MOD E Tech Abdominal Trauma

Question 1

Abdominal Trauma

You are presented with a 21 year old male patient who has what appears to be a deep stab wound to the lower margin of the left hypochondrium in the anterior axillary line. He appears to be profoundly shocked

Answer 1

Primary Survey

• Catastrophic Haemorrhage – none evident
• Airway – Clear
• Breathing – tachypnoeic, bilateral b.s.
• Circulation – tachycardic, weak, abdomen rigid
• Disability – unresponsive to voice or pain

Baseline Observations:

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• Pupils – dilated but reactive
• Pulse – 130/min
• Skin – pale, cool, moist
• Resps. – 40/min

B.P. – 90/50

Question 2

Abdominal Trauma

Answer 2

• A leading cause of preventable trauma death
• Often goes unrecognized
• Internal injury difficult to assess in the field
• Massive blood loss can lead to shock and death

Question 3

Abdominal Trauma

The abdomen is divided into 3 anatomical areas:

Answer 3

1. Abdominal cavity
2. Pelvis
3. Retroperitoneal cavity

Question 4

Pathophysiology

Abdominal Trauma

Answer 4

Abdominal cavity:

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•Solid organs (liver, spleen) haemorrhage

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•Hollow organs (small intestine, colon) filled with enzymes and bacteria

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•Can hold large volume of blood (“Silent reservoir”)

Question 5

Pelvis

Answer 5

•Contains the bladder, lower part of the large intestine and, in the female, the uterus and ovaries

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•The iliac artery and vein lie over the posterior part of the pelvic ring and may be torn in pelvic fractures

Question 6

Retro-peritoneal Area

Answer 6

• Lies against posterior abdominal wall
• Contains kidneys, ureters, pancreas, abdominal aorta, vena cava and part of duodenum
• These structures often injured by shearing forces produced in rapid deceleration

Question 7

Shear Injury

Pathophysiology

Retroperitoneal cavity:

Answer 7

•Solid organs (kidneys, pancreas)

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• Large blood vessels (aorta and vena cava)
• Potential space that can hold massive amount of blood

Question 8

Mechanism of injury

Answer 8

•Abdominal injury can result from both blunt and penetrating forces

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•All penetrating abdominal trauma must be recognised as serious injury, regardless of the cause

Question 9

Assessment

Answer 9

•Observe the mechanism of injury

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•In RTC’s look for impact speed and severity of deceleration. Was a seat belt worn? – lap belts are particularly associated with perforated abdominal structures

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•In cases of stabbing and gunshot wound, what was the length of weapon, or the type of gun and range?

Question 10

Restraint Devices

What types of injuries should you anticipate?

Question 11

Stab Wounds

Answer 11

• Low energy
• Multiple wounds from a single weapon
• Cone of injury
• A knife, ice pick, and scissors are common weapons. Injuries are usually limited to depth and area of penetration.

Would a longer knife have a larger cone of injury?

Question 12

Stab Wounds: Key Issues

Answer 12

•Type of weapon

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•Number of wounds

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•Depth of penetration

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• Anatomic structures along potential path
• Stab injuries MUST be assumed to have done serious damage until proved otherwise

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•Mortality from isolated stab wounds is approx. 1-2%

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• Damage to liver, spleen or major blood vessels causes massive haemorrhage, although many isolated stab injuries cause little major damage due to the mobility of intra-abdominal structures such as the intestines
• Upper abdominal stab wounds may have caused major intra-thoracic damage if the weapon was directed upwards.

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•Lung, direct cardiac injury and pericardial tamponade can all result from an “upper abdominal” stab injury.

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• Similarly, chest stabbing wounds may injure abdominal and thoracic organs if the diaphragm is penetrated
• Upper abdominal stab wounds may have caused major intra-thoracic damage if the weapon was directed upwards.

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•Lung, direct cardiac injury and pericardial tamponade can all result from an “upper abdominal” stab injury.

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•Similarly, chest stabbing wounds may injure abdominal and thoracic organs if the diaphragm is penetrated

Question 13

Gunshot Wounds: Cavitation

Question 14

Blunt trauma

Blunt impact will create a definable injury pattern:

Answer 14

• Compression
• Crush
• Shearing
• Collision

Ejection

Question 15

Assessment

Answer 15

• ABCD’s
• Evaluate whether “time critical” or “non-time critical”

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•Load & Go with time critical patients and continue management en route

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•Perform a secondary survey on non-time critical patients

1.Consider the mechanism of trauma

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2.Inspect from nipples to knees, including the flanks

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3.Palpate the area that you have inspected

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4.Auscultate the abdomen for dullness or bowel sounds indicative of bleeding

Specifically assess:

•Both chest and abdomen

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• Examine abdomen for external wounds, contusions, seat belt abrasions, evisceration (DCAP, BTLS)
• Assess all four quadrants by gentle palpation for tenderness, guarding and rigidity
• Consider the potential for pelvic injuries and gently assess lower ribs for fractures

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•Shoulder tip pain could indicate splenic injury.

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Many patients found later to have significant intra-abdominal trauma show little or no evidence of this in the early stage, so do not rule out injury if initial examination is normal

Question 16

Management

Answer 16

•Ensure <c>ABCD’s</c>

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•High flow oxygen (target SpO2 94-98%)

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•Assist ventilation if required (12-20/min)

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•Obtain IV access as needed en route to hospital

Specifically consider:

•Cover exposed bowel with warm dressings soaked in crystalloid

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•Do NOT attempt to push eviscerated organs back in

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•Leave impaled objects in situ

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• Ensure position of comfort whilst ensuring spinal immobilisation
• Administer Entonox if required but be cautious if the injury could also affect the thoracic cavity

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•Consider Paramedic assistance for IV pain relief.

Question 17

You are dispatched to a high-speed RTC. Your patient is the 18-year-old unrestrained male driver of the van.

On the basis of the kinematics, what internal injuries do you suspect?

Question 18

Primary Survey

• A - Gurgling with breathing
• B - Rapid and shallow
• C - Minor bleeding from scalp laceration, radial pulse rapid and weak, skin cool and diaphoretic
• D - GCS score 8 (E-2, V-2, M-4)
• E - Obvious left wrist deformity
• Why is this patient in shock?

Question 19

Primary Survey

• A - Patent
• B - Rapid and shallow; decreased BS on left side
• C - No external hemorrhage, fast radial pulse, cool and clammy skin
• D - Anxious, GCS score 15
• E - No other injuries noted

How would you manage this patient?

Question 20

Primary Survey

Answer 20

• A - Patent
• B - Rapid; BS equal
• C - No external hemorrhage; radial pulse absent; rapid carotid pulse; skin pale
• D - GCS score 13 (E-3, V-4, M-6)
• E – legs in an unnatural position

What are the potential causes of shock?

Question 21

Pelvic Fractures

How can pelvic fractures be recognized and managed in the prehospital setting?

Answer 21

Question 22

Your patient sustained a close-range shotgun blast to the abdomen. A segment of bowel is eviscerated.

How are eviscerations managed?

Question 23

Impaled Objects

How are impaled objects managed in the field?

Question 24

Summary

Answer 24

•Maintain high index of suspicion - always consider kinematics

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•Stabilise pelvic injury

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•Survival may depend on rapid transport to an appropriate facility where surgical intervention is immediately available