18.abdominal Injury

ABDOMINAL: The
abdomen (colloquially called the belly,] tummy or midriff) is the part of

the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen
is the front part of the abdominal segment of the trunk. The region occupied by the abdomen is
called the abdominal cavity.
The abdominal cavity contains most organs of the digestive system, including the stomach,
the small intestine, and the colon with its attached appendix. Other digestive organs are known as
the accessory digestive organs and include the liver, its attached gallbladder, and the pancreas,
and these communicate with the rest of the system via various ducts. The spleen, and organs of
the urinary system including the kidneys, and adrenal glands also lie within the abdomen, along
with many blood vessels including the aorta and inferior vena cava.
ABDOMINAL INJURY: Abdominal trauma is an injury to the abdomen. Signs and symptoms

include abdominal pain, tenderness, rigidity, and bruising of the external abdomen.
TYPES OF ABDOMINAL INJURIES BLUNT TRAUMA

BLUNT TRAUMA:
Product least visible signs of injury
Causes:
Deceleration:
Contents damaged by change in velocity
Compression:
Organs trapped between other structures
Shear:
Parts of an organ is able to move while another parts is fixed.
PENETRATING TRAUMA
 Energy transmitted to surrounding tissue
 Results in-
 Uncontrolled hemorrhage
 Organ damage
 Spillage of hollow organ contents
 Irritation & Inflammation of abdominal lining
 Liver most commonly affected organ
 Common causes -Shotgun Trauma, stab wound, cuts & tears
 Produces least visible signs of injury
ABDOMINAL ORGAN INJURIES

DIAPHRAGMATIC INJURY • Partially protected by bony structures, diaphragm is commonly
injured by penetrating trauma (Automobile deceleration may lead to rapid rise in intra-
abdominal pressure and a burst injury • Diaphragmatic tear usually indicates multi-organ
involvement.
CLINICAL MANIFESTATIONS • Decreased breath sounds • Abdominal peristalsis heard in
thorax • Acute chest pain and shortness of breath may indicate diaphragmatic tear • May be hard
to diagnose because of multisystem trauma or the liver may "plug" the defect and mask it
ESOPHAGEAL INJURY : • Penetrating injury is more common than blunt injury • May be
caused by knives, bullets, foreign body obstruction • May be caused by iatrogenic(related to
illness cause by medical examination or treatment) perforation
• May be associated with cervical spine injury.
CLINICAL MANIFESTATIONS • Pain at site of perforation • Fever • Difficulty swallowing
• Cervical tenderness • Peritoneal irritation
STOMACH INJURY : • Penetrating injury is more common than blunt injury; in one-third of
patients, both the anterior and the posterior walls are penetrated • May occur as a complication
from cardiopulmonary resuscitation or from gastric dilation.
CLINICAL MANIFESTATIONS • Epigastric pain • Epigastric tenderness • Signs of
peritonitis • Bloody gastric drainage
LIVER INJURY DESCRIPTIONS • Most commonly injured organ; blunt injuries (70% of
total) usually occur from motor vehicle crashes and steering wheel trauma • Highest mortality
from blunt injury and gunshot wound • Hemorrhage is most common cause of death from liver
injury; overall mortality 10%–15%.
CLINICAL MANIFESTATIONS • Persistent hypotension despite adequate fluid resuscitation
• Guarding over right upper or lower quadrant; rebound abdominal tenderness • Dullness to
percussion • Abdominal distention and peritoneal irritation • Persistent thoracic bleed
SPLEEN INJURY DESCRIPTIONS • Most commonly injured organ with blunt abdominal
trauma • Injured in penetrating trauma of the left upper quadrant
CLINICAL MANIFESTATIONS • Hypotension, tachycardia, shortness of breath • Peritoneal
irritation • Abdominal wall tenderness • Left upper quadrant pain • Fixed dullness to percussion
in left flank; dullness to percussion in right flank that disappears with change of position.
PANCREAS INJURY : • Most often penetrating injury (gunshot wounds at close range) • Blunt
injury from deceleration; injury from steering wheel • Often associated (40%) with other organ
damage (liver, spleen, vessels).
CLINICAL MANIFESTATIONS • Pain over pancreas • Paralytic ileus • Symptoms may occur
late (after 24 hr); epigastric pain radiating to back; nausea, vomiting • Tenderness to deep
palpation
SMALL INTESTINES INJURY: • Duodenum, ileum, and jejunum; hollow viscous structure
most often injured by penetrating trauma • Gunshot wounds account for 70% of cases • Incidence
of injury is third only to liver and spleen injury • When small bowel ruptures from blunt injury,
rupture occurs most often at proximal jejunum
CLINICAL MANIFESTATIONS • Testicular pain • Referred pain to shoulders, chest, back
• Mild abdominal pain • Peritoneal irritation • Fever, jaundice, intestinal obstruction
LARGE INTESTINES INJURY: • One of the more lethal injuries because of fecal
contamination; occurs in 5% of abdominal injuries • More than 90% of incidences are
penetrating injuries • Blunt injuries are often from safety restraints in motor vehicle crashes.
CLINICAL MANIFESTATIONS • Pain, muscle rigidity • Guarding, rebound tenderness •
Blood on rectal examination • Fever
RETROPERITONEAL INJURY • Blunt or penetrating trauma to the abdomen or posterior

