Download Abdominal and Genitourinary Trauma

Chapter 36
Abdominal and
Genitourinary Trauma
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.
National EMS Education
Standard Competencies
Abdominal and Genitourinary Trauma
• Recognition and management of:
− Blunt versus penetrating mechanisms
− Evisceration
− Impaled object
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of:
− Solid and hollow organ injuries
− Blunt versus penetrating mechanisms
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Evisceration
Injuries to the external genitalia
Vaginal bleeding due to trauma
Sexual assault
Vascular injury
Retroperitoneal injuries
Introduction
• Abdominal cavity extends from diaphragm
to pelvis
− Injuries can be life threatening.
− Contains several vital organ systems
Introduction
• Damage from trauma can be decreased by:
− Empty bladder
− Toned abdominal muscles
Introduction
• Perform assessment and intervention
quickly and cautiously.
− Delays can have disastrous consequences.
− Blunt abdominal trauma is the leading cause of
morbidity and mortality.
Introduction
• Trauma to the GU system can result from
blunt or penetrating trauma
− Consider when injuries involve:
• Lower rib cage
• Abdomen
• Pelvis
• Upper legs
Introduction
• Your field account is the only source of
information for understanding the events
and mechanism that led to trauma.
− Critical for injuries that are not apparent
Anatomic Regions
• Cavity extends from diaphragm to pelvic
brim
• Divided into three sections:
− Anterior abdomen
− Flanks
− Posterior abdomen
Anatomic Regions
Anatomic Regions
• Quadrant system
describes location
in abdomen
− Four regions
• Periumbilical area:
around the navel
Anatomic Regions
• Peritoneum: membrane that lines the cavity
• Mesentery: double fold of tissue in
abdomen
Anatomic Regions
• Internally divided into three regions:
− Peritoneal space
− Retroperitoneal space
− Pelvis
Anatomic Regions
Abdominal Organs
and Vital Vessels
• Abdomen contains many organs
− Solid organs
− Hollow organs
• Abdomen also contains vital vessels
Abdominal Organs
and Vital Vessels
Abdominal Organs
and Vital Vessels
Solid Organs
• Liver: largest organ in the abdomen
− Functions include:
• Detoxifying the blood
• Processing hemoglobin before it is stored
• Regulating blood clotting
• Removing bacteria from the bloodstream
• Regulating fat
Solid Organs
• The spleen is highly vascular.
− Functions include filtering and storing blood.
− If the body needs extra blood, the spleen
provides it to the circulatory system.
− Detects pathogenic organisms and produces
lymphocytes
Solid Organs
• The pancreas is located under the liver and
behind the stomach.
− Acinar cells produce and secrete enzymes that
aid in digestion.
− Secretes insulin from the islets of Langerhans
Hollow Organs
• The stomach is an intraperitoneal organ.
− Concave on its right and convex on its left side
• Uppermost part: fundus
• Largest part: body
• Lower part: antrum
Hollow Organs
• Three layers of the
stomach wall:
− Longitudinal
muscle
− Circular layer
− Oblique layer
Hollow Organs
• Blood is supplied to the stomach from the
celiac trunk.
− Blood is returned via the portal vein
• The stomach contains acid to assist in
digestion.
Hollow Organs
• Small and large
intestines
− Run from stomach to
anus
− Digest and absorb
water and nutrients
• Gallbladder
− Saclike organ on the
lower surface of the
liver
− Reservoir for bile
Hollow Organs
• Duodenum: first part of the small intestine
• Pylorus: circumferential muscle at the end
of the stomach
• Cecum: pouch at junction of small and large
intestine
Hollow Organs
• Colon: large intestine
− Absorbs sodium and other ions
− Excretes other metallic ions into wastes
− The last 20 cm is the rectum.
Organs of the Genitourinary
System
• The abdomen contains organs of the
urinary system.
− Kidneys filter blood and excrete waste.
− Urinary bladder: hollow, muscular sac
− Ureters: thick-walled, hollow tubes
Organs of the Genitourinary
System
• The abdomen contains organs of the
reproductive system.
The female reproductive system
Organs of the Genitourinary
System
The male reproductive system
The Diaphragm
• Dome-shaped muscle
• Separates the thoracic cavity from the
abdominal cavity
Physiology
• Some abdominal trauma can cause shock
due to blood loss.
− Bleeding may produce few signs and
symptoms.
Physiology
• Organs most frequently injured after blunt
trauma include:
− Spleen and liver
• If a patient has unexplained symptoms of
shock, suspect abdominal trauma.
