Abdominal & Genitourinary

Trauma

EMS Professions
Temple College
 Abdominal Trauma
Most patients survive long enough to reach
hospital
Common factors that lead to death
Delayed resuscitation
Inadequate volume
Inadequate diagnosis
Failure to evaluate
Delayed surgery
 Abdominal Trauma
Death results from increased hemorrhage
due to:
solid organ injuries
hollow organ injuries
abdominal vascular injuries
pelvic fractures
Additional Injury
Spillage of hollow organ contents
Peritonitis
 Prevention Strategies
What are possible strategies for preventing
deaths due to abdominal and genitourinary
trauma?
What role can EMS Systems play in these
strategies?
 Abdominal Boundaries
Diaphragm
Anterior abdominal wall
Pelvic skeletal structures
Vertebral column
Muscles of the abdomen and flanks
 Abdominal & Pelvic Cavities
Retroperitoneal
Kidneys, ureters, bladder, reproductive organs,
inferior vena cava, abdominal aorta, pancreas
Peritoneal
Bowel, spleen, liver, stomach, gall bladder
Pelvic
Rectum, ureters, pelvic vascular plexus,
femoral arteries, femoral veins, pelvic skeletal
structures, reproductive organs
 High Index of Suspicion
Mechanism of Injury
Seat Belts
Steering wheel in unrestrained
Trauma to abdomen, lower chest, back, flank,
buttocks, and perineum
Pain in uninjured shoulder
Kehrs Sx
Murphys Sx
Turners Sx
Hypovolemic shock or diffusely tender abdomen
w/ no identifiable cause bleeding UPO
 Mechanisms of Injury
Blunt mechanisms
Forces
Compression forces
Shearing forces
Deceleration forces
Sources
MVCs
Seat belt injury
Steering wheel injury
Falls
Assaults
Blast
 Mechanisms of Injury
Penetrating mechanisms
Low velocity
knife
ice pick
Medium velocity
gunshot/handgun
shotgun
High velocity
high power hunting rifle
military weapon
 Mechanisms of Injury
Penetrating Injury - Ballistics
Low velocity
injury usually limited to depth and travel of weapon
injury usually limited to area near penetration
Medium velocity
travel direction easily redirected
greater external soft tissue injury
High velocity
energy wave
cavitation
 Pathophysiology
Hemorrhage
Limited external signs
Rapid blood loss possible
Hypovolemic shock
Blood does not result in peritonitis
Spillage of Contents
Enzymes, Acids, Bacteria
Chemical irritant to peritoneum
Localized pain Generalized abdominal pain
Muscular spasm (rigid abdomen)
 Solid Organ Injuries
Death usually 2 to hemorrhage
May to due to blunt or penetrating
mechanism
 Solid Organ Injuries
Spleen
Frequently injured solid organ
Usually due to blunt trauma
Often 2 trauma to ribs 9-11 on left side
Bleeds easily
Capsule around spleen tends to promote slow
development of shock
Rapid shock onset when capsule ruptures
May present with left shoulder pain
diaphragm irritation
 Solid Organ Injuries
Liver
Largest organ in abdomen
Frequently injured organ
May be due to blunt or penetrating trauma
Often 2 trauma to ribs 8-12 on right side
Bleeding
Slow and contained under capsule
Enters peritoneal cavity
 Solid Organ Injuries
Pancreas
Lies across lumbar spine
Usually due to penetrating trauma
also due to compression against vertebral column by
steering wheel, handle bars, or other object
Sudden deceleration produces straddle injury
Very little hemorrhage
Irritation to peritoneum
fluid loss from leakage of pancreatic enzymes
auto-digestion of tissue
 Hollow Organ Injuries
Death may result from hemorrhage and/or
content spillage
May result from penetrating or blunt trauma
 Hollow Organ Injuries
Stomach
Usually injured due to blunt trauma
Full stomach prior to incident risk of injury
Spillage of contents into peritoneal cavity
Immediate pain, tenderness, guarding, and rigidity
Small and Large Intestines
Usually injured due to penetrating trauma
Spillage of contents into peritoneal cavity
Immediate pain, tenderness, guarding, and rigidity
 Hollow Organ Injuries
Colon
Spillage of contents into peritoneal cavity
Immediate pain, tenderness, guarding, and rigidity
Spillage of bacteria into peritoneal cavity
May take 6 hrs to develop S/S of peritonitis
Small Bowel
Spillage of contents into peritoneal cavity
Immediate pain, tenderness, guarding, and rigidity
Less bacteria
May take 24-48 hours for S/S to manifest
 Abdominal Vascular Injuries
High mortality due to rapid
blood loss
Survival dependent upon extent
of injury and time to surgery
abdominal aorta, inferior vena
cava, femoral arteries
shearing
dissection
transection
 Pelvic Injuries
Increase risk of intraperitoneal structure
injury
vascular structures
hollow organs
Genitourinary Trauma
 Kidney Trauma
50% of all GU trauma
Blunt
Direct blow to back, flank, upper abdomen
Suspect in Fx of 10th - 12th ribs or T12, L1, L2
Acceleration/Deceleration
Shearing of renal artery/vein
Penetrating
Rare, usually associated
GSW or Stab wound
 Kidney Trauma S/S
Gross Hematuria
80% of cases
absence does not exclude renal injury
Localized flank/Abdominal pain
Pain/Tenderness of lower ribs, upper lumbar
spine, groin, shoulder or flank
Hypovolemia
 Ureter Trauma
Less than 2% of GU trauma
Usually secondary to penetrating trauma
Rupture
Extraperitoneal
Intraperitoneal
 Extraperitoneal Rupture
Urine in umbilicus, anterior thighs, scrotum,
inguinal canals, perineum
Dysuria
Hematuria
Suprapubic Tenderness
Induration
redness secondary to tissue damage from urine
 Intraperitoneal Rupture
Urgency to void, inability to void
Shock
Abdominal distention
 Bladder Injury
Most often injured due to blunt trauma
Full bladder may increase risk of injury
Often associated with pelvic fractures
Should not attempt urinary catheterization
Localized pelvic pain
 Urethra
Usually due to pelvic fracture, deceleration
or straddle injuries
Blood at external meatus
Perineal bruising
Butterfly bruise
Scrotal Hematoma
 Urethra
Urinary catheters should not be passed if
these are present.
Rectal exam should be performed before
passing a urinary catheter in a patient whose
urethra may be disrupted
 Male External Genitalia
Accidental or Intentional Injury
Highly vascular w/rich sensory nerve supply
Pain
Psychological issues
Hemorrhage
 Male External Genitalia
Penile/Scrotal
Zipper
Foreign body
Avulsion/Amputation
Fracture
Scrotal/Testicular
Penetrating injury
Blunt injury
Management
Control bleeding / Indirect ice / Analgesia
Psychological and Modesty Concerns
 Female External Genitalia
Usually intentional 2 assault
Primarily soft tissue injury
Hemorrhage likely
Look for other injuries
Sexual Assault
Emotional state provides additional challenge
Managed as other soft tissue bleeding
control hemorrhage
facility with trained personnel (sexual assault)
 Abdominal Trauma Assessment
Less important to diagnose exact injury
Treat clinical findings
Management the same regardless of specific
organ injured
 Abdominal Rigidity
Do not rely on rigidity
Bleeding may not cause rigidity if free
hemoglobin is not present
Bleeding in retroperitoneal space will not
cause rigidity
May cause flank ecchymosis
Adult can accommodate 1.5 liters w/o
distention
 Bowel Sounds
Little value, if any, in pre-hospital
assessment of trauma patient
Absent if shock is present, regardless of
abdominal injury
Requires minutes for adequate assessment
Does not give any information you cannot get
some other way
 Abdominal Trauma Assessment
Evidence may be masked by other injuries
or intoxicants
head injury
hypoxia
alcohol
drugs
 Abdominal Trauma Assessment
Mechanism & Kinematics
History and Physical Exam
Patient Complaints
Inspection
External signs of injury
abrasions, ecchymosis, seat belt sign
distention
wounds
impaled object
evisceration
perineal blood, blood at meatus
 Abdominal Trauma Assessment
History and Physical Exam
Gentle palpation
Percussion and Auscultation of little value
Evidence of shock
out of proportion to obvious injuries
Guarding
Evidence of peritonitis
Pelvic instability
Abdominal Trauma Management
C-Spine Motion Restriction IF indicated
Airway
Assist ventilations if needed
High flow O2
Control External Bleeding
Determine need for rapid transport/surgery
Not all need trauma center
Transport to appropriate Facility
Abdominal Trauma Management
En route
Treat shock
MAST/PASG application w/o inflation
May be helpful in pelvic fracture
IV of LR/NS enroute
Titrate fluids to BP ~ 90 mm Hg
Indirect ice may be helpful in genitalia injury
Collect and package amputated genitalia
Abdominal Trauma Management
Abdominal Evisceration
Do not replace organs into abdomen
Cover exposed bowel with saline moistened
multi trauma dressing
Cover first dressing with second dry dressing
Do not use 4 x 4
Abdominal Trauma Management
Leave impaled objects in place
Shorten if necessary for transport
Leave part of object exposed
NPO
Caution with
Sedatives
Narcotic Analgesics
 Trauma In Pregnancy

