ABDOMINAL TRAUMA

Prepared by Samah Ishtieh

MSN. Mangement

17\3\2011
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OBJECTIVES:

Identify the common mechanisms of injury associated with abdominal trauma. Describe the pathophysiologic changes as a basis for signs and symptoms. Identify selected abdominal injuries (S &S ).
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OBJECTIVES

Discuss the NURSING of patients with abdominal trauma. Identify appropriate nursing diagnosis. Plan appropriate interventions for patients with abdominal trauma.
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INTRODUCTION
Abdominal injuries are common in patients who sustain major trauma. Unrecognized abdominal injuries are frequently the cause of preventable death. Approximately one-fifth of all traumatized pt requiring operative intervention have sustained trauma to the abdomen.
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Abdominal trauma

Abdominal trauma is an injury to the abdomen. It may be blunt or penetrating and may involve damage to the abdominal organs.

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TYPES OF INJURIES
Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Blunt trauma: liver spleen (most common).

Penetrating: liver, small bowel and stomach. Penetrating: present with single or multiple injuries
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Penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, blunt abdominal trauma is more likely to be missed because clinical signs are less obvious. Penetrating trauma is further subdivided into stab wounds and bullet wounds, which have different treatments.
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Multiple injuries, abdominal trauma can lead to hemorrhage, hypovolemic shock, and death. Yet even a serious, life-threatening abdominal injury may not cause obvious signs and symptoms, especially in cases of blunt trauma.
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Key responses to decrease mortality and morbidity include : - aggressive resuscitation efforts, - adequate volume replacement, - early diagnosis of injuries, and - surgical intervention if warranted
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ORGANS
Solid Organs
Liver Spleen Kidneys Pancreas
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Hollow Organs
Stomach Small bowel Large bowel Bladder
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Mechanisms of injury
The most common mechanism of blunt injury is MVC (motor vehicle crash). Firearm , stabbings, are associated with Penetrating trauma. Injuries result from acceleration, deceleration, or both forces. Crushing forces compress the duodenum Or the pancreas against the vertebral column.

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Mechanisms of injury
Forces applied to solid organ can rupture a surrounding capsule & injury the parenchyma as well. Structures attached by ligaments or blood vessels may be stressed at their attachment points

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Mechanisms of injury
Belts if improperly positioned cause deceleration injuries to the lower abdomen , Frontal impact crashes with a bent steering wheel associated with spleen & liver injuries as

well as head &chest trauma.

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PATHOPHYSIOLOGY

Blood loss: (mesenteric attachments of the intestines ) semi fixed by ligaments, stressed, tears , bleeding. Liver & spleen ( rich blood supply) & capsulated , compression, rupture, hemorrhage. Pain: rigidity, spasm, rebound tenderness Irritants(blood or gastric contents or enzymes)
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Pancreatic & duodenal injury: diffuse abdominal, tenderness and pain radiating from epigastric to the back.

Splenic injury: referred shoulder pain (Kehr`s sign) . Because of: stress, blood in the abdominal cavity and direct bowel injury
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 Spleen injury is usually associated with blunt trauma. Fractures of ribs 10 to 12 on the left should raise your suspicion of spleen damage, which ranges from laceration of the capsule or a nonexpanding hematoma to ruptured subcapsular hematomas or parenchymal laceration.
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Spleen injury

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CT scan showing the Spleen

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 Liver injury is common because of the livers size and location. Severity ranges from a controlled subcapsular hematoma and lacerations of the parenchyma to hepatic avulsion or a severe injury of the hepatic veins. ((
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Because liver tissue is very friable and the livers blood supply and storage capacity are extensive, a patient with liver injuries can hemorrhage profusely and may need surgery to control the bleeding.

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Liver injury

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LIVER INJURY

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PANCERAS INJURY

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The most common kidney injury is a contusion from blunt trauma; suspect this type of injury if your patient has fractures of the posterior ribs or lumbar vertebrae.

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KIDNEY & BLADDER

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Other renal injuries include lacerations or contusion of the renal parenchyma caused by shearing and compression forces; the deeper a laceration, the more serious the bleeding.

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Deceleration forces may damage the renal artery; collateral circulation in that area is limited, so any ischemia is serious and may trigger acute tubular necrosis.

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Hollow organ injuries, which can occur with blunt or penetrating trauma, most commonly involve the small bowel. Deceleration with shearing may tear the small bowel, generally in relatively fixed or looped areas

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Blunt forces cause most bladder injuries. The bladder rises into the abdominal cavity when full, so its more susceptible to injury. If a distended bladder ruptures or is perforated, urine is likely to escape into the abdomen.

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If the bladder isnt full when ruptured, urine may leak into the surrounding pelvic tissues, vulva, or scrotum.

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Genitourinary tract - Perinephric hematomas should be entered only after vascular control has been obtained. Repair of many renal injuries (including partial nephrectomy) is now possible. When nephrectomy is required, it is reassuring to know that the contra lateral kidney is functioning.
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DIAPHRAGM

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Diaphragmatic injuries are notoriously difficult to diagnose. Small diaphragmatic injuries on the right side may heal without incident, and the liver protects against potential hernias. Small injuries on the left side may result in symptomatic diaphragmatic hernias. Acute diaphragmatic defects are best approached through the diaphragm.
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Colon/Rectum - In contrast to military teaching, an increasing number of surgeons utilize primary repair for simple colon injuries without associated shock or significant fecal soilage. Even a small missed colon injury may be lethal
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NURSING CARE

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As always, your primary priorities are to maintain the patients airway, breathing, and circulation. Next, perform a rapid neurologic examination and assess him head to toe to identify obvious injuries and signs of prolonged exposure to heat or cold.
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Ask the patient (or his family, emergency personnel, or bystanders) about his history allergies, medications, preexisting medical conditions, when he last ate, and events immediately preceding or related to his injury.
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If your patient sustained blunt trauma, as in a motor vehicle crash (MVC), keep his neck and spine immobilized until X-rays rule out a spinal injury. If his viscera are protruding, cover them with a sterile dressing moistened with 0.9% sodium chloride solution to prevent drying.
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The following interventions are routine for a patient with abdominal trauma:

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 Insert two large-bore intravenous (I.V.) lines to infuse 0.9% sodium chloride or lactated Ringers solution, according to facility protocol.

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 Control the patients pain without sedating him, so you can continue to assess his injuries and ask him questions. Generally, I.V. analgesics such as morphine can adequately manage pain without sedation.

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Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. For example, bloody urine or a prostate gland found to be in a high position during a rectal exam could indicate damage to the urinary tract
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If the patient is to have a rectal examination, delay catheter insertion until afterward

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 Draw blood specimens stat for baseline

lab values.

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 Insert a gastric tube to decompress the patients stomach, prevent aspiration, and minimize leakage of gastric contents and contamination of the abdominal cavity. This also gives you access to gastric contents to test for blood

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Administer tetanus prophylaxis and antibiotics as ordered.

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The FAST option Focused abdominal sonography for trauma (FAST) offers 98% to 100% specificity in blunt abdominal trauma, and is accurate 98% of the time. FAST is especially helpful for pregnant patients or those bleeding from multiple injuries. Its also useful in identifying pericardial fluid in penetrating trauma.
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FAST can demonstrate the presence or absence of pericardial fluid, abdominal fluid, and some parenchymal injuries via a 2to 3-minute exam. A hand-held transducer is positioned on four key areas to evaluate fluid collection.
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Unstable patients with penetrating abdominal trauma, such as gunshot wounds, stab wounds, or other impalements, usually proceed directly to the operating department without DPL or FAST.
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Thanks for good listening

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