Physiology
• Hollow organs are more resilient.
− More likely to be injured and burst when full
• May cause toxins to be released into the abdominal
cavity
• Spillage can cause peritonitis.
Physiology
• Two types of
peritonitis:
− Chemical peritonitis
• May have sudden
onset
− Bacterial peritonitis
• May develop over
several hours
• Also classified as:
− Primary
• Infection travels
from blood or
lymph nodes into
peritoneum.
− Secondary
• Infection travels
from GI or biliary
tract into the
peritoneum.
Mechanism of Injury
• Trauma is the leading cause of death in
patients ages 1 to 44 years.
− About 80% of all significant traumas involve the
abdomen.
Blunt Trauma
• Can cause
compression and
crushing injuries
• Results from
compression or
deceleration forces
• Leads to a closed
abdominal injury
Blunt Trauma
• Common MOI—Shearing
− Caused by rapid deceleration
• Organs continue forward motion, causing tear
− Signs of abdominal bleeding may include:
• Referred shoulder pain
• Unexplained hypotension
• Multiple traumas present
Blunt Trauma
• Common MOI—Crushing
− Abdominal contents are crushed between:
• Anterior abdominal wall, and
• Spinal column
− Results from direct strikes or falling objects
Blunt Trauma
• Common MOI—Compression
− Results from direct blow or external
compression from a fixed object
− Forces will deform hollow organs.
• Can rupture the small intestine or diaphragm
Penetrating Trauma
• Results from low-velocity gunshot or stab
wounds
• Causes an open abdominal injury
• Gunshot wounds cause more injury than
stab wounds.
Penetrating Trauma
• Damage is a function of energy imparted.
− Kinetic energy = Mass/2 × Velocity2
− Velocity delivered is divided into three levels:
• Low velocity (< 200 ft per second)
• Medium velocity (200–2,000 ft per second)
• High-velocity (> 2,000 ft per second)
Penetrating Trauma
• Contributors to the extent of injury include:
− Trajectory or direction the projectile traveled
− Distance the projectile traveled
− Profile of the bullet
Motor-Vehicle Crashes
• Five typical patterns of impact
− Frontal
− Lateral
− Rear
− Rotational
− Rollover
Motor-Vehicle Crashes
• Consider transporting the patient if one of
the following is present:
− Ejection from vehicle
− High-speed crash
− Death of passenger
− Falls greater than
15′, or three times
patient’s height
− Pedestrian crash
− Motorcycle crash
− Unrestrained
occupants
− Penetrating wounds
to head, chest, or
abdomen
Motor-Vehicle Crashes
• Seat belts can
cause blunt trauma
to the abdominal
organs.
Motorcycle Falls or Crashes
• No structural protection exists.
− Protection: protective devices worn by driver
• Helmets do not protect for severe cervical injury.
− Consider transport to a trauma center with:
• Crashes at speeds greater than 20 mph
• Separation of rider and motorcycle
Falls from Heights
• Body’s position or orientation determine
types of injuries and survivability.
• Forces can be dissipated by:
− Surface the person has fallen
− Degree to which surface can deform under
force
Falls from Heights
• A fall produces acceleration at 9.8 m/sec2.
− Height plus stopping distance predict magnitude
of forces.
• Transport patients to a trauma center if falls
are greater than 20 ft.
Blast Injuries
• Generated fragments can travel at velocities
of 4,500 fps
• Injuries may be from four mechanisms:
• Primary blast
• Secondary blast
• Tertiary blast
• Quaternary blast
General Pathophysiology
• Hemorrhage is a concern with abdominal
trauma.
− Estimation of blood volume lost is difficult.
− Signs and symptoms depend on:
• Volume of blood lost
• Rate of loss
General Pathophysiology
• Increased hypovolemia results in agitation
and confusion.
− The heart increases rate and stroke volume.
• Increased hypoperfusion leads to ischemia and
heart failure.
General Pathophysiology
• Injuries can result in organ spillage into the
abdominal cavity.
− Will eventually result in localized pain
• Localized if contamination is confined
• Generalized if entire peritoneal cavity is involved
Patient Assessment
• During evaluation, look for evidence of
hemorrhage or spillage of bowel contents.
− Have a high index of suspicion.
− Provide tissue perfusion and oxygen delivery.
Patient Assessment
• Evaluation must be
systematic.
