3. Topics
Introduction to Abdominal Injury
Abdominal Anatomy and Physiology
Pathophysiology of Abdominal Injury
Assessment of the Abdominal Injury Patient
Management of the Abdominal Injury Patient
5. Introduction to Abdominal
Injury
One of body’s largest cavities
Multiple vital organs
Large volumes of blood can be lost before
signs and symptoms manifest
Must be alert for signs of transmitted injury:
– Deformity, swelling, and ecchymosis
Prevention:
– Highway safety
7. Abdominal Anatomy
and Physiology
Boundaries
– Superior: Diaphragm
– Inferior: Pelvis
– Posterior: Vertebral column and posterior and
inferior ribs
– Lateral: Muscles of the flank
– Anterior: Abdominal muscles
8. Abdominal Anatomy
and Physiology
Three Specific Spaces
– Peritoneal Space
Organs covered by abdominal (peritoneal) lining
– Retroperitoneal Space
Organs posterior to the peritoneal lining
– Pelvic Space
Organs contained within the pelvis
14. Accessory Organs
Liver
– Located in upper right quadrant
– Receives 25% of cardiac output
Greatest blood reserve
– Suspended by ligamentum teres
Can lacerate liver in deceleration trauma
– Function
Detoxifies blood
Removes damaged or aged erythrocytes
Stores glycogen and agents for metabolism
– Liver tissue will grow to normal size following
partial removal
15. Accessory Organs
Gallbladder
– Small hollow organ located behind and beneath
liver
– Receives bile
Waste product from reprocessing of red blood cells
Used to digest fatty foods (emulsification)
16. Accessory Organs
Pancreas
– Produces endocrine hormones and exocrine
enzymes
Glucagon
Insulin
Digestive enzymes that return the chyme pH to normal
and break down proteins
17. Accessory Organs
Spleen
– Part of immune system
– Located behind stomach and lateral to kidney in
upper left quadrant
– Function
Immunology
Stores large volume of blood
– Most fragile abdominal organ
– Commonly injured in blunt trauma affecting the left
flank
18. Urinary System
Components
– Kidneys
Collect waste products in blood stream
Concentrate products into urine
Reabsorb water and salt
Regulate body osmotic balance
– Adrenal glands
Superior and attached to kidneys
Component of endocrine system
Release epinephrine and norepinephrine
23. Pregnant Uterus
Affects on Maternal Physiology
– Increases circulatory blood volume by 45%
Greater volume but fewer red blood cells
Results in relative anemia
– Cardiac output increases by 40%
– Heart rate increases by 15 bpm
– Compresses the vena cava in 3rd trimester
Supine hypotensive syndrome
24. Vasculature
Key Vessels
– Abdominal aorta
Blood supply to abdomen
Left of spinal column
– Iliac arteries
Bifurcation of aorta at the upper sacral level
– Inferior vena cava
Adjacent to spinal column
25. Vasculature
Portal System
– Venous subsystem
– Collects venous blood, fluid, and nutrients
absorbed by the bowel
– Transports to liver
Detoxification, storage of excess nutrients
Adds deficient nutrients
27. Peritoneum
Serous membrane that surrounds the interior
of most of the abdominal cavity
Covers most of small bowel and some of the
abdominal organs
Small amount of fluid between peritoneal
layers
Mesentery
– Omentum
Additional fold
Insulates and protects anterior surface of abdomen
30. Pathophysiology of
Abdominal Injury
Mechanism of Injury
– Penetrating Trauma
Energy transmitted to surrounding tissue
Results in:
Uncontrolled hemorrhage
Organ damage
Spillage of hollow organ contents
Irritation and inflammation of abdominal lining
Liver most commonly affected organ
Shotgun trauma
Multiple projectiles
31. Mechanism of Injury
Blunt Trauma
– Produces least visible signs of injury
– Causes
Deceleration
Contents damaged by change in velocity
Compression
Organs trapped between other structures
Shear
Part of an organ is able to move while another part is fixed
Example: ligamentum teres
