Download Thoracic and Abdominal Trauma Course Material

EMS “Live” In-Station Continuing Education
CE Provider:
University of Texas Southwestern Medical Center at Dallas
Department of Emergency Medicine
Division of Emergency Medical Services
Course Title:
Thoracic and Abdominal Trauma
Course Approval Number:
UTSW – 11M2016
TDH – 101606
Date:
November 2016
National Registry
Content Area and Hours:
Mandatory: Airway, Breathing, and Circulation – 1.0 hour
Mandatory: Trauma – 3.0 hours
National Continued Competency
Program (NCCP)
Content Area and Hours:
National Component
 Trauma
o Fluid Resuscitation – 0.5 hours
Local or Individual Component – 3.5 hours
TDH
Content Area and Hours:
Additional units: – 4.0 hours
Skills Proficiency
Verification:
Class Location:
_________________________________________________
Instructor Name:
_________________________________________________
Student Name:
_________________________________________________
In order to accrue the CE hours required for recertification, the student must attend and participate in the live CE
component represented by this module and complete any required skill demonstrations.
STUDENT VERSION
This form shall serve as a written record of the participant's successful completion of the EMS educational activity as outlined in the Texas Administrative
Code, Title 25, Part 1, Chapter 157, Subchapter C and as outlined in CECBEMS Standards and Requirements for Organization Accreditation.
11M2016 Thoracic and Abdominal Trauma
Page 1 of 31
Thoracic and Abdominal Trauma
Cognitive Objectives: Upon successful completion of this course, the student will be able to:
 Differentiate
Psychomotor Objectives:
 No psychomotor objectives listed for this CE module
Affective Objectives:
 No affective objectives listed for this CE module
This continuing education activity is approved by the University of Texas Southwestern Medical Center at Dallas, an
organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS).
You have participated in a continuing education program that has received CECBEMS approval for continuing education
credit. If you have any comments regarding the quality of this program and/or your satisfaction with it, please contact
CECBEMS at: CECBEMS -5111 Mill Run Road -Dallas, Texas 75244 - (972) 387-2862 [email protected].
CECBEMS is an organization established to develop and implement policies to standardize the review and approval of
EMS continuing education activities. The cosponsoring organizations of CECBEMS are the National Association of
Emergency Medical Technicians, the American College of Emergency Physicians, the National Association of Emergency
Medical Services Physicians, the National Association of State Emergency Medical Services Directors, the National
Council of State Emergency Medical Services Training Coordinators, and the National Registry of Emergency Medical
Technicians, and the National Association of EMS Educators.
Kenneth Navarro
Gil Salazar, MD
CE Program Coordinator
CE Program Medical Director
For ECG practice or review, visit www.ecglibrary.com. To access the latest version of the protocols, for patient care
alerts or updates on new medications, visit www.biotel.ws. References and bibliographies for all CE modules are on file
and available upon request. To comment on this module, good or bad, e-mail [email protected]
11M2016 Thoracic and Abdominal Trauma
Page 2 of 31
Thoracic and Abdominal Trauma
Thoracic Trauma Statistics

Thoracic injuries are responsible for twenty-five percent of all trauma deaths (Khandhar,
Johnson, & Calhoon, 2007).

One-half of multi-systems trauma patients have thoracic injuries.

Two-thirds of potentially fatal thoracic trauma patients reach the ED alive and only fifteen
percent require surgery (Campbell, 2012). However, many of these patients would die without
RAPID transport and intervention with chest tubes, blood, pericardiocentesis, etc.
Gross Thoracic Anatomy

Ribs
o 12 paired ribs
o Upper 10 pairs are attached in two places; in back to the spinal column and in front,
either to the sternum or rib above. The bottom 2 pairs are attached to the spine only
and are called “floating ribs.”
o Lower ribs cover and protect the upper abdominal organs: liver, spleen, kidneys,
pancreas and stomach. Assume patients with injuries at or below the nipple line also
have abdominal injuries.
o An artery, vein, and nerve are found on the lower edge of each rib; they circulate blood
to and stimulate the intercostal muscles.
o The first rib is tucked under the clavicle, making the palpable space under the clavicle
the first intercostal space.
Figure 1: Adult thoracic skeleton. Image retrieved from https://s-media-cacheak0.pinimg.com/originals/a8/73/76/a87376435d3a9b3248c04bdc247644eb.jpg
11M2016 Thoracic and Abdominal Trauma
Page 3 of 31

Muscles
o Intercostal muscles are found between the ribs and connect ribs to each other.
o Latissimus dorsi, pectoral, and serratus muscles pad the thoracic cavity, offering
protection.
o The diaphragm is a muscle of ventilation. Because its superior surface is attached to the
bottom of the lungs, it drops down into the abdomen during inhalation, pulling the lungs
with it to increase the size and volume of the chest cavity. During exhalation it rises up
into the chest cavity to push out used air and gases.
o Muscles in the neck are attached to the upper ribs; this is why we see suprasternal
retractions, etc.