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Bruising
Road rash
Localized swelling
Lacerations
Distention or pain
© Dr. P. Marazzi/Photo Researchers, Inc.
• Examine for:
Patient Assessment
• Look for shock not proportional to external
evidence.
• Abdominal organs are susceptible to
significant bleeding.
− Can be fatal
Patient Assessment
• When assessing a genitourinary injury:
− Provide privacy for the patient.
− Look for blood on the undergarments.
− Only inspect the external genitalia if:
• The patient reports pain.
• There are external signs of injury.
Scene Size-Up
• Scene safety is priority.
• Penetrating or blunt trauma is caused by an
external force.
− Situation may be dangerous to the paramedic.
Primary Assessment
• Form a general impression.
− Note the manner in which the patient is lying.
• Body or abdominal movement irritates inflamed
peritoneum.
• Patient may also present with guarding.
Primary Assessment
• Airway and breathing
− Keep airway clear of vomitus.
• Note the nature of the vomitus.
− Assess for adequate breathing.
• Supplemental oxygen with a nonrebreathing mask
may be necessary.
Primary Assessment
• Circulation
− Superficial abdominal injuries usually don’t
produce external bleeding.
− To determine stage of shock, evaluate:
• Pulse and skin color
• Temperature
• Condition
Primary Assessment
• Circulation (cont’d)
− When caring for genitourinary emergency,
remember the system is very vascular.
− To determine the presence of shock:
• Assess pulse rate and quality.
• Determine skin condition, color, and temperature.
• Check capillary refill time.
Primary Assessment
• Circulation (cont’d)
− Closed injuries do not have visible signs of
bleeding.
− If the patient is visibly bleeding, control it.
− Consider the MOI, and expose that body part.
Primary Assessment
• Transport decision
− Abdominal injuries call for short on-scene time.
− Patients should be evaluated at the highest
trauma center available.
Primary Assessment
• Transport decision (cont’d)
− Patients with a genitourinary system injury
should be taken to a trauma center.
− Treatment may require a specialist.
History Taking
• Obtain the following with blunt trauma
caused by a motor-vehicle crash:
− Types of vehicles
− Speed of travel
− How vehicles
collided
− Other information:
• Use of seat belts
• Air bag
deployment
• Patient’s position
History Taking
• If a patient has stab
wounds, determine:
• In a gunshot case,
determine:
− Type of knife
− Angle of entry
− Type of gun
− Number of shots
− Number of wounds
− Estimated distance
Secondary Assessment
• Inspect the abdomen.
− May involve ecchymosis, abrasions, lacerations
− Note blood from vagina or rectum.
− Peritonitis could result in decreased or absent
abdominal sounds.
Secondary Assessment
• Perform palpation and percussion.
− Start with the quadrant furthest from injury.
• Note whether the patient has hematuria.
− Dark brown: bleeding in upper urinary tract
− Bright red: bleeding in lower portion of tract
Secondary Assessment
• Determine if the patient is pregnant.
− Risk of massive blood loss is increased
− Management should start with the ABCs.
− Tilt patients at least 15° to the left to prevent
vena cava syndrome.
Secondary Assessment
• New technologies include:
− Portable ultrasound machines
− Telemedicine
• Misconception: patients without pain or
abnormal vital signs are unlikely to have
serious injuries.
Secondary Assessment
• Abdominal trauma
may include:
− Abdominal
evisceration
− Injury to the
diaphragm
• Signs of rupture
may include:
− Abdominal pain
− Abdominal sounds
in the chest
− Sunken abdomen
Secondary Assessment
• Examine the patient’s neck and chest.
• Assess the patient’s pain.
− Somatic pain: sharp and localized
− Visceral pain: deep aching with cramping
Secondary Assessment
• Perform a thorough full-body exam.
− Conduct en route.
− Assess the same structures as the rapid exam
but more methodically.
Reassessment
• Field documentation should include:
− Seat belt use
− Location, intensity, quality of pain
− Nausea or vomiting
− Contour of abdomen
− Ecchymosis or open areas on soft-tissue
− Rebound tenderness, guarding, rigidity, spasm,
localized pain
Reassessment
• Field documentation should include
(cont’d):
− Changes in LOC and vital signs
− Other injuries found
− Alcohol, narcotics, analgesic
− Results of assessment
Emergency Medical Care
• Ensure an open
airway.
• Establish IV
access.
• Apply pressure
dressings if
necessary.
• Apply a:
− Cardiac monitor
− Pulse oximetry
− Capnography
• Transport to a
hospital or trauma
center.
