Abdominal trauma

Hera Tashjian February 2008

Epidemiology
Common in patients who sustain major trauma Third cause of traumatic death (after head and chest injuries) Mortality rate 13-15 %

Mechanism of injury
Abdomen is vulnerable to injury because of minimal bony protection Most common mechanism for blunt injury is MV crash; stabbings and physical assault are associated with penetrating injury Frontal impact crashes with bent steering wheel and broken windshield associated with spleen and liver injuries Rear impact crashes can result in abdominal injuries if driver is unrestrained Depending on side of the impact, side crashes result in spleen or liver injuries

Types of injury
Blunt: most commonly injured organs are spleen and liver Penetrating: most commonly liver, small bowel, stomach. Usual concurrent injuries with chest traumas (fracture of lower rib cage, pelvic fracture)

Hepatic injuries
Can result in profuse hemorrhage S & S: upper right quadrant pain; abdominal muscle rigidity, spasm or involuntary guarding; rebound tenderness; hypoactive or absent bowel sounds; signs of hemorrhage or hypovolemic shock

Splenic injuries
S & S: signs of hemorrhage or hypovolemic shock; pain in the left shoulder (Kehrs sign); tenderness in the upper left quadrant; abdominal muscle rigidity, spasm or involuntary guarding

Hollow organ injuries

Small bowel is most frequently injured organ S & S: peritoneal irritation: abdominal muscle rigidity, spasm or involuntary guarding; rebound tenderness

Renal injuries
Most common injury is blunt contusion Suspect renal in jury if there is fracture of the posterior ribs of lumbar vertebrae. S & S: ecchymosis over the flank; flank or abdominal tenderness elicited during palpation Gross or microscopic hematuria

Bladder and urethral injuries

Majority of bladder traumas are blunt. Urethral trauma more common in males than females. Most common with pelvic fractures. S & S: suprapubic pain; urge, but inability to urinate; hematuria; blood in urethral meatus; blood in scrotum; rebound tenderness; displacement of prostate gland; abdominal muscle rigidity, spasm or involuntary guarding

Assessment
Questions to ask:
Was the patient wearing any restraints or protective devices? Inappropriately positioned lap belts may injure lower abdominal structures. The use of a lap belt without a shoulder belt is associated with hollow organ injuries especially the small bowels. What is the location, intensity, and quality of pain? Is there an urge to urinate or defecate?

Physical assessment (1)

Primary and secondary assessment Inspect: the contour of the abdomen (flat or distended); Ecchymosis:
over the ULQ suggests splenic injury; around the umbilicus suggests intraperitoneal bleeding; Over flank area suggests retroperitonal bleeding. May not be noted on initial presentation.

Inspect gunshot wounds

Physical assessment (2)

Auscultate all four quadrants. Auscultate the chest Palpate all four quadrants; the flanks Diagnostic procedures:
Abdominal CT X-rays Cystogram/urethrogram Ultrasound

Labs: liver function studies; urine and stool analysis; pregnancy testing for females of childbearing age

Nursing management
Insert two large-bore IVs and initiate hydration Administer blood as indicated Insert an indwelling catheter Assist in inserting gastric tube Cover open wounds with sterile dressing Stabilize impaled objects Administer antibiotics Administer analgesics Prepare patient for operative intervention or hospitalization Provide psychological support

Questions?