ensure the survival of the mother and fetus. 2) Transport the casualty on her left side, tilt the right side of the spine board, elevate the casualty's right leg or manually displace the uterus to the left is relieve supine hypotension. (4) Genitourinary Injuries (1) Damage to the kidneys, ureters and bladder often present with hematuria, which will not be noted unless the casualty has a urinary catheter, unlikely in a combat environment. (2) Injuries to external genitalia result in soft tissue hemorrhage, significant pain and psychological concern. (a) Control hemorrhage with direct pressure or pressure dressings. (b) Manage amputated genital body parts as you would any other amputated body part given the supplies available to the battlefield. NOTE: What options do you have when treating an abdominal evisceration? A small plastic bag can be used in conjunction with an abdominal bandage. Wrap the plastic bag around the intestines and cover with an abdominal dressing. Apply moist dressings to the segment and a larger dry bandage, when possible, to protect the casualty from hypothermia. If wound is large and you can put abdominal contents back into the hole in the abdomen, do so and cover with abdominal bandage. How should an obviously pregnant female be transported? Transport the casualty on her left side, tilt the right side of the spine board, elevate the casualty's right leg or manually displace the uterus to the left is relieve supine hypotension. What is the proper way to manage an amputated part (based on your EMT training)? How practical is this in a combat environment? Wrap in sterile gauze, place in a plastic bag, and keep the part cool. Supplies may not be available and access to a cool environment for the part may not practical. 4. Learning Step / Activity 4. Manage Abdominal Trauma - Demonstration and Practical Exercise Method of Instruction: Instructor to Student Ratio: Time of Instruction: Media: Demonstration/Practical Exercise (Hands-on) 1:10 20 mins Large Group Instruction

Combat Casualty Assessment scenarios are not used during this initial phase of skill training. Information below contains training minimums, additional sessions should be conducted based on the needs of the students. See Instructor Guidance for additional information. For all aspects of this practical exercise, student groups will be utilized.

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Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 The goal of this practical exercise is to provide the student with an opportunity to apply management techniques that have been explained and demonstrated through their training as a medic. Training should focus on principles and practical application, not on achieving a specified numbers of repetitions. a. Given a combat casualty with an evisceration, dress and bandage the wound. Position the casualty correctly for transport. b. Given a combat casualty with an abdominal impalement, dress and bandage the wound. Position the casualty correctly for transport.
SECTION IV.

SUMMARY Method of Instruction: Lecture Instructor to Student Ratio is: 1:60 Time of Instruction: 5 mins Media: Large Group Instruction

Review / Summarize Lesson

Uncontrolled hemorrhage and time are the enemies of the abdominal trauma casualty and have immediate consequences to life. You must be alert to the dangers associated with the failure to promptly recognize abdominal injury and the early onset of shock in these casualties. As you've seen, early recognition, rapid evacuation and stabilization at the appropriate echelon of care are the key to survival for casualties of abdominal injury.

5.

Learning Step / Activity 5. Optional Student Homework Method of Instruction: Instructor to Student Ratio: Time of Instruction: Media: Study Assignment 1:445 0 mins Large Group Instruction

1. During a mortar attack on your COB in Afghanistan, several soldiers, and US civilians were injured. What is the most common cause of penetrating injuries in combat? a. b. c. d. Gunshot wounds. IEDs. Fragmentation wounds. Amputations.

Page 5 b (1) (b) 2. You suspect abdominal trauma on a casualty that was thrown fifteen feet when a building he was about to enter exploded. He is pale and has a rapid pulse, and abdominal redness with no obvious external bleeding. What is the primary factor in assessing abdominal trauma? a. b. c. d. The determination that an abdominal injury does exist. Bruising to the abdomen. Abdominal distention. Abdominal rigidity.

Page 5 b (1) (d) 3. What is the most reliable indicator of intra-abdominal bleeding?

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Abdominal Trauma C168W013 / Version 1.1 01 Jan 2010 a. b. c. d. Abdominal bruising. Abdominal distention. Mechanism of injury and pain. The presence of hypovolemic shock from an unexplained source.

Page 5 d (1) 4. What is the evacuation category for a casualty with abdominal trauma. a. b. c. d. Urgent. Immediate. Urgent surgical. Priority.

Page 7 a (1) (a) 5. Your unit is conducting medical treatment for members of the local village outside your COB in Afghanistan. A pregnant civilian is brought to you for evaluation of abdominal pain and vaginal bleeding after a fall. You determine that she is about 16 weeks pregnant. During pregnancy, how long is the uterus protected by the pelvis? a. b. c. d. Until about the 20 week. th Until about the 8 week. th Until about the 12 week. th Until about the 6 week.
th

Page 7 b (3) (a)

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