Introduction
• Blunt abdominal trauma is the leading cause
of morbidity and mortality in all ages.
Abdominal Cavity
• Largest cavity in the body
• Extends from the diaphragm to the pelvis
• Assessment should be made quickly and cautiously.
Prevention Strategies
• Reduction of morbidity and mortality
– Safety equipment
– Prehospital education
– Advances in hospital care
– Development of trauma systems
• You are dispatched to the home of an older person who has fallen.
• When you arrive, you find the patient between the bed and a wall.
• He is conscious, alert, and orientated, answering all questions and following all commands.
Anatomy Review
• Anatomic boundaries
– Diaphragm to pelvic brim
• Divided into three sections
– Anterior abdomen
– Flanks
– Posterior abdomen or back
• Peritoneum
– Membrane that covers the abdominal cavity
• The internal abdomen is divided into three regions:
– Peritoneal space
– Retroperitoneal space
– Pelvis
Abdominal Organs
• Three types of organs
– Solid
– Hollow
– Vascular
Physiology Review
• The spleen and liver are the organs most commonly injured during blunt trauma.
• Few signs and symptoms may be present.
• Must have a high index of suspicion.
• The patient is complaining of pain to his right leg.
• You are able to place a backboard under him to facilitate moving him away from the bed.
– With the patient complaining of leg pain, after you have moved him, what do you want to look for?
Mechanism of Injury
• Eight percent of all significant trauma involves the abdomen.
• Unrecognized abdominal trauma is the leading cause of unexplained deaths due to a delay in surgical intervention.
• Two types of abdominal trauma
– Blunt
– Penetrating
Blunt Trauma
• Two thirds of all abdominal injuries
• Most are due to motor vehicle crashes
• Injuries are the result of compression or deceleration forces.
– Crush organs or rupture them
• Three common injury patterns
– Shearing
– Crushing
– Compression
Penetrating Trauma
• Most commonly from low velocity impacts
(i.e., gunshots or stab wounds).
• An open abdominal injury
– Skin is broken.
– Results in laceration of deeper structures
Motor Vehicle Collisions
• Five patterns
– Frontal
– Lateral
– Rear
– Rotational
– Rollover
Motorcycle Falls
• Less structural protection
• Rider protective devices
– Helmet
– Gloves
– Leather pants and/or jacket
– Boots
Falls
• Usually occur during criminal activity, attempted suicide, or intoxication
• Note or observe position or orientation of the body at the moment of impact.
Blast Injuries
• Commonly associated with military conflict
• Seen in mines, chemical plants, and with terrorist activities
• Four different mechanisms
– Primary blast
– Secondary blast
– Tertiary blast
– Miscellaneous blast injuries
Pathophysiology
• Hemorrhage is a major concern in abdominal trauma.
• Hemorrhage can be
– Internal
– External
Injuries to Solid Organs
• Liver
• Kidney
• Spleen (Kehr’s sign)
• Pancreas
• Diaphragm
Injuries to Hollow Organs
• Small/large intestine
• Stomach
• Bladder
Retroperitoneal Injuries
• Grey Turner’s sign
• Cullen’s sign
• Vascular injuries
• Duodenal injuries
• The patient has a lateral rotation of the leg and the leg appears to be shortened.
• You find and palpate a weak pedal pulse.
– What should you suspect? What do you want to look out for?
Assessment
• Look for evidence of hemorrhage.
• Have a high index of suspicion.
• Priorities begin with adequate tissue perfusion.
• Evaluation must be systematic.
• Prioritize injuries.
Scene Size-Up
• Scene safety
• Number of patients
• Need for additional help
Initial Assessment
• Mental status
• Patient’s airway, breathing, and circulatory status
• Prioritizing the patient
Focused History
and Physical Exam
• Expose the abdomen.
• Inspect for signs of trauma.
– DCAP-BTLS
• Percuss the abdomen.
• Palpate the abdomen.
• In blunt trauma, determine
– The types of vehicles involved
– The speed they were traveling
– Collision patterns
– Use of seatbelts
– Air bag deployment
– The patient’s position in the vehicle
• In penetrating trauma caused by gunshot, determine
– Type of weapon used
– Number of shots
– Distance from victim
• In penetrating trauma caused by stabbing, determine
– Type of knife
– Possible angle of entrance wound
– Number of stab wounds
Detailed Physical Exam
• Should be conducted
en route to hospital
• Assess the same structures as a rapid trauma exam.
– Cullen’s sign
– Grey Turner’s sign
Ongoing Assessment
• Repeat initial exam.
• Retake vital signs.
• Check interventions.
Management
• Open airway with spinal precautions.
– Oxygen via NRB mask
– Two large-bore IVs
– Monitor
• Minimize external hemorrhage.
• Do not delay transport.
• Use of pain medications is somewhat controversial.
Pelvic Fractures
• The majority are a result of blunt trauma
• Suspect multi-system trauma.
• Signs and symptoms
– Pain to pelvis, groin, or hip
– Hematomas or contusions to pelvic region
– Obvious bleeding
– Hypotension without obvious external bleeding
• Types of MOIs in pelvic fractures
– Anterior-posterior compression in head-on collisions
– Lateral compression in side impacts
– Vertical shears in falls from heights
– Saddle injuries from falling on objects
Assessment and Management
• Search for entrance and exit wounds in penetrating trauma.
• Quick transport and treatment of hypotension
• In open-book fractures
– Splint the hips at the level of the superior anterior iliac crests.
– PASG is a controversial treatment.
• The pelvis is a ring, with its sacral, iliac, ischial, and pubic bones held together by ligaments.
• It takes a large amount of force to damage this area.
Summary
• Anatomy review
• Mechanism of injury
• Pathophysiology
• Assessment and management
• Pelvic fractures