Pleural Membranes
o The parietal pleura is a thin membrane which lines the chest cavity.
o The visceral pleura is a matching membrane that covers the surfaces of the lungs and
other structures in the chest cavity.
o There is normally no space between these two membranes; they are held together by a
small amount of fluid. A potential space exists and when the membranes are separated
by air or blood, pneumothorax and hemothorax occur. This potential space can hold 3
liters of blood on each side, leading to hemorrhagic shock with some hemothoraces.
Figure 2: Pleural Membranes and the Pleural Space. Image retrieved from
http://www.myvmc.com/uploads/VMC/DiseaseImages/598_Normal_L_Pleura.jpg
11M2016 Thoracic and Abdominal Trauma
Page 4 of 31

Lungs
o Fill 100% of the pleural cavity, 100% of the time.
o The adhesion of the two pleural surfaces ‘glues’ the lungs to the inner wall of the chest
and the top of the diaphragm. When trauma causes the pleurae to separate, air or
blood fills the pleural space, separating the lungs from the chest cavity while
simultaneously deflating them.

Mediastinum
o Space between the lungs which contains the trachea, main bronchi, heart, aorta,
superior and inferior vena cavae, esophagus.
Deadly Dozen
The major types of thoracic trauma are known collectively as the Deadly Dozen (Yamamoto,
Schroeder, Morley, & Beliveau, 2005). Each of these injuries may present as an immediate lifethreatening condition requiring rapid intervention to prevent patient deterioration. In other cases, the
injuries may be potentially life-threatening and possibly even masked by the patient’s normal
compensatory mechanisms. In either case, paramedics must perform a systematic and organized
assessment to decrease the chances of missing a problem that could be corrected in the field.
Recognizing the signs and symptoms of these injuries and providing early management is critical for
producing better patient outcomes.

Deadly Dozen
o Lethal Six: These are life-threatening injuries which must be quickly identified

Airway obstruction (teeth, blood, edema, vomitus)

Open pneumothorax

Tension pneumothorax

Massive hemothorax

Flail chest

Cardiac tamponade
o Hidden Six: Other potentially life-threatening injuries may be harder to recognize and
are often identified with the help of more sophisticated hospital testing. These can
include:

Traumatic aortic rupture

Tracheal or bronchial tree injury

Myocardial contusion
11M2016 Thoracic and Abdominal Trauma
Page 5 of 31

Pulmonary contusion

Esophageal injury

Diaphragmatic tears
After establishing ABCs, the initial/primary survey moves directly to the neck and chest region to
quickly search for these injuries and determine if the chest needs needle decompression.
General Assessment
The major indications of chest injury include shortness of breath, chest pain, and respiratory distress.
In addition, the following are suspicious and significant findings:

Shock

Cyanosis

Hemoptysis

Chest wall contusions and abrasions

Crepitus

Flail chest

Subcutaneous emphysema

Open wounds

Distended neck veins

Tracheal deviation

Diminished or absent breath sounds
General Treatment for All Trauma

Paramedic Basics
o 100% oxygen and if ventilatory assistance is needed, oral or nasal pharyngeal airway,
bag valve mask, and intubation – ON SCENE
o Spinal restriction - ON SCENE
o Pulse oximetry and capnography - ENROUTE
o Continuous ECG monitoring – ENROUTE
o IVs ENROUTE and if fluid boluses are needed, administer only enough fluid to maintain
a radial pulse.
o Frequent reassessment for development of tension pneumothorax, cardiac tamponade,
etc.
11M2016 Thoracic and Abdominal Trauma
Page 6 of 31
o Rapid Transport to a Trauma Center once airway and spinal immobilization have been
addressed. Unless extrication is prolonged, do not use up the patient’s valuable Golden
Hour starting IVs on the scene; these patients need blood, chest tubes, pericardiocentis,
and surgical intervention, and prehospital IVs do not make a large difference in the final
outcome of trauma patients.
o Specific interventions for some chest and abdominal injuries

Stabilization of flail chest, needle decompression, etc.

Cover abdominal eviscerations with a moist, sterile dressing
Specific Chest Injuries

Rib Fractures
o Epidemiology

Rib fractures are common, occurring in about 10% of all patients who suffer blunt
trauma (Liman, Kuzucu, Tastepe, Ulasan, & Topcu, 2003; Ziegler & Agarwal,
1994).
o Complications

Ribs 4-9 are most commonly fractured because they are thin and poorly
protected. Great force is needed to fracture the short, thick bones of the sternum
and the 1st, and 2nd ribs; always suspect serious underlying injuries with these
fractures.

