Abdominal and Genitourinary Trauma

Abdominal & Genitourinary Trauma : 

Abdominal & Genitourinary Trauma EMS Professions Temple College

Abdominal Trauma : 

Abdominal Trauma Most patients survive long enough to reach hospital Common factors that lead to death Delayed resuscitation Inadequate volume Inadequate diagnosis Failure to evaluate Delayed surgery

Abdominal Trauma : 

Abdominal Trauma Death results from increased hemorrhage due to: solid organ injuries hollow organ injuries abdominal vascular injuries pelvic fractures Additional Injury Spillage of hollow organ contents Peritonitis

Prevention Strategies : 

Prevention Strategies What are possible strategies for preventing deaths due to abdominal and genitourinary trauma? What role can EMS Systems play in these strategies?

Abdominal Boundaries : 

Abdominal Boundaries Diaphragm Anterior abdominal wall Pelvic skeletal structures Vertebral column Muscles of the abdomen and flanks

Abdominal & Pelvic Cavities : 

Abdominal & Pelvic Cavities Retroperitoneal Kidneys, ureters, bladder, reproductive organs, inferior vena cava, abdominal aorta, pancreas Peritoneal Bowel, spleen, liver, stomach, gall bladder Pelvic Rectum, ureters, pelvic vascular plexus, femoral arteries, femoral veins, pelvic skeletal structures, reproductive organs

High Index of Suspicion : 

High Index of Suspicion Mechanism of Injury Seat Belts Steering wheel in unrestrained Trauma to abdomen, lower chest, back, flank, buttocks, and perineum Pain in uninjured shoulder Kehr’s Sx Murphy’s Sx Turner’s Sx Hypovolemic shock or diffusely tender abdomen w/ no identifiable cause  bleeding UPO

Mechanisms of Injury : 

Mechanisms of Injury Blunt mechanisms Forces Compression forces Shearing forces Deceleration forces Sources MVCs Seat belt injury Steering wheel injury Falls Assaults Blast

Mechanisms of Injury : 

Mechanisms of Injury Penetrating mechanisms Low velocity knife ice pick Medium velocity gunshot/handgun shotgun High velocity high power hunting rifle military weapon

Mechanisms of Injury : 

Mechanisms of Injury Penetrating Injury - Ballistics Low velocity injury usually limited to depth and travel of weapon injury usually limited to area near penetration Medium velocity travel direction easily redirected greater external soft tissue injury High velocity energy wave cavitation

Pathophysiology : 

Pathophysiology Hemorrhage Limited external signs Rapid blood loss possible Hypovolemic shock Blood does not result in peritonitis Spillage of Contents Enzymes, Acids, Bacteria Chemical irritant to peritoneum Localized pain  Generalized abdominal pain Muscular spasm (rigid abdomen)

Solid Organ Injuries : 

Solid Organ Injuries Death usually 2° to hemorrhage May to due to blunt or penetrating mechanism

Solid Organ Injuries : 

Solid Organ Injuries Spleen Frequently injured solid organ Usually due to blunt trauma Often 2° trauma to ribs 9-11 on left side Bleeds easily Capsule around spleen tends to promote slow development of shock Rapid shock onset when capsule ruptures May present with left shoulder pain diaphragm irritation

Solid Organ Injuries : 

Solid Organ Injuries Liver Largest organ in abdomen Frequently injured organ May be due to blunt or penetrating trauma Often 2° trauma to ribs 8-12 on right side Bleeding Slow and contained under capsule Enters peritoneal cavity

Solid Organ Injuries : 

Solid Organ Injuries Pancreas Lies across lumbar spine Usually due to penetrating trauma also due to compression against vertebral column by steering wheel, handle bars, or other object Sudden deceleration produces straddle injury Very little hemorrhage Irritation to peritoneum fluid loss from leakage of pancreatic enzymes auto-digestion of tissue

Hollow Organ Injuries : 

Hollow Organ Injuries Death may result from hemorrhage and/or content spillage May result from penetrating or blunt trauma

Hollow Organ Injuries : 

