PCTH - Abdominal and Pelvic Injuries

Question 1

The largest cavity in the body is ______________.

Answer 1

abdomen

Question 2

The abdomen encompasses what (i.e. runs from what structure to what other structure)?

Answer 2

thorax to pelvis

starts around 4th-5th ribs

Question 3

True or False. Upper parts of the abdomen may be considered as part of the chest.

Answer 3

True (therefore always important to remember possibility of abdo injuries accompanying chest injuries)

Question 4

What are the three parts of the abdomen?

Answer 4

1) intrathoracic abdomen
2) true abdomen
3) retroperitoneal abdomen

Question 5

What is the most common MOI for abdominal injuries?

Answer 5

blunt trauma

Question 6

Where is the intrathoracic abdomen located and what structures lie within this area?

Answer 6

• located immediately below the diaphragm
• protected by the lower ribs
• contains liver, spleen, stomach gallbladder, transverse colon

Question 7

Where is the true abdomen located and what structures lie within it?

Answer 7

• located immediately below the lower ribs and extends to the pelvis
• contains the large & small intestines, portion of the liver & bladder
• in females: uterus, fallopian tubes, and ovaries too

Question 8

Where is the retroperitoneal abdomen located and what structures lie within it?

Answer 8

• located immediately behind intrathoracic and true abdomen
• contains kidneys, ureters, pancreas, ascending and descending colon, abdominal aorta and inferior vena cava (IVC)

Question 9

Mortality rates for abdominal injuries secondary to blunt trauma?

Answer 9

10-30%

Question 10

Abdominal injuries can be caused by different types of blunt trauma. What are these types and how do they cause such injuries?

Answer 10

1) Direct compression - direct trauma to abdomen

2) Deceleration - high to low speeds (amusement park rides, ex.) ⇒ consider rupturing of hollow organs or organs being ripped away from their attachment points to the body

Question 11

True or false. Blunt trauma to the abdomen can present with little evidence of injury.

Answer 11

True. There may also not be a lot of associated pain if there are other distracting injuries

Question 12

Abdominal injuries secondary to penetrating trauma is most commonly caused by what?

Answer 12

bullets or knives

Question 13

What details/characteristics are of importance when assessing abdominal injuries secondary to penetrating trauma?

Answer 13

• angle of entry (assessing their position, assailant’s position and their respective heights)
• presence of air (anything that is pink and frothy = assume there is involvement of the lungs and treat as open pneumo)

Question 14

What may abdominal injuries from penetrating trauma look like on assessment of ENTRY wounds?

Answer 14

• entry wound may be difficult to see
• may be easily overlooked (especially the smaller the wound)
• may have darkened, burnt edges if fired from close range (gather info re: caliber of bullet, distance, etc. if possible)

Question 15

What may abdominal injuries from penetrating trauma look like on assessment of EXIT wounds?

Answer 15

• exit wounds are typically bigger and tend to be more messy (just due to force it takes to get through the body)
• not proportional to entry wound
• may be multiple depending on ammunition used, ragged edges

*note: exit wounds may not always be present

Question 16

What is more important:

a) distinguishing which wound is an entry/exit wound
b) the total number of wounds present
c) both are equally important

Answer 16

b) the total number of wounds present

Question 17

What are considerations re: low vs high velocity projectiles (penetrating trauma) and internal abdominal injuries?

Answer 17

• Low-velocity projectiles: inflict damage primarily by damaging tissue via direct contact (i.e. hollow organs like stomach, intestine, etc. - the damage is more localized to the specific area that the projectile hit)
• High-velocity projectiles: inflict damage by tissue contact and transfer of kinetic energy (i.e. solid organs may have a lot more damage as it passes through, destroys surrounding tissue and cascades through as kinetic energy is transferred)

Question 18

Damage done is (directly/inversely) proportional to tissue density.

Answer 18

directly (i.e. higher tissue density = more damage)

Question 19

What general assessments are to be conducted for abdominal injuries?

Answer 19

• CLAPPD - P: pulsatile masses; D: distension
• TAR - tenderness, asymmetry, rigidity
• L vs R: comparing left side to right side and checking all four quadrants (UL, UR, LL, LR)
  
  • consider things like Kehr’s sign which is when patient presents with referred L shoulder pain and splenic injury
  • R shoulder pain and liver/gallbladder injury
• Scene assessment - ask witnesses to gather info, look for things like shell casings

Question 20

According to the BLS PCS under Abdominal/Pelvic Injury section, in situations involving a patient with a blunt or penetrating injury, the paramedic shall:

Answer 20

1) consider potential life/limb/function threats, such as,

1. rupture, perforation, laceration, or hemorrhage of organs and/or vessels in the abdomen and potentially in the thorax or pelvis, and
2. spinal cord injury