Injured lung and blood vessels under the fracture typically cause more problems
than the fracture itself. Pneumo and hemothoraces are possible complications
as are lung contusions. Contusions take up space needed for gas exchange and
can created hypoxemia.

Commonly found in the elderly secondary to osteoporosis.

Sternal fractures easily injure the heart and great vessels in the mediastinum.

Fractures of the lower ribs are frequently associated with spleen or liver injuries
(Al-Hassani et al., 2010; Bergeron et al., 2003; Sirmali et al., 2003).
o Signs and symptoms

Localized pain with breathing, movement, palpation, coughing

Bruising or deformity to outside chest wall

Splinting or guarding

Crepitus
11M2016 Thoracic and Abdominal Trauma
Page 7 of 31

Flail Chest
o Pathophysiology

A segment of the chest wall is free floating and occurs when:

Two or more adjacent ribs are broken in two or more places

Rib fractures produce a free-floating sternum

The unattached section of chest wall then moves paradoxically or opposite
the normal direction of the chest wall during inhalation and exhalation.

This can be a critical injury because the force it takes to create it also bruises and
tears lung tissue; this injury almost always produces lung contusions. Mortality
rates are between 13 and 40% (Clark, Schecter, & Trunkey, 1988; Perna &
Morera, 2010). Patients are also at risk for both pneumo and hemothorax.
o Signs and Symptoms

Paradoxical movement may or may not be present because initially, muscle
spasms can splint the flail segment. Palpating the chest wall and locating pain
and crepitus is a much more beneficial way to identify flail segments. If seen, the
segment moves inward with inspiration and bulges out during expiration.
Figure 3: Flail Segment and Paradoxical Movement, Image retrieved from http://www.lhsc.on.ca/_images/Thoracic_Surgery/flail_000.jpg

Chest wall bruising, abrasions

Crepitus

Localized chest pain accompanied by splinting/guarding

With large flail segments, respiratory distress may be present.

Pneumo and or hemothoraces due to jagged bone ends; breath sounds may
then be diminished.
11M2016 Thoracic and Abdominal Trauma
Page 8 of 31
o Treatment

Paramedic basics

Stabilize the flail segment with manual pressure or bulky dressings taped to the
chest wall.

Simple Pneumothorax
o Pathophysiology

Typically, penetrating trauma tears through the pleura, allowing air to enter the
potential space, causing a loss of negative intrapleural pressure. This will cause
the lung on the affected side to collapse. It can also be caused by blunt trauma
secondary to fractured ribs.
Figure 4: Simple pneumothorax. Image retrieved from https://upload.wikimedia.org/wikipedia/commons/4/46/Blausen_0742_Pneumothorax.png
o Signs and Symptoms

Simple pneumothoraces in healthy individuals are typically well tolerated and
self-limiting because air can enter and leave the pleural space. Patients with
poor respiratory reserve (elderly, COPD, cystic fibrosis, etc.) will not tolerate
even simple pneumothoraces well.

Chest pain, which is sometimes referred to the arm or shoulder on the affected
side
11M2016 Thoracic and Abdominal Trauma
Page 9 of 31

Dyspnea/tachypnea (which does not worsen with each breath)

Decreased or absent breath sounds.
o Treatment


Paramedic basics

Watch closely for development of a tension pneumothorax
Tension Pneumothorax
o Pathophysiology

This is a life-threatening injury because its wound acts like a one-way valve,
allowing air inhaled from the airways to enter but not leave the pleural space.

With each breath, more air is packed into the potential space of the pleural.

Air is under pressure and once it has compressed the lung and structures on the
affected side, it progresses to structures in the mediastinum.

The superior and inferior vena cavae collapse and venous return to the heart is
lost.

Pressure is also exerted on the myocardium, keeping it from contracting
normally.

Both lead to a diminished or absent cardiac output.

Besides loss of airway and blood flow into the heart, compression of the
myocardium leads to shock from mechanical failure of the heart.
Figure 5: Tension Pneumothorax. Image retrieved from
http://www.learningradiology.com/medstudents/recognizingseries/Recognizing%20a%20PTX-2012/data/images/img11.jpg
11M2016 Thoracic and Abdominal Trauma
Page 10 of 31
o Epidemiology

Tension pneumothorax accounts for 0.2–1.7% of all prehospital calls involving
trauma (Sanders, 2007)
o Signs and Symptoms

Conscious patients will present with increasing apprehension, agitation, and
severe respiratory distress, which worsens with each breath

Unconscious patients will be difficult to ventilate

Diminished breath sounds with hyperresonance to percussion

Tachycardia, hypotension, and tachypnea

Increased AP diameter with bulging intercostals muscles

Late signs – Tracheal deviation away from the injured side (rare and most often
seen on x-ray) and JVD

Indications the patient is decompensating include worsening respiratory distress
and cyanosis, loss of radial pulse, and decreasing level of consciousness.
o Treatment

Paramedic basics

Management of tension pneumothorax typically involves reducing the pressure in
the pleural space by emergent chest decompression with needle thoracostomy.