Hollow Organ Injuries Stomach Usually injured due to blunt trauma Full stomach prior to incident  risk of injury Spillage of contents into peritoneal cavity Immediate pain, tenderness, guarding, and rigidity Small and Large Intestines Usually injured due to penetrating trauma Spillage of contents into peritoneal cavity Immediate pain, tenderness, guarding, and rigidity

Hollow Organ Injuries : 

Hollow Organ Injuries Colon Spillage of contents into peritoneal cavity Immediate pain, tenderness, guarding, and rigidity Spillage of bacteria into peritoneal cavity May take 6 hrs to develop S/S of peritonitis Small Bowel Spillage of contents into peritoneal cavity Immediate pain, tenderness, guarding, and rigidity Less bacteria May take 24-48 hours for S/S to manifest

Abdominal Vascular Injuries : 

Abdominal Vascular Injuries High mortality due to rapid blood loss Survival dependent upon extent of injury and time to surgery abdominal aorta, inferior vena cava, femoral arteries shearing dissection transection

Pelvic Injuries : 

Pelvic Injuries Increase risk of intraperitoneal structure injury vascular structures hollow organs

Genitourinary Trauma : 

Genitourinary Trauma

Kidney Trauma : 

Kidney Trauma 50% of all GU trauma Blunt Direct blow to back, flank, upper abdomen Suspect in Fx of 10th - 12th ribs or T12, L1, L2 Acceleration/Deceleration Shearing of renal artery/vein Penetrating Rare, usually associated GSW or Stab wound

Kidney Trauma S/S : 

Kidney Trauma S/S Gross Hematuria 80% of cases absence does not exclude renal injury Localized flank/Abdominal pain Pain/Tenderness of lower ribs, upper lumbar spine, groin, shoulder or flank Hypovolemia

Ureter Trauma : 

Ureter Trauma Less than 2% of GU trauma Usually secondary to penetrating trauma Rupture Extraperitoneal Intraperitoneal

Extraperitoneal Rupture : 

Extraperitoneal Rupture Urine in umbilicus, anterior thighs, scrotum, inguinal canals, perineum Dysuria Hematuria Suprapubic Tenderness Induration redness secondary to tissue damage from urine

Intraperitoneal Rupture : 

Intraperitoneal Rupture Urgency to void, inability to void Shock Abdominal distention

Bladder Injury : 

Bladder Injury Most often injured due to blunt trauma Full bladder may increase risk of injury Often associated with pelvic fractures Should not attempt urinary catheterization Localized pelvic pain

Urethra : 

Urethra Usually due to pelvic fracture, deceleration or straddle injuries Blood at external meatus Perineal bruising Butterfly bruise Scrotal Hematoma

Urethra : 

Urethra Urinary catheter’s should not be passed if these are present. Rectal exam should be performed before passing a urinary catheter in a patient whose urethra may be disrupted

Male External Genitalia : 

Male External Genitalia Accidental or Intentional Injury Highly vascular w/rich sensory nerve supply Pain Psychological issues Hemorrhage

Male External Genitalia : 

Male External Genitalia Penile/Scrotal Zipper Foreign body Avulsion/Amputation Fracture Scrotal/Testicular Penetrating injury Blunt injury Management Control bleeding / Indirect ice / Analgesia Psychological and Modesty Concerns

Female External Genitalia : 

Female External Genitalia Usually intentional 2° assault Primarily soft tissue injury Hemorrhage likely Look for other injuries Sexual Assault Emotional state provides additional challenge Managed as other soft tissue bleeding control hemorrhage facility with trained personnel (sexual assault)

Abdominal Trauma Assessment : 

Abdominal Trauma Assessment Less important to diagnose exact injury Treat clinical findings Management the same regardless of specific organ injured

Abdominal Rigidity : 

Abdominal Rigidity Do not rely on rigidity Bleeding may not cause rigidity if free hemoglobin is not present Bleeding in retroperitoneal space will not cause rigidity May cause flank ecchymosis Adult can accommodate 1.5 liters w/o distention

Bowel Sounds : 