32. Mechanism of Injury
Blast Injuries
– Blunt and penetrating MOIs
– Irregular shaped shrapnel and debris
– Pressure wave
Compresses and relaxes air-filled organs
Contuses or ruptures organs
– Abdominal injury is secondary concern during
blast injury
34. Pathophysiology of
Abdominal Injury
Injury to the Abdominal Wall
– Skin and muscles transmit blunt trauma to
internal structures
Erythema
Swelling and ecchymosis occur over several hours
– Penetrating trauma may appear minimal
externally in comparison to internal trauma
Muscle may mask the size of the external wound
Evisceration may be present
35. Pathophysiology of
Abdominal Injury
Injury to the Abdominal Wall
– Trauma to thorax, buttocks, flanks, and back may
penetrate abdomen Lower chest may injure
spleen, liver, stomach, or gallbladder
– Diaphragmatic tears:
Herniation of abdominal contents into thorax
36. Pathophysiology of
Abdominal Injury
Injury to the Hollow Organs
– May rupture with compression from blunt forces
– May tear due to penetrating trauma
– Spillage of contents
Retroperitoneal space
Peritoneal space
Pelvic space
– Intestines have a large amount of bacteria:
Leakage can result in sepsis
– Manifestations of Blood Loss
Hematochezia, hematemesis, hematuria
37. Pathophysiology of
Abdominal Injury
Injury to the Solid
Organs
– Dense and less
strongly held
together
– Prone to contusion
Bleeding
Fracture (rupture)
– Unrestricted
hemorrhage if organ
capsule is ruptured
38. Pathophysiology of
Abdominal Injury
Specific Organs
– Spleen
Pain referred to left
shoulder
– Pancreas
Pain radiates to back
– Kidneys
Pain radiates from
flank to groin and
hematuria
– Liver
Ligamentum Teres
39. Pathophysiology of
Abdominal Injury
Injury to the Vascular Structures
– Abdominal aorta and vena cava
Prone to direct blunt or penetrating trauma
May be injured in deceleration injuries
– Blood accumulates beneath diaphragm
Irritation of muscular structures
Produces referred pain in the shoulder region
Presence of blood in abdomen stimulates vagus nerve
resulting in slowing of heart rate
– Blood can isolate in any of the abdominal spaces
40. Pathophysiology of
Abdominal Injury
Injury to the Mesentery and Bowel
– Provides bowel with circulation, innervation, and
attachment
– Disrupts blood vessels supplying the bowel
Leads to ischemia, necrosis, or rupture
– Blood loss minimal
Peritoneal layers contain hemorrhage
– Tear of mesentery may rupture bowel
– Penetrating trauma to the lateral abdomen likely
to injure large bowel
41. Pathophysiology of
Abdominal Injury
Injury to the Peritoneum
– Delicate and sensitive lining of anterior abdomen
– Peritonitis
Inflammation of the peritoneum due to:
Bacterial irritation
Due to torn bowel or open wound
Chemical irritation
Caustic nature of digestive enzymes
Urine initiates inflammatory response
Blood does not induce peritonitis
– Symptoms
42. Pathophysiology of
Abdominal Injury
Injury to the Pelvis
– Serious skeletal injury
Life-threatening hemorrhage
Potential injury to pelvic organs
Ureters
Bladder
Urethra
Female Genitalia
Prostate
Rectum
Anus
43. Pathophysiology of
Abdominal Injury
Injury During Pregnancy
– Trauma is the number one killer of pregnant
females
Penetrating abdominal trauma accounts for 36% of
maternal mortality
Gunshot wounds account for 40–70% of penetrating trauma
Blunt trauma due to improperly worn seatbelts
Auto collisions are leading cause of mortality
45. Pathophysiology of
Abdominal Injury
Injury During Pregnancy
– Maternal Changes
Increasing size and weight of uterus
Increasing maternal blood volume
Protects mother from hypovolemia
30–35% of blood loss necessary before signs of shock
Uterus is thick and muscular
Distributes forces of trauma uniformly to fetus
Reduces chances for injury
46. Pathophysiology of
Abdominal Injury
Injury During Pregnancy