Insert a 14-gauge or 16-gauge IV catheter into the affected pleural space
at the second intercostal space in the midclavicular line. The needle and
catheter must be at least 2½” long.

Failure to identify the midclavicular line increases the risk of puncturing
structures in the mediastinum.
Figure 6: Landmarks for Needle Thoracostomy. Image retrieved from
http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2013/nejm_2013.368.issue19/nejmvcm1111468/20140418-01/images/medium/nejmvcm1111468_f1.gif
11M2016 Thoracic and Abdominal Trauma
Page 11 of 31

Insert the catheter just above the third rib to avoid the nerve, artery and
vein that lie just beneath each rib.

Advance the catheter its entire length, followed by needle removal, thus
leaving the plastic catheter as a conduit into the pleural space.

This allows the air trapped in the space to be released or aspirated.

Treatment guidelines for the BioTel system DO NOT recommend
attaching a one-way valve or making one from a finger of a sterile glove.

The maneuver effectively relieves the pressure and converts a tension
pneumothorax into a simple pneumothorax.

A 2005 study looked at the ability of 25 emergency physicians to accurately
locate the site for needle decompression on human volunteers.

Twenty-one of the physicians had ATLS training.

Only 60% were able to correctly identify the second intercostal space, and
all would have placed the thoracentesis needle medial to the midclavicular
line.

Complications and Precautions of Needle Thoracostomy

Commonly available 14–16 gauge IV catheters have an associated failure
rate ranging from 50–65% with anterior insertion because they are too
short (Ball et al., 2010; Stevens et al., 2009)

Longer catheters may prevent under-penetration, but also increases overpenetration, which may result in injury to the lung, subclavian vessels,
heart and great vessels (Zengerink et al., 2008)

A tension pneumothorax that was initially relieved may also re-accumulate
undetected as a result of catheter kinking or plugging.

Pearls

Needle thoracostomy is a relatively simple procedure but diagnosis of a
tension pneumothorax is not easy, especially in the field.

Conscious patients will not want to co-operate with examination because
they are hypoxic

Hyperresonant percussion is hard to detect and the affected side is not
silent as sounds are transmitted across the chest

Diagnosis is even more difficult if there is significant thoracic adipose
tissue
11M2016 Thoracic and Abdominal Trauma
Page 12 of 31

If the person is unconscious respiratory rate can be depressed due to a
head injury, not elevated.

Even if the patient produces a hiss of air during insertion, you probably
won’t hear it because of prehospital background noise.


Don't expect the patient to rapidly improve

Try blowing through one of those things!

It takes minutes for the pressure to dissipate, not seconds.
Hemothorax
o Pathophysiology

With this injury, blood fills the pleural space.

Generally, blood loss into the pleural space is 1000-1500 mL.

Massive hemothorax occurs with the loss of 1,500 mL of blood; each thoracic
cavity can hold up to 3,000 mL of blood.

Death can occur secondary to hypoxia from the collapsed lung, hemorrhagic
shock, and a mediastinal shift which decreases venous return to the heart
(uncommon).
o Morbidity/Mortality - When hemothorax is associated with injury to great vessels or the
heart:

50% will die immediately

25% live 5-10 minutes

25% may live 30 minutes or longer
o Signs and Symptoms

Dyspnea, tachycardia, tachypnea and if massive hemorrhage, hypotension

Look for signs of collapsed lung and hypoxia - anxiety, diminished breath sounds,
and dullness to percussion

Look for and signs of hemorrhagic shock – hypotension, flat neck veins, pale skin
o Treatment


Paramedic basics
Open Pneumothorax/Sucking Chest Wound
o Pathophysiology

When a penetrating chest wound is larger than the patient’s trachea (size of
patient’s little finger), air takes the path of least resistance and is drawn in and
out of the wound rather than the trachea and airways.
11M2016 Thoracic and Abdominal Trauma
Page 13 of 31

Because air moves in and out of the pleural space and cannot reach the alveoli,
patients can become hypoxic.
o Signs and Symptoms

Sucking sounds with inhalation

Bubbling around wound site
o Treatment

Paramedic Basics

Promptly apply an occlusive dressing (defibrillator pad, Vaseline gauze, rubber
glove, plastic wrap) and seal 3 sides.

Cardiac Tamponade
o Pathophysiology

This is a collection of blood within the nonelastic pericardial sac.

Maximal blood loss into the pericardium is minimal (300 mL), but as little as 50
mL can diminish filling and drop cardiac output.