abdomen. • Kidney, ureters, pancreas, or duodenal injuries • Associated with posterior rib
fractures & lumbar vertebral injuries. • Deceleration forces may injure the renal artery
CLINICAL MANIFESTATIONS • Haemorrhage usually from pelvic or lumbar fractures
• Gray turner’s sign – 12 hours or later • cullen’s sign – 12 hours or later
RENAL INJURY : Classification of Injury

• Grade I : Contusion or Subcapsular Hematoma
• Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation
• Grade III: Laceration >1cm with urinary Extravasation
• Grade IV: Parenchymal Laceration
• Grade V: Renovascular injury
PATHOPHYSIOLOGY OF ABDOMINAL INJURY

DECELERATION • Rapid decelaration causes differential movement among adjacent
structures. As a result, shear forces are created & cause hollow, solid, visceral organs & vascular
pedicles to tear, especially at relatively fixed points of attachment.
CRUSHING • Intra abdominal contents are crushed between the anterior abdominal wall & the
vertebral column or posterior thoracic cage. This produces a crushing effect, to which solid
viscera (eg. spleen, liver, kidneys) are especially vulnerable.
EXTERNAL COMPRESSION • Direct blows or from external compression against a fixed

object (eg. lap belt, spinal column). External compressive forces result in a sudden & dramatic
rise in intraabdominal pressure & culminate in rupture of a hollow organ .
SYMPTOMS • Pain or tenderness • A rapid heart rate • Rapid breathing • Sweating • Cold,
clammy, pale or bluish skin • Confusion or low level of alertness • Blunt trauma may cause
bruising. • Cullen’s sign • Grey turner’s sign • Kehr’s sign(occurrence of acute pain in the tip of
the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person
is lying down and the legs are elevated)
COMPLICATIONS: Hematoma rupture Peritonitis Intra abdominal collection of pus (abcess)

Intestinal blockage (obstruction) Abdominal compartment syndrome.
DIAGNOSTIC STUDIES
HISTORY TAKING AMPLE History • A: Allergy • M: Medications • P: Past medical history
• L: Last meal • E: Event - What happened
General Examination : Relating to hemodynamic stability (Vital Signs)

Abdominal findings:
• Inspection :
For abdominal distension
For contusions or abrasions
Lap belt ecchymosis
PHYSICAL EXAMINATION
Palpation : For tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum
Percussion : Dullness/ shifting dullness Intraabdominal collection
Auscultation : Where to auscultate & What to listen for??? All four quadrants for the +/- of
bowel sounds
The classical ‘seatbelt’ sign. The bruising on the left breast is from the shoulder belt and the low
bruising to the abdominal wall is from the lap belt.
 Drug & alcohol screens