Bowel Sounds Little value, if any, in pre-hospital assessment of trauma patient Absent if shock is present, regardless of abdominal injury Requires minutes for adequate assessment Does not give any information you cannot get some other way

Abdominal Trauma Assessment : 

Abdominal Trauma Assessment Evidence may be masked by other injuries or intoxicants head injury hypoxia alcohol drugs

Abdominal Trauma Assessment : 

Abdominal Trauma Assessment Mechanism & Kinematics History and Physical Exam Patient Complaints Inspection External signs of injury abrasions, ecchymosis, “seat belt sign” distention wounds impaled object evisceration perineal blood, blood at meatus

Abdominal Trauma Assessment : 

Abdominal Trauma Assessment History and Physical Exam Gentle palpation Percussion and Auscultation of little value Evidence of shock out of proportion to obvious injuries Guarding Evidence of peritonitis Pelvic instability

Abdominal Trauma Management : 

Abdominal Trauma Management C-Spine Motion Restriction IF indicated Airway Assist ventilations if needed High flow O2 Control External Bleeding Determine need for rapid transport/surgery Not all need trauma center Transport to appropriate Facility

Abdominal Trauma Management : 

Abdominal Trauma Management En route Treat shock MAST/PASG application w/o inflation May be helpful in pelvic fracture IV of LR/NS enroute Titrate fluids to BP ~ 90 mm Hg Indirect ice may be helpful in genitalia injury Collect and package amputated genitalia

Abdominal Trauma Management : 

Abdominal Trauma Management Abdominal Evisceration Do not replace organs into abdomen Cover exposed bowel with saline moistened multi trauma dressing Cover first dressing with second dry dressing Do not use 4 x 4

Abdominal Trauma Management : 

Abdominal Trauma Management Leave impaled objects in place Shorten if necessary for transport Leave part of object exposed NPO Caution with Sedatives Narcotic Analgesics

Trauma In Pregnancy : 

Trauma In Pregnancy Leading cause of death during pregnancy MVCs result in 50% of prenatal mortality

Trauma In Pregnancy : 

Trauma In Pregnancy Most common cause of fetal death from trauma is maternal death Consider possibility of pregnancy in any female trauma patient of childbearing age Sexual assault may be the cause of trauma What is best for mom is best for baby Treatment for pregnant patient same as non pregnant patient Consideration for emergent C-section

Alterations In Pregnancy : 

Alterations In Pregnancy Pregnant uterus can compress inferior vena cava when patient supine Decreases cardiac output by 30 - 40% Blood volume increases by 40-50% 30% blood loss may occur before symptoms develop

Alterations In Pregnancy : 

Alterations In Pregnancy Blood flow to uterus and placenta can be selectively reduced Fetus can be in distress while mother appears to be stable

Alterations In Pregnancy : 

Alterations In Pregnancy As uterus increases in size and blood flow Increased risk of: Penetration Rupture Placental abruption Premature rupture of membranes 10-20% increase in oxygen demand Decreased peristalsis and delayed gastric emptying Increased risk of emesis and aspiration

Pregnancy Trauma Management : 

Pregnancy Trauma Management C-spine Motion Restriction Transport with patient on left side or elevate right side of board Airway anticipate vomiting &  risk of aspiration Assist ventilation as needed High flow O2 3rd trimester O2 demand increases 10-20%

Pregnancy Trauma Management : 

Pregnancy Trauma Management Control External Bleeding Determine need for rapid transport/surgery Not all need trauma center Consider needs of sexual assault victim Transport to appropriate Facility Consider need for emergent C-section Mark height of fundus on mother’s abdomen Reassess frequently

Pregnancy Trauma Management : 

Pregnancy Trauma Management Treat for Shock Aggressive fluid resuscitation Increased intravascular volume Increased volume requirements to resuscitate Consider MAST (legs only) Prepare for complications of pregnancy Premature labor & delivery Hemorrhage complications abruptio placenta uterine rupture

Pregnancy Trauma Management : 

Pregnancy Trauma Management Increased fundal height, uterine tenderness could be placental abruption Initial management is always directed at the resuscitation and stabilization of the mother If baby is delivered may be premature may need volume resuscitation