2) if patient has evisceration of intestines,

1. make no attempt to replace intestines back into the abdomen, and
2. cover eviscerated intestines (or any abdominal contents) using moist, sterile large bulky dressings

3) if patient has a pelvic fracture,

1. attempt to stabilize the clinically unstable pelvis with a circumferential sheet wrap or a commercial device,
2. secure patient to spinal board* or adjustable break-away stretcher
3. avoid placing spinal immobilization or stretcher straps directly over pelvic area,
4. secure and immobilize lower limbs to prevent additional pelvic injury

Question 21

Treatment for eviscerated abdomen

Answer 21

• never put anything back into the abdomen
• moisten abdo pad with STERILE saline
• apply to cover abdomen (no use of force or pressure on area)
• cover with occlusive dressing (non-adhesive) so things like foil blanket, plastic bags etc. that is bigger than abdo pad
• apply tape to cover occlusive dressing (if you need to dry the patient do so, in order for tape to stick)
• *note: consider heat loss - apply blanket, helpful for heat retention and also keeping dressing moist

Question 22

Which has higher mortality rate with regards to abdominal trauma: blunt or penetrating injury?

Answer 22

Blunt (potential for bursting organs vs. penetrating trauma may only affect specific organ that was injured)

Question 23

What is the most significant sign of abdominal trauma?

Answer 23

drop in BP

Question 24

Extrication of patient with eviscerated abdomen

Answer 24

Keep them in the position you found them

if sitting, fore and aft them (laying them back and putting them on a board/extrication device may pull/move abdominal contents)

Question 25

True or false. If intestines are allowed to dry, they may become irreversibly damaged.

Answer 25

True

Question 26

What sorts of scene observations would be helpful in your assessment/treatment of the patient with abdominal injuries?

Answer 26

• blood loss/flluid loss (esimation of volume and where it’s coming from)
• type of blood/fluid
• object causing protrusion
  
  • type of gun/blade; height and distance of assailant/angle of attack, number of times struck -most reliable from bystander)
  • If blunt - speed of object/incident; type of object; area affected
• angle of entry vs exit (if applicable)

Question 27

True or False. vast majority of aneurysms can exist with no symptoms.

Answer 27

True. Can have no effect until they become symptomatic

Question 28

True or False. No matter the size of the aneurysm, signs and symptoms will always present the same.

Answer 28

False.

Question 29

Arterial aneurysms

Answer 29

weakness in a section of the artery (such as aorta) that causes the weak spot to expand as blood collects (also remember that arterial blood travels at a higher pressure/more turbulent blood flow which can cause risk of rupture)

Question 30

Signs and symptoms of leaking/ruptured AAA

Answer 30

• pulsating feeling near navel
• deep, constant pain in abdomen or on the side of the the abdomen
• back pain

Question 31

Aortic dissection/dissecting aneurysm

Answer 31

when a tear occurs in the inner layer of the body’s main artery (aorta). Blood rushes through the tear, causing the inner and middle layers of the aorta to split/get ripped apart (dissect)

Question 32

Sign/symptoms of aortic dissection

Answer 32

• suddent onset of intense and persistent abdominal or back pain, described as a tearing/ripping/searing sensation
• pain that radiates to your back or legs
• sweatiness
• clamminess
• dizziness
• N/V
• low BP
• fast pulse

Question 33

As per BLS PCS Abdominal Pain (Non-Traumatic) Standard, in situations involving a patient with abdominal pain that is believed to be of a non-traumatuc origina, the paramedic shall:

Answer 33

1. consider potential life/limb/function threats, such as

1. leaking or ruptured AAA
2. ectopic pregnancy
3. other non-abdominal disorders that may present with abdominal pain including diabetic ketoacidosis and pulmonary embolism
4. perforated or obstructed hollow organs with or without peritonitis
5. acute pancreatitis
6. testicular torsion
7. pelvic infection, and
8. strangulated hernia;

2. perform, at a minimum, a secondary survery to assess the abdomen for,

1. pulsations
2. scars (*i.e. previous surgeries or potential complications)
3. discolouration
4. distention
5. masses
6. guarding
7. rigidity
8. tenderness

3. If a pulsatile mass is discovered, not initiate, or discontinue, further abdominal palpation

4. if abdominal aneurysm is suspected, palpate femoral pulses for weakness/absence; and

5. observe for melena, hematemesis, or frank rectal bleeding (hematochezia)

Question 34

Ectopic pregnancy

Answer 34

when a fertilized egg implants and grows outside the main cavity of the uterus

Question 35

True or false. Perforated or obstructed hollow organs can be caused by something as simple as colonscopies (i.e. camera causing rip or tear).