Leading cause of death during

pregnancy

MVCs result in 50% of prenatal

mortality
 Trauma In Pregnancy
Most common cause of fetal death from
trauma is maternal death
Consider possibility of pregnancy in any
female trauma patient of childbearing age
Sexual assault may be the cause of trauma
What is best for mom is best for baby
Treatment for pregnant patient same as non
pregnant patient
Consideration for emergent C-section
 Alterations In Pregnancy
Pregnant uterus can compress inferior vena
cava when patient supine
Decreases cardiac output by 30 - 40%
Blood volume increases by 40-50%
30% blood loss may occur before symptoms
develop
 Alterations In Pregnancy
Blood flow to uterus and placenta can be
selectively reduced
Fetus can be in distress while mother
appears to be stable
 Alterations In Pregnancy
As uterus increases in size and blood flow
Increased risk of:
Penetration
Rupture
Placental abruption
Premature rupture of membranes
10-20% increase in oxygen demand
Decreased peristalsis and delayed gastric
emptying
Increased risk of emesis and aspiration
Pregnancy Trauma Management
C-spine Motion Restriction
Transport with patient on left side or elevate
right side of board
Airway
anticipate vomiting & risk of aspiration
Assist ventilation as needed
High flow O2
3rd trimester O2 demand increases 10-20%
 Pregnancy Trauma Management
Control External Bleeding
Determine need for rapid transport/surgery
Not all need trauma center
Consider needs of sexual assault victim
Transport to appropriate Facility
Consider need for emergent C-section
Mark height of fundus on mothers
abdomen
Reassess frequently
Pregnancy Trauma Management
Treat for Shock
Aggressive fluid resuscitation
Increased intravascular volume
Increased volume requirements to resuscitate
Consider MAST (legs only)
Prepare for complications of pregnancy
Premature labor & delivery
Hemorrhage complications
abruptio placenta
uterine rupture
 Pregnancy Trauma Management
Increased fundal height, uterine tenderness
could be placental abruption

Initial management is always directed at the

resuscitation and stabilization of the mother
If baby is delivered
may be premature
may need volume resuscitation