– Risk of uterine and fetal injury increases with the
length of gestation
– Penetrating trauma may cause fetal and maternal
blood mixing
– Blunt trauma complications
Uterine rupture
Abruptio placentae
Premature rupture of amniotic sac
47. Pathophysiology of
Abdominal Injury
Injury to Pediatric Patients
– Children have poorly developed abdominal
musculature and smaller diameter
– Rib cage more cartilaginous
Transmits injury to organs beneath easier
– Increased incidence of injury to
Liver
Kidney
Spleen
– Shock
Compensate well for blood loss
May not show signs and symptoms until 50% of blood is
lost
50. Assessment of the Abdominal
Injury Patient
Scene Size-up
– Auto Crash Injury Patterns
Frontal impact
Compress abdomen
Liver, spleen, and rupture of hollow organs
Right impact
Liver, ascending colon, and pelvis
Left impact
Spleen, descending colon and pelvis
Children and pedestrians
Abdominal injuries common
– Gunshot Wounds
Type and caliber of weapon
Check whether assailant still on scene
51. Assessment of the Abdominal
Injury Patient
Initial Assessment
– Level of consciousness
– Drug or alcohol use
May mask injury
– As you evaluate airway, breathing, and
circulation, be observant for any associated signs
and symptoms of hypovolemia.
52. Assessment of the Abdominal
Injury Patient
Rapid Trauma Assessment
– Rapid and Full Trauma Assessment
– Closely examine regions with a high index of
suspicion
– Expose and Examine for DCAP-BTLS
If suspected pelvic injury, DO NOT test pelvis
Palpate entire abdomen
Evaluate for entrance and exit wounds
– OPQRST Assessment
Characteristics of pain
Tenderness versus rebound tenderness
– SAMPLE History
– Vital Assessment
53. Assessment of the Abdominal
Injury Patient
Considerations with Pregnant Patients
– Be observant for
Signs of shock
Signs may not develop until 30% of blood volume lost
Body begins shunting blood from GI/GU to primary organs
Supine hypotensive syndrome
Premature contractions
Vaginal hemorrhage
Uterine rupture versus abruptio placentae
54. Assessment of the Abdominal
Injury Patient
Ongoing Assessment
– Trend vital signs
Every 5 minutes for critical patients
– Evaluate for
Progressive peritonitis
Progressive hemorrhage
BP and capillary refill
Pulse rate and pulse oximetry
Mental status
Skin condition
Ineffective aggressive fluid resuscitation
56. Management of the Abdominal
Injury Patient
General Management
– Position patient
Position of comfort unless spinal injury
Flex knees or left lateral recumbent
– General shock care
– PASG application
– Specific injury care
Impaled objects or eviscerations
57. Management of the Abdominal
Injury Patient
Fluid Resuscitation
– Large-bore IV with isotonic solution
– Large-bore IV for use if patient’s BP drops below
80 mmHg
– Fluid challenge 250 mL or 20 mL/kg
Limit to 3 L
– Titrate to systolic blood pressure of 80 mmHg
58. Management of the Abdominal
Injury Patient
Cover any exposed
abdominal organs
with a dressing
moistened with
sterile saline
Stabilize any
impaled objects
59. Management of the Abdominal
Injury Patient – PASG
Contraindications
– Concurrent
penetrating chest
trauma
– Abdomen inflation
contraindicated in
pregnancy
Inflate legs only
Indications
– Evisceration
If SBP <60 mmHg
– Intra-abdominal
bleeding
– Shock
Incremental inflation
titrated to BP and
Pulse
60. Management of the Abdominal
Injury Patient
Management of the Pregnant Patient
– Positioning:
Left lateral recumbent
If on backboard tilt backboard
Facilitates venous return
– Oxygenation:
High-flow O2
Consider PPV by BVM if hypoxia ensues
– Maintain high index of suspicion for intra-
abdominal bleeding
Consider IV and PASG
61. Summary
Introduction to Abdominal Injury
Abdominal Anatomy and Physiology
Pathophysiology of Abdominal Injury
Assessment of the Abdominal Injury Patient
Management of the Abdominal Injury Patient