Emergency Medical Care
• Administering pain medication is
controversial.
− Consult with medical direction en route.
Evisceration
• Protrusion of
abdominal organs
through a wound
− Apply a sterile
dressing over the
evisceration.
− Transport to the
closest hospital.
Evisceration
• Strangulation of the bowel causes
decreased blood flow to the protruding part.
• Patients may feel more comfortable with
knees bent.
− Encourage not to cough or bear down.
Impaled Objects
• Stabilize the
object.
• Transport patient in
the position found.
− Intervene early.
© Custom Medical Stock Photo
• Significant infection
may develop.
Pathophysiology of Specific
Injuries
• Abdominal trauma can be life threatening.
− May bleed profusely
− May produce peritonitis and systemic infection
Injuries to Solid Abdominal
Organs
• Liver injuries
− Suspect with:
• Right-sided chest and abdominal trauma
• Fractures to the 7th and 9th ribs
− Suspect laceration when penetration involves:
• Right upper abdomen
• Right lower chest
Injuries to Solid Abdominal
Organs
• Spleen injuries
− Ruptured spleens have been reported in cases
where contact was minor.
• If ruptured, blood spills into the peritoneum.
Injuries to Solid Abdominal
Organs
• Spleen injuries (cont’d)
− Suspect spleen lacerations if:
• 9th through 10th ribs are fractured
• Left upper quadrant tenderness
• Hypotension
• Tachycardia
• Left shoulder pain appears 1 to 2 hours after injury
Injuries to Solid Abdominal
Organs
• Pancreas injuries
− High-energy forces are needed to damage
− Patients present with vague upper and
midabdominal pain radiating into the back.
Injuries to Solid Abdominal
Organs
• Diaphragm injuries
− Signs and symptoms: ventilatory compromise
− Injuries are not isolated.
− May result from blunt and penetrating trauma
Injuries to Hollow
Intraperitoneal Organs
• Injuries to the small and large intestines
− Most common from penetrating trauma
− Rupture causes peritonitis.
− Stomach rupture causes:
• Rapid burning epigastric pain
• Rigidity
• Rebound tenderness
Injuries to Hollow
Intraperitoneal Organs
• Stomach injuries
− Commonly result from penetrating trauma
− Trauma results in the spilling of acidic material.
− Antacid medications may delay symptoms.
Retroperitoneal Injuries
• Injuries to this area do not present with
signs and symptoms of peritonitis.
− Occasionally bleeding can lead to:
• Grey Turner sign
• Cullen sign
Vascular Injuries
• Penetrating trauma is the major cause.
• Often masked by other injuries
• Significance depends on:
− How many vessels were injured
− length of time since the injury
Duodenal Injuries
• Rupture may occur in high-speed
deceleration injuries.
− Contents spill into the retroperitoneum.
− Contamination causes abdominal pain or fever.
• Close proximity to other organs
Kidney Injuries
• Generally caused
by large forces
• Suspect injury with:
− Fractures of the
11th and 12th ribs
− Flank tenderness
Kidney Injuries
• Rupture presents with:
− Pain on inspiration
− Gross hematuria
• Penetrating renal trauma occurs with
wounds in the abdomen or lower chest.
Ureter Injuries
• Difficult to identify
• Rarely lead to an immediate life-threatening
condition
Bladder and Urethra Injuries
• Associated with other significant injuries
• May result in bladder rupture or laceration
− Based on severity of mechanism and degree of
bladder distention
• Usually associated with pelvic injuries
Bladder and Urethra Injuries
• Rupture is associated with a high mortality
rate.
− Trauma often causes damage to other organs
or vascular structures.
− Urine may spill into the abdominal cavity.
Assessment of Specific
Injuries
• Signs may not develop until a significant
amount of blood is lost.
− Bleeding can cause tenderness or distention.
• Liver injuries result in blood and bile into the
peritoneal cavity.
Assessment of Specific
Injuries
• Signs/symptoms of
splenic rupture are
nonspecific.
− Only Kehr sign
may be present.
Assessment of Specific
Injuries
• Pancreatic injuries have subtle or absent
signs.
− Suspect after localized blow to the midabdomen
− Patients report vague upper and midabdomenal
pain radiating to the back.
Assessment of Specific
Injuries
• Findings of vascular injures depends on
whether or not the bleeding is contained.
• Blunt renal trauma may present as flank
pain and hematuria.
