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Chapter 16: Abdominal and Genitourinary Trauma : 

Chapter 16: Abdominal and Genitourinary Trauma Galveston College EMS Critical Care Paramedic 2009

Introduction : 

Introduction Abdominal and genitourinary trauma are unique challenges for the critical care transport team Devastating, life-threatening injury may often remain occult until the very late stages of hemorrhagic shock The critical care paramedic (CCP) must appreciate the mechanism of injury, have a high index of suspicion, and frequently re-evaluate the patient with abdominal or genitourinary trauma This lesson reviews the anatomy and physiology, pathophysiology, assessment, and management of both systems

Abdominal Trauma : 

Abdominal Trauma Major cause of death As with any body cavity injury, it is difficult, if not impossible, to control bleeding from an internal injury without surgeryAbdominal trauma can be difficult to diagnose until the patient is in the later stages of shock CCP must look for clues that indicate abdominal trauma

Anatomy and Physiology : 

Anatomy and Physiology Abdominal cavity divided into three spaces: Peritoneal Retroperitoneal Pelvic

Peritoneal Space : 

Peritoneal Space Organs and structures in the peritoneal space include: Stomach Proximal duodenum Ascending colon Transverse colon Sigmoid colon Liver Gall bladder Spleen

Retroperitoneal Space : 

Retroperitoneal Space Retroperitoneal organs include: Kidneys Ureters Distal duodenum Descending colon Pancreas

Pelvic Space : 

Pelvic Space Pelvic organs include: Urinary bladder Rectum In the female, also the ovaries and fallopian tubes Superficially, the abdomen is divided by horizontal and vertical lines Cross at the umbilicus to form four quadrants Visceral peritoneum, parietal peritoneum, and mesentery form a large, continuous sheet of serous membrane that lines the peritoneal space Also serves to cover and suspend the peritoneal organs

Mesentery (1 of 2) : 

Mesentery (1 of 2) Double layer of serous membrane connected by loose connective tissue Extends inferiorly from the posterior wall of the abdominal cavity Space between the double layer serves as a conduit for the vast vascular network, nerves, and lymphatic structures to and from the large and small intestines Acts as a supportive structure for the digestive tract, preventing the intestines from moving and entangling

Mesentery (2 of 2) : 

Mesentery (2 of 2) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Omentum : 

Omentum Greater and lesser omentum are similar double-layer membranes hanging from the greater and lesser curvatures of the stomach, respectively Greater omentum lies over and conforms to the abdominal viscera Adipose tissue pads, protects, and insulates the underlying structures Lesser omentum lies in the space between the liver and stomach Provides an access route for blood vessels entering the liver as well as support for the stomach

Digestive Tract : 

Digestive Tract Abdominal components of the digestive tract include: Esophagus Distal portion under the diaphragm Stomach Small intestine Duodenum, jejunum, and ilium Large intestine (colon) Rectum

Stomach (1 of 4) : 

Stomach (1 of 4) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Stomach (2 of 4) : 

Stomach (2 of 4) Most of the stomach lies in the upper-left quadrant of the abdomen Immediately inferior to the diaphragm Between the level of vertebrae T7 and L3 Exact size and extension can vary between individuals and meals Stomach receives food from the upper GI tract via the esophagus and empties through the pyloric sphincter into the duodenum

Stomach (3 of 4) : 

Stomach (3 of 4) Divided into four regions Cardia Where the esophagus enters the stomach Named due to its proximity to the heart just across the diaphragm Fundus Lies superior to the gastroesophageal junction Contacts the abdominal surface of the diaphragm Body Largest of four regions Extends from the fundus to the pylorus Pylorus Region that connects to the duodenum via the pyloric sphincter

Stomach (4 of 4) : 

Stomach (4 of 4) Has rich vascular supply Three branches celiac artery formed by: Left gastric artery Branch of the splenic artery Branch of the common hepatic artery

Digestive Functions of the Stomach : 

Digestive Functions of the Stomach Digestive functions carried out by chemical and mechanical means Chime exits the stomach through the pyloric sphincter and enters the small intestine, where further digestion and up to 90 percent of nutrient absorption occurs