Tamponade occurs when a penetrating injury (stab wounds most common, but
small missiles, fractured rib, etc. can also prompt this injury) lacerates the
pericardial sac and myocardium.

As blood accumulates in the sac, it compresses the ventricles, decreasing filling
and pumping action.

Stroke volume and cardiac output then fall.
Figure 7: Cardiac Tamponade. Image retrieved from
https://upload.wikimedia.org/wikipedia/commons/9/9f/Blausen_0164_CardiacTamponade_02.png
11M2016 Thoracic and Abdominal Trauma
Page 14 of 31
o Signs and Symptoms

Dyspnea

Penetrating chest wound and or fractures of the left 3rd, 4th, or 5th ribs

Beck’s Triad:


Distended neck veins

Hypotension –Narrowed pulse pressure

Muffled heart sounds
Paradoxical pulse/Pulsus paradoxus – peripheral pulses are lost during
inspiration due to increased pressure on the heart when the lungs fill.

Breath sounds should be normal and the trachea midline.
o Treatment

Paramedic Basics

Pericardiocentesis (removal of blood from the pericardial sac) of as little as 20
mL of blood can make a dramatic difference.

Myocardial Contusion
o Pathophysiology

This potentially lethal injury occurs when blunt trauma crushes the sternum and
heart, which lies underneath it.

Bruising of the right atrium and ventricle occur most commonly, but pericardial
tamponade, valvular rupture, and cardiac rupture can also be found.

The injury pattern is the same as for acute myocardial infarction, and arrhythmias
may occur.
o Signs and Symptoms

Chest pain, shortness of breath

Sternal fracture or retrosternal chest pain

Don’t underestimate simple bruising to the chest and the mechanism of injury.

About 1 in four will have no external evidence of trauma

Always be suspicious of frontal impact injuries to the center of the chest.

Shock (rare) can occur if a large part of the myocardium has been injured.

Arrhythmias/Palpitations – Sinus tachycardia is most common, but PVCs, V-tach,
and V-fib can also occur.

12-lead ECG may display ST elevation and or T wave inversion
11M2016 Thoracic and Abdominal Trauma
Page 15 of 31
Figure 8: ECG from a 6 year old female involved in a motor-vehicle collision. The patient suffered a head injury (initial GCS of 10) and mild
orthopedic injuries. This ECG was part of the routine workup. Notice the sinus tachycardia and right bundle branch block (RBBB). This would be an
unusual baseline finding in a child, and therefore one should suspect myocardial contusion. There appears to be lead misplacement, V2 to V3, as
the R' wave disappears in V2, then reappears in V3. V1 and V2 (labelled V3) have the typical downsloping ST depression of RBBB, with a typical
negative T-wave. However, V3 (labelled V2) has ST segment elevation, which is not normal for RBBB. Notice lead aVL also has ST elevation.
Normal RBBB has no ST elevation in any lead. Three weeks after discharge, this patient was jumping on a trampoline when the contused area of
the heart ruptured. She quickly deteriorated into cardiac arrest and could not be resuscitated. Image retried from http://hqmededecg.blogspot.com/2012/07/right-bundle-branch-block-after-blunt.html
o Treatment


Paramedic basics

Treatment of arrhythmias, if present
Pulmonary Contusion
o Pathophysiology

Mortality from a bleeding lung ‘bruise’ is between 14-25%!

Alveoli fill with blood from bleeding lungs and or vessels. This causes:


Poor gas exchange

Increased pulmonary vascular resistance

Decreased lung compliance

Hypoxia
This injury is commonly missed because other more obvious injuries are usually
associated with it.

Complications and death are usually from Adult Respiratory Distress Syndrome
(ARDS) and pneumonia.
o Signs and symptoms

Contusions, abrasions to chest wall

Crepitus or flail chest

Hemoptysis
11M2016 Thoracic and Abdominal Trauma
Page 16 of 31

This injury is rarely seen on physical exam and patients may have no complaints
until hours later.

Symptoms develop over time, usually within 24 hours.

Recognizing the MOI is critical to prevent further complications and death.
o Treatment
o Paramedic basics

Traumatic Asphyxia
o Pathophysiology

Although no asphyxiation has occurred, this injury pattern gets its name because
patients resemble strangulation patients.

Severe forces (steering wheels, heavy objects, car falling off a jack onto the
chest, entrapment between a vehicle and loading dock, etc.) abruptly increase
intrathoracic pressure, forcing blood out of the heart and up into the neck and
head.

Small capillaries and venules rupture, leaving skin of the upper chest, neck and
head cyanotic/purplish in color.
o Signs and Symptoms

Bluish/purplish discoloration above the level of the crush; skin below this level is
normal in color.

Cyanosis and swelling of the head and neck

Petechiae of face and neck

Swelling and edema to eyelids, tongue, lips, etc.