Assessment of Specific
Injuries
• Suspect bladder injury if:
− Trauma to the lower abdomen or pelvis
− Inability to urinate
− Blood in the penile opening
− Tenderness on palpation of suprapubic region
• Signs and symptoms are nonspecific.
Assessment of Specific
Injuries
• Signs of peritoneal irritation may indicate
intraperitoneal bladder rupture.
• Ultrasound may be used in the field.
Management of Specific
Injuries
• Maintain a high index of suspicion.
• Management of solid organ injuries
includes:
− Providing rapid transport
− Monitoring vital signs
Management of Specific
Injuries
• Care of bladder and urethra injuries:
− Secure the airway.
− Address breathing issues.
− Support the circulatory system.
− Immobilize the spine if necessary.
Pathophysiology of Injuries to
the Male Genitalia
• Injuries to the testicle or scrotal sac
− Loss of fertility is the major concern.
− Blunt trauma is caused by motor vehicle
crashes, physical assaults, sports injuries
− Penetrating trauma is caused by stabbings,
gunshots, blasts, or animal bites
Pathophysiology of Injuries to
the Male Genitalia
• Penis injuries
− Priapism can have nontraumatic causes.
− A fractured penis may occur if erect and:
• Impacted against partner’s pubic symphysis
• Bent too far via self-manipulation
Assessment of Injuries to the
Male Genitalia
• Contusions result in painful hematomas.
• Rupture and torsion are difficult to identify.
• Intrascrotal bleeding does not require much
force.
Assessment of Injuries to the
Male Genitalia
• Penile fracture may present as pain and a
large hematoma.
• When penetrating trauma occurs:
− Control hemorrhage.
− Assess the patient for other injuries.
Management of Injuries to the
Male Genitalia
• Treat with attention to hemorrhage or
evisceration.
− Apply gentle compression and ice packs.
− Provide pain relief and emotional support.
Management of Injuries to the
Male Genitalia
• If Fournier gangrene occurs, provide prompt
transport to the hospital.
• Attempt to recover an amputated penis.
• If an object is placed around the penis or
testicles, do not attempt removal.
Pathophysiology of Injuries to
the Female Genitalia
• Blunt trauma may
result from:
− Motor vehicle crashes
− Saddle type injuries
• Penetrating trauma
may result from:
− Stabbings to the lower
pelvis
− Gunshot wounds
Assessment of Injuries to the
Female Genitalia
• Signs of trauma may include:
− Hematomas and ecchymosis
− Bleeding from the vagina
− Tenderness on palpation of the lower pelvis
Management of Injuries to the
Female Genitalia
• Use compression for external hemorrhage.
• Administer replacement fluids if
hypotensive.
• Do not attempt to remove any object that is
stuck in the vaginal canal.
Summary
• Unrecognized abdominal trauma is the
leading cause of unexpected death in
trauma patients.
• The abdomen contains many vital organs
and structures.
• The quadrant system is generally used to
describe a location in the abdomen.
• The peritoneum is a membrane that lines
the abdominal cavity. Abdominal trauma
can lead to peritonitis.
Summary
• The retroperitoneal space is the area
behind the peritoneum.
• When a patient has experienced trauma to
the chest or abdomen, you should suspect
that he or she also has additional internal
abdominal injuries.
• Injury to the abdomen may be slow to
develop, and can be fatal.
Summary
• Solid organs have a large blood supply and
can easily be crushed by blunt trauma.
• Injury to hollow organs can cause the
release of toxins into the abdominal cavity,
causing major peritonitis.
• At least two thirds of all abdominal injuries
involve blunt trauma.
• Penetrating trauma causes open abdominal
injury.
Summary
• During assessment, note the manner in
which the patient is lying. Prioritize the
ABCs.
• Assessment should never delay patient
care and transport!
• Try to obtain as many details about an
injury as possible.
• Peritonitis can take hours to days to
develop.
Summary
• Generally, management of patients with
abdominal trauma is straightforward:
− Ensure a secure airway.
− Establish intravenous access and fluid
replacement.
− Minimize hemorrhaging with pressure
dressings.
− Apply a cardiac monitor and oxygen therapy,
and then transport.
Summary
• Pelvic fractures can result in damage to the
major vascular structures.
• Because of the forces required to break the
pelvis, if the patient has a pelvic fracture,
suspect multisystem trauma.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Green–Jones & Bartlett Learning;
Purple–Jones & Bartlett Learning. Courtesy of
MIEMSS; Blue–Courtesy of Rhonda Beck;
Red–© Margo Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.