Answer 35

True

Question 36

S/Sx of testicular torsion

Answer 36

abnormal positioning of testicles with discolouration, suddent onset ++ pain

most common in young males

Question 37

Melena

Answer 37

darkened stool - indicative of rectal bleeding that has been going on for awhile (dark blood = old blood) + will have distinct smell

Question 38

hematochezia

Answer 38

passive of fresh blood (bright red blood) through anus/in stool

*more concerning than melena

Question 39

Assessment for non-traumatic abdominal injuries

Answer 39

• pain scale
• OPQRST
• Last BM/urine
• colour/consistency/smell
• blood
• N/V

Question 40

Treatment for non-traumatic abdominal injuries

Answer 40

• vitals
• early recognition
• positioning

Question 41

As per BLS PCS Nausea/Vomiting Standard, in situations involving a patient with nausea/vomiting, the paramedic shall:

Answer 41

1. consider potential life/limb/function threats, such as,

1. acute coronary syndrome/acute myocardial infarction (eg. STEMI),
2. anaphylaxis
3. increased intracranial pressure
4. toxicological emergencies
5. bowel obstructions
6. infection
7. acute pancreatitis
8. intra-abdominal emergencies,
9. uremia

2. perform, at a minimum, a secondary survery to assess abdomen, as per Abdominal Pain (Non-traumatic standard)

3, prepare for potential problems, including airway compromise

Question 42

Treatment for nausea/vomiting

Answer 42

• vitals
• O₂ if indicated
• positioning
• dimenhydrinate (Gravol)

Question 43

Pelvis: What is it

Answer 43

Sturdy ring of bones that consist of the sacrum, coccyx (tail bone), and L and R coxal (hip) bones

Question 44

Function of the pelvis

Answer 44

• protect delicate organs of the abdominopelvic cavity
• anchor point for powerful muscles of the hip, thigh, and abdomen

Question 45

When are pelvic fractures typically evident?

Answer 45

When fractures are present in at least 2 places

Question 46

Pelvic fractures have the potential for what amount of blood loss?

Answer 46

1 liter

Question 47

Due the force required to cause a pelvic fracture, what portion of patients suffering from a pelvic fracture would also present with intraabdominal injuries?

Answer 47

1/3

Question 48

Indications of pelvic fracture

Answer 48

• high energy MOI (ex. MVCs, falls; *consider less energy MOI needed for older people)
• instability or pain on manipulation of pelvis during RTS
• inability to weight bear
• unusual rotation of feet (inward, legs are even length)

Question 49

Treatment for pelvic fracture

Answer 49

• 5P’s pre and post
• attempt to stabilize with circumferential sheet wrap or commercial device
• secure knees and legs together for support
• appropriate extrication (i.e. scoop)

Question 50

Can you use a cravat from sagar as a substitute for a circumferential sheet wrap when supporting the pelvis?

Answer 50

No. Using cravats run the risk of being placed on too tight causing increased pressure on injury which is not desired (you want to just support it)

Question 51

With regards to splinting, which takes priority: femur fracture or pelvis?

Answer 51

Pelvis (more porential for blood loss and requires A LOT of force to break a pelvis)

also remember your splinting priorities

Question 52

When is the ONLY possible situation in which a spinal board is acceptable to be used on a patient with a suspected pelvic fracture?

Answer 52

On initial ax when you initially have not assessed the pelvis yet and had rolled the patient onto a spinal board because there were prone/semi-prone to save yourself a future roll

OTHERWISE, always use scoop!! you do not want to be rolling patients with pelvic fractures

Question 53

Where is the hip located?

Answer 53

Where the top of the femur joins to meet the pelvis

Question 54

Typical hip fracture is where, and prominent in which population?

Answer 54

Head of femur

prominent in elderly

Question 55

Is the use of a sager warranted for a hip fracture, as typical fractures occur at the head of the femur and thus technically a femur fracture?

Answer 55

NO. never use a sagar because you’ll just be pulling the whole freaking bone out of the socket.

when in duobt, always treat as hip fracture (over just treating a “femur fracture”)

Question 56

Pelvic Fracture vs Hip fracture

Answer 56

Pelvic fracture - instability on palpation, pain on both sides, equal lengths of legs

Hip fracture - outward rotation and pain on one side, potential pain on palpation of pelvis

*you can’t REALLLLYYY tell the difference between the two so if there is pain when rocking the pelvis and instability, just treat as a pelvic fracture

Question 57

Assessment/Signs and symptoms of hip fracture

Answer 57

• 5P’s
• Inability to bear weight
• pain potentially on palpation
• shortening and external rotation (telltale sign of hip fracture)

Question 58

Treatment for hip fracture

Answer 58

• buddy splint (splint just below fracture site and tie legs, figure 8 feet)
• fore & aft lift (for SUPER tiny people) OR scoop
• pain control

Question 59

If a patient has a suspected hip fracture, paramedics are not supposed to use a pelvic wrap. If they then have both a possible hip and pelvic fracture, what are the appropriate steps for treatment?

Answer 59

Treat the worse one - aka the pelvis so pelvic wrap that sucker