Hemorrhage of the conjunctiva

Jugular venous distention
o Treatment


Paramedic basics

Thorough assessment for other life-threatening chest injuries
Aortic Dissection/Rupture
o Morbidity/Mortality

85-95% die instantly

Only 10-15% survive transport to the hospital

33% of survivors die within 6 hours

33% of survivors die within 24 hours

33% of survivors survive 3 days or longer
11M2016 Thoracic and Abdominal Trauma
Page 17 of 31



Mechanism of injury

Shearing forces

Compression of the aorta on the vertebra

Increase of pressure inside the vessel during the trauma
Signs and Symptoms

Chest wall bruising, crepitus, etc.

Retrosternal or interscapular chest pain

Dyspnea

Stridor due to airway compression

Hoarseness due to laryngeal compression

Dysphagia (difficulty swallowing) due to esophageal compression

Upper extremity hypotension with absent or decreased femoral pulses

Extremity pain due to ischemia

Paraplegia
Commotio Cortis
o Pathophysiology

This is cardiac arrest from a minor blow to the chest which is thought to occur
during ventricular repolarization. At autopsy, no injuries to the ribs, sternum, or
heart are typically found.

V-fib is the most common arrhythmia, but complete heart block and left bundle
branch blocks have also been identified.

It causes about 20 deaths per year in the U.S., and patients have only a 15%
chance of survival.

It most commonly occurs in young athletes; their AP diameter is small, and their
ribs are very compliant because they are not fully calcified.
o Signs and Symptoms

In some patients a minor bruise is found over the sternum.

Cardiac arrest

History of a blow to the chest, followed by the patient taking a step or two before
collapsing.
o Treatment

Cardiac arrest protocols
11M2016 Thoracic and Abdominal Trauma
Page 18 of 31
Abdominal Trauma
Abdominal Trauma Statistics/Facts

Abdominal trauma has a mortality rate of 13-15%.

Unrecognized abdominal injuries are often the cause of preventable death because they
commonly have little or no pain and minimal signs of external injury.

Solid organs may bleed slowly or rapidly, and signs and symptoms of injury to hollow organs
are typically subtle and delayed. Pay attention to the mechanism of injury and even minor
bruising to the abdomen.

Findings of intra-abdominal injury are usually delayed; if found in the pre-hospital setting,
assume significant injury has occurred.

The liver and the spleen are the most commonly injured organs from blunt trauma and with
penetrating trauma, the liver, small intestine, and stomach are the most likely to be injured.

Multiple lower rib fractures typically have severe intra-abdominal injuries without significant
abdominal pain; patients are focused on the rib pain.
Body Systems and Anatomy

Digestive, endocrine, urinary, and some reproductive organs, and the major vessels of the
circulatory system are located within the abdomen.

Many organs lie in the lower thorax and are referred to as the thoracic abdomen. They are
under the diaphragm, but covered by the lower ribs.
o Liver
o Gallbladder
o Spleen
o Stomach
o Transverse colon

Organs of the peritoneal or ‘true’ abdomen are the:
o Small intestine
o Bladder
o Uterus, fallopian tubes, and ovaries (pelvic portion of true abdomen)

Organs of the retroperitoneal abdomen: Injuries to organs in the retroperitoneal abdomen are
difficult to evaluate because they do not cause abdominal tenderness and distention.
Hemorrhage and shock occur without findings of an acute abdomen.
o Kidneys and ureters
11M2016 Thoracic and Abdominal Trauma
Page 19 of 31
o Inferior vena cava
o Abdominal aorta
o Pancreas
o Much of the duodenum
o Ascending and descending colon
o Rectum
o The iliac vessels are located in the pelvic section of the retroperitoneal abdomen.
Abdominal trauma or pelvic fractures which injure these vessels can create
exsanguinating hemorrage with no or only minimal early symptoms.

Organs inferior to the peritoneal cavity
o Urinary bladder
o Penis, testes, and prostate
General Assessment of Abdominal Injuries

Significant level of shock without other injuries

Peritoneal signs – Abdominal distention and tenderness, and tenseness of the abdominal wall
reflect SEVERE hemorrhage.

Cullen’s sign – Bruising around the umbilicus. It can occur from both intra and retroperitoneal
bleeding and is not usually seen in the first few hours after the injury. This can be seen in
patients who delay calling EMS; if found, transport.

Grey-Turner’s sign – bruising to the flanks indicative of retroperitoneal bleeding. Like Cullen’s,
this can be a later development.

