MOD E Tech Abdominal Trauma Flashcards
Abdominal Trauma
You are presented with a 21 year old male patient who has what appears to be a deep stab wound to the lower margin of the left hypochondrium in the anterior axillary line. He appears to be profoundly shocked
Primary Survey
- Catastrophic Haemorrhage – none evident
- Airway – Clear
- Breathing – tachypnoeic, bilateral b.s.
- Circulation – tachycardic, weak, abdomen rigid
- Disability – unresponsive to voice or pain
Baseline Observations:
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- Pupils – dilated but reactive
- Pulse – 130/min
- Skin – pale, cool, moist
- Resps. – 40/min
B.P. – 90/50
Abdominal Trauma
- A leading cause of preventable trauma death
- Often goes unrecognized
- Internal injury difficult to assess in the field
- Massive blood loss can lead to shock and death
Abdominal Trauma
The abdomen is divided into 3 anatomical areas:
- Abdominal cavity
- Pelvis
- Retroperitoneal cavity
Pathophysiology
Abdominal Trauma
Abdominal cavity:
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•Solid organs (liver, spleen) haemorrhage
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•Hollow organs (small intestine, colon) filled with enzymes and bacteria
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•Can hold large volume of blood (“Silent reservoir”)
Pelvis
•Contains the bladder, lower part of the large intestine and, in the female, the uterus and ovaries
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•The iliac artery and vein lie over the posterior part of the pelvic ring and may be torn in pelvic fractures
Retro-peritoneal Area
- Lies against posterior abdominal wall
- Contains kidneys, ureters, pancreas, abdominal aorta, vena cava and part of duodenum
- These structures often injured by shearing forces produced in rapid deceleration
Shear Injury
Pathophysiology
Retroperitoneal cavity:
•Solid organs (kidneys, pancreas)
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- Large blood vessels (aorta and vena cava)
- Potential space that can hold massive amount of blood
Mechanism of injury
•Abdominal injury can result from both blunt and penetrating forces
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•All penetrating abdominal trauma must be recognised as serious injury, regardless of the cause
Assessment
•Observe the mechanism of injury
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•In RTC’s look for impact speed and severity of deceleration. Was a seat belt worn? – lap belts are particularly associated with perforated abdominal structures
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•In cases of stabbing and gunshot wound, what was the length of weapon, or the type of gun and range?
Restraint Devices
What types of injuries should you anticipate?
Stab Wounds
- Low energy
- Multiple wounds from a single weapon
- Cone of injury
- A knife, ice pick, and scissors are common weapons. Injuries are usually limited to depth and area of penetration.
Would a longer knife have a larger cone of injury?
Stab Wounds: Key Issues
•Type of weapon
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•Number of wounds
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•Depth of penetration
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- Anatomic structures along potential path
- Stab injuries MUST be assumed to have done serious damage until proved otherwise
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•Mortality from isolated stab wounds is approx. 1-2%
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- Damage to liver, spleen or major blood vessels causes massive haemorrhage, although many isolated stab injuries cause little major damage due to the mobility of intra-abdominal structures such as the intestines
- Upper abdominal stab wounds may have caused major intra-thoracic damage if the weapon was directed upwards.
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•Lung, direct cardiac injury and pericardial tamponade can all result from an “upper abdominal” stab injury.
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- Similarly, chest stabbing wounds may injure abdominal and thoracic organs if the diaphragm is penetrated
- Upper abdominal stab wounds may have caused major intra-thoracic damage if the weapon was directed upwards.
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•Lung, direct cardiac injury and pericardial tamponade can all result from an “upper abdominal” stab injury.
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•Similarly, chest stabbing wounds may injure abdominal and thoracic organs if the diaphragm is penetrated
Gunshot Wounds: Cavitation
Blunt trauma
Blunt impact will create a definable injury pattern:
- Compression
- Crush
- Shearing
- Collision
Ejection
Assessment
- ABCD’s
- Evaluate whether “time critical” or “non-time critical”
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•Load & Go with time critical patients and continue management en route
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•Perform a secondary survey on non-time critical patients
1.Consider the mechanism of trauma
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2.Inspect from nipples to knees, including the flanks
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3.Palpate the area that you have inspected
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4.Auscultate the abdomen for dullness or bowel sounds indicative of bleeding
Specifically assess:
•Both chest and abdomen
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- Examine abdomen for external wounds, contusions, seat belt abrasions, evisceration (DCAP, BTLS)
- Assess all four quadrants by gentle palpation for tenderness, guarding and rigidity
- Consider the potential for pelvic injuries and gently assess lower ribs for fractures
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•Shoulder tip pain could indicate splenic injury.
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Many patients found later to have significant intra-abdominal trauma show little or no evidence of this in the early stage, so do not rule out injury if initial examination is normal
Pelvic Fractures
How can pelvic fractures be recognized and managed in the prehospital setting?