 Rigid sigmoidoscopy: is indicated for patients presenting with injuries in the pelvis or if
blood is found on rectal examination.
 Magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct
injuries
 Chest, and cervical spine radiographs
 Arteriographs
COLLABORATIVE MANAGEMENT
Initial Assessment and Resuscitation
Primary survey
Identification & treatment of life threatening conditions
 Airway , with cervical spine precautions
 Breathing
 Circulation
 Disability
 Exposure
EMERGENCY CARE
• I V fluids • Control external bleeding • Dressing of wounds • Protect eviscerated organs with a
sterile dressing • Stabilize an impaled object in place • Give high flow oxygen • Immobilize the
patient with a fractured pelvis • Keep the patient warm • Analgesics
MANGEMENT BASED ON ORGANS

• DIAPHRAGMATIC TEARS : Repaired surgically to prevent visceral herniation in later
years.
• ESOPHAGEAL INJURY: Gastric decompression with a nasogastric tube, antibiotic therapy
 surgical repair of the esophageal tear.
• GASTRIC INJURY: Partial gastrectomy may be needed if extensive injury has occurred.
• LIVER INJURY: Managed nonoperatively or operatively, depending on the degree of injury

and the amount of bleeding. Albumin transfusion  Blood glucose regulation
• SPLEEN INJURY • Splenectomy is the treatment of choice when the patient is markedly
hemodynamically unstable, or when the spleen is totally macerated.
• PANCREATIC INJURY :Depends on the degree of pancreatic damage, but drainage of the
area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage
from pancreatic enzymes.
• SMALL AND LARGE BOWEL : Perforation or lacerations are managed by surgical

exploration and repair. Colostomy
Common Operative Procedures 1. Restrictive Thoracotomy 2. Laparatomy & Definitive

Repair
OTHER TREATMENT Nutritional supplementation: TPN Enteral feeding

Antibiotics Intravenous fluid infusion Blood components transfusion
NURSING MANAGEMENT
 Increased risk of hypovolemia and shock related to abdominal trauma and internal bleeding.
 Increased risk of sepsis related to acute inflammatory process and peritonitis.
 Increased risk of severe fluid, electrolyte, and metabolic imbalances related to injury or
inflammation.
 Risk for imbalanced body temperature related to infection
 Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or
restlessness
 Impaired elimination due to abdominal & retroperitoneal injury , nerve injury
 Body image disturbance related to presence of colostomy bag, wound.
 Deficient knowledge about abdominal injury, recovery, and the rehabilitation process
 Anxiety related to the symptoms of disease and fear of death.

18.abdominal Injury

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18.abdominal Injury

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ABDOMINAL: The

abdomen (colloquially called the belly,] tummy or midriff) is the part of

ABDOMINAL INJURY: Abdominal trauma is an injury to the abdomen. Signs and symptoms

TYPES OF ABDOMINAL INJURIES BLUNT TRAUMA

ABDOMINAL ORGAN INJURIES

RETROPERITONEAL INJURY • Blunt or penetrating trauma to the abdomen or posterior

RENAL INJURY : Classification of Injury

PATHOPHYSIOLOGY OF ABDOMINAL INJURY

EXTERNAL COMPRESSION • Direct blows or from external compression against a fixed

COMPLICATIONS: Hematoma rupture Peritonitis Intra abdominal collection of pus (abcess)

General Examination : Relating to hemodynamic stability (Vital Signs)

 Drug & alcohol screens

MANGEMENT BASED ON ORGANS

• LIVER INJURY: Managed nonoperatively or operatively, depending on the degree of injury

• SMALL AND LARGE BOWEL : Perforation or lacerations are managed by surgical

Common Operative Procedures 1. Restrictive Thoracotomy 2. Laparatomy & Definitive

OTHER TREATMENT Nutritional supplementation: TPN Enteral feeding

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