Mechanism of injury – Recognize the significance of rapid deceleration and compression
forces, even if patients have no complaints.
o Bent steering wheel
o Seat belt signs
o Contusions, abrasions, etc. to abdomen, flank, or back

Findings of intra-abdominal injury are usually DELAYED; if found in the pre-hospital setting,
assume significant injury has occurred.
Specific Abdominal Injuries

Hepatic Injury
o Pathophysiology
11M2016 Thoracic and Abdominal Trauma
Page 20 of 31

The liver is predominantly located in the RUQ, but extends transversely across
the midline.

Although a solid organ, it is easily ruptured, lacerated, and fragmented. Also,
severe vascular injury can occur to its many blood vessels.

The liver is extremely vascular and holds 30% of cardiac output.
o Signs and Symptoms

Right upper quadrant pain

Fracture of right lower ribs

Signs of hemorrhagic shock

Abdominal tenderness, rigidity, guarding
o Treatment


Paramedic Basics
Splenic Injury
o Pathophysiology

The spleen is a very vascular organ and filters 10-15% of the total blood volume
every minute.

Like the liver, it can be lacerated, ruptured, fractured, or have its vessels torn.

The spleen is the most commonly injured organ after blunt trauma.

It is completely encircled and covered with peritoneum except for the insertion
sites of the splenic artery and vein. This capsule provides protection but with
injury, it can stretch, trapping blood and hiding overt signs/symptoms of the
injury.

Splenic damage commonly occurs with contact sports injuries. When the spleen
is enlarged (splenomegaly) from infection, it is vulnerable to rupture with only
minimal force.

Delayed Splenic Rupture – Although uncommon, it has a high mortality rate.
Because it can encapsulate bleeding, signs and symptoms are typically delayed
for 48 hours. The first indication of trouble is typically Kehr’s sign – referred pain
to the left shoulder when blood collects under the diaphragm, irritating its phrenic
nerve. Pain is then transferred along the nerve pathway to the left shoulder.
Hemorrhage can quickly follow.

Spleens enlarge with infection (they vacuum up old WBCs and bacteria) and
blood diseases. Minor trauma in the presence of splenomegaly from pre-existing
illness (mononucleosis, malaria, typhus, sickle cell, etc) can cause major injury
11M2016 Thoracic and Abdominal Trauma
Page 21 of 31
and hemorrhage. Although uncommon, enlarged spleens can also
spontaneously rupture. Pay attention when patients with sickle cell disease and
mononucleosis complain of abdominal pain or have abdominal trauma.
o Signs and Symptoms


Hypotension and signs of hemorrhagic shock

Fractures of the left 10th-12th ribs

Referred pain in the left shoulder (Kehr’s sign)

Left upper quadrant tenderness

Abdominal tenderness, rigidity, guarding
Hollow Organ Injuries
o Pathophysiology

Injury to hollow organs is typically subtle and delayed. These organs spill their
contents into the abdominal cavity, and it takes time for irritation, inflammation,
and peritonitis to develop. Again, mechanism of injury may be the only initial
clue.

The small bowel is the hollow organ most frequently injured, but the gallbladder
and urinary bladder can also rupture.

Penetrating injuries as well as blunt trauma that causes deceleration and
shearing are common causes; lap belts without shoulder harnesses have been
known to cause compression and rupture of the intestines.
o Signs and Symptoms


Initially, none may be present; rely on the mechanism of injury

Peritoneal irritation – tenderness, muscle wall rigidity, involuntary guarding

Evisceration of bowel or stomach
Renal Injuries
o Pathophysiology

A blunt contusion to the kidney is its most common injury; suspect this injury with
fractures of the posterior ribs or lumbar vertebrae.

Tearing of the renal artery causes severe hemorrhage. Sometimes the artery is
damaged, leading to a delay in signs and symptoms and necrosis of the kidney.
o Signs and Symptoms

Flank and periumbilical bruising and tenderness – these are late findings

Bruising, abrasions, tenderness, or fractures of the lower, posterior ribs

Hematuria
11M2016 Thoracic and Abdominal Trauma
Page 22 of 31

Pelvic Fractures
o Pathophysiology

The pelvis is a strong bone that is difficult to fracture.

Fractures of the pelvis can be life-threatening, and blood loss is the leading
cause of death; open pelvic fractures and fractures that are hypotensive upon
presentation have a 50% mortality rate.

Bleeding may be the result of lacerated veins, arteries, or the fracture itself.
More than one fracture site is common, and each is capable of 500mL of blood
loss. Hemorrhage can be into the abdomen or retroperitoneal space and if major
veins and or arteries are torn, shock will rapidly occur.

Displaced fractures are capable of injuring the perineum, genitourinary
structures, or rectum.
o Signs and Symptoms

Pain

Crepitus

Bruising to anterior and retroperitoneal abdomen

Hypovolemic shock without external blood loss

Shortening or abnormal rotation of the affected leg
o Treatment

Paramedic basics
Geriatric Trauma

Airways can be difficult to manage due to loss of teeth and the presence of dental appliances.

Aging lungs and hearts have poor reserves needed for compensation, and many elderly have
COPD and CHF. Stiff vessels are slower to constrict.

Chest injuries can be acutely lethal or lead to pneumonia, deep vein thrombosis, pulmonary
embolus, and death a few days or weeks later.

Fractures of the hip and pelvis are life-threatening for this age group.

Elderly bones fracture very easily, especially when osteoporosis is present. For people with
this disease, bones literally crumble with even slight pressure, or with the simple acts of
bending over or getting out of a chair or bed. Finding the following drugs in the patient’s
medical history signals the presence of this debilitating disease:
o Boniva® - bandronate sodium
11M2016 Thoracic and Abdominal Trauma
Page 23 of 31
o Fosamax® - alendronate sodium
o Miacalcin® - calcitonin
o Evista® - raloxifene

Medications that can alter the treatment and outcome for elderly trauma.
o Beta blockers (propanolol, metoprolol, etc.) block the compensatory response of
tachycardia. Normal or bradycardic heart rates can be present while the patient is in
shock, allowing patients to rapidly deteriorate.
o Calcium channel blockers (verapamil, etc.) normally dilate blood vessels. Patients on
these may not be able to compensate with needed vasoconstriction.
o Nonsteroidal anti-inflammatory agents – NSAIDS (ibuprophen- Motrin®, Advil®, aspirin,
etc.) are taken by many elderly for arthritis. They alter platelet aggregation and can
increase the risk of bleeding.
o Anticoagulants (aspirin, Plavix®-clopidogrel, Ticlid®-ticlopidine, heparin, Coumadin®warfarin sodium) make it harder for blood to clot; patients are at risk for bleeding rapidly
and progressing into shock and death. Elderly on anticoagulants who have sustained
facial and airway trauma are at an extreme risk for airway edema and obstruction.
Patients on anticoagulants who sustain head trauma can easily bleed intracranially.
o A diabetic episode may be responsible for elderly trauma and confusion; always obtain
a blood glucose level before assuming someone has a head injury or is senile.
o Many elderly with chronic pain have a strong pain tolerance; they may minimize their
pain or some just have diminished pain responses. Bottom line, even minor pain can
signal significant trauma in this age group.
Linear Trauma Assessment
If not done in a linear manner, injuries are less likely to be identified. Inspection and palpation of the
neck, anterior and posterior chest wall, abdomen, and pelvis are critical to identify life-threatening
injuries of the torso.
1. Assure scene is safe, look at mechanism of injury, identify number of patients and the need for
extra manpower and equipment
2. Establish level of consciousness while immobilizing cervical spine
3. Evaluate airway for quality and intervene with oxygen, adjuncts, and ventilation as needed
4. Evaluate circulation by checking:
a. For external bleeding
b. Pulses – presence and quality of radial and carotid pulses
11M2016 Thoracic and Abdominal Trauma
Page 24 of 31
c. Skin – color, moisture, temperature
5. Evaluate neck for stepoffs, tracheal deviation, jugular venous distention, subcutaneous
emphysema
6. Remove clothing and inspect, palpate, and auscultate the chest for DCAP-BLS-TICS:
a. Deformities
b. Contusions
c. Abrasions
d. Penetrations
e. Burns
f. Lacerations
g. Swelling
h. Tenderness
i. Instability
j. Crepitus
k. Plus
i. Paradoxical movement
ii. Hyperresonance/Hyporessonance
iii. Presence/absence of breath sounds
iv. Heart tones
7. Remove clothing and inspect the abdomen, flanks and pelvis for DCAP-BLS. Palpate the
pelvis for:
a. Tenderness
b. Instability
c. Crepitus
8. Quickly observe and palpate the extremities for:
a. DCAP-BLS-TICS
b. Assess PMS, even in unconscious patients – many still have reflexes
9. Inspect the back for:
a. DCAP-BLS-TICS
Classification of Shock

Compensated
o Weakness, lightheadedness, anxiety
o Thirst
11M2016 Thoracic and Abdominal Trauma
Page 25 of 31
o Paleness
o Diaphoresis
o Tachycardia
o Tachypnea
o Decreased urinary output

Decompensated
o Hypotension
o Bradycardia, bradypnea
o Cyanosis
o Altered mental status
o Coma
o Cardiac arrest
11M2016 Thoracic and Abdominal Trauma
Page 26 of 31
11M2016 Thoracic and Abdominal Trauma
Page 27 of 31
11M2016 Thoracic and Abdominal Trauma
Page 28 of 31
11M2016 Thoracic and Abdominal Trauma
Page 29 of 31
11M2016 Thoracic and Abdominal Trauma
Page 30 of 31
11M2016 Thoracic and Abdominal Trauma
Page 31 of 31