Small Intestine (1 of 2) : 

Small Intestine (1 of 2) From 15 to 25 feet long Diameter is 1–1.5 inches In every abdominal quadrant and takes up the most space in the peritoneal cavity Often injured when the abdomen is subjected to traumatic insult Suspended by the mesentery and protected by the greater omentum

Small Intestine (2 of 2) : 

Small Intestine (2 of 2) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Duodenum : 

Duodenum Shortest segment of the small intestine About 10 inches long Shaped like “C” Most in the retroperitoneal cavity Re-enters the peritoneal cavity just before its transition with the jejunum In addition to chyme from the stomach, receives digestive secretions from the pancreas and gall bladder Aids in digestion and lowers the pH of chime

Jejunum : 

Jejunum About 8 feet long Site of the bulk of digestion and absorption in the small intestine

Ileum : 

Ileum About 8 feet long Ileocecal valve at its terminus regulates the flow of material from the small intestine to the first segment of the large intestine, the cecum

Large Intestine : 

Large Intestine From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

General Information : 

General Information Horseshoe-shaped route around the small intestine to its terminus at the anus Responsible for reabsorbing water, electrolytes, and some vitamins from the intestines Overall about 5 feet long Divided into the cecum, colon, and rectum Colon further divided into the ascending, transverse, and descending colon

Cecum : 

Cecum Small, expandable pouch that receives material from the ilium Begins the process of fecal collection

Ascending Colon : 

Ascending Colon Considered a retroperitoneal structure Ascends the right posterolateral wall of the abdominal cavity, turns at the hepatic flexure below the liver, and transitions to the transverse colon

Transverse Colon : 

Transverse Colon Suspended by the mesentery Curves anteriorly to re-enter the peritoneal cavity Transitions to the descending colon at the splenic Travels inferiorly along the left posterolateral wall of the abdominal cavity Transitions to the sigmoid colon at the iliac fossa with the sigmoid flexure before ending at the rectum

Rectum : 

Rectum Forms the lasts 6 inches of the digestive tract Storage area for fecal material before defecation

Accessory Organs : 

Accessory Organs Accessory organs of the digestive tract include: Liver Gallbladder Pancreas

Liver (1 of 4) : 

Liver (1 of 4) In the upper-right quadrant of the abdomen in the peritoneal cavity Some bony protection from the inferior rib cage

Liver (2 of 4) : 

Liver (2 of 4) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Liver (3 of 4) : 

Liver (3 of 4) Falciform ligament Bisects the liver into left and right lobes Anchors the liver to the posterior and anterior abdominal walls Inferior margin of the falciform ligament thickens to form the ligamentum teres Ligamentus terres Remnant of the fetal umbilical vein Encapsulated in a tough, fibrous layer that is itself encased in a layer of visceral peritoneum From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Liver (4 of 4) : 

Liver (4 of 4) Blood supply Arterial Hepatic artery Receives about 25 percent of cardiac output In addition to a rich arterial supply, receives all venous blood exiting the digestive system through the hepatic portal vein Venous Venous return is via the hepatic vein, which deposits blood into the inferior vena cava The hepatic portal vein, hepatic artery, nerves, lymphatic structures, and hepatic bile ducts pass through the hilus

Liver Functions : 

Liver Functions Metabolic regulation Monitors circulating levels of carbohydrates, fats, and amino acids Hematologic regulation Removes old or damaged red blood cells from circulation Synthesizes plasma proteins Synthesizes and secretes bile Helps digest fats Produced in the liver, stored in the gallbladder, excreted into the duodenum

Gall Bladder (1 of 2) : 

Gall Bladder (1 of 2) On the posterior surface of the liver Stores and concentrates bile produced in the liver before secretion into the duodenum Cystic duct Common hepatic duct Common bile duct Hepatopancreatic sphincter

Gall Bladder (2 of 2) : 

Gall Bladder (2 of 2) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Pancreas (1 of 2) : 

Pancreas (1 of 2) Retroperitoneal structure About 6 inches long Completes exocrine functions Digestive enzymes and buffers secreted into duodenum Pancreatic duct Serves endocrine functions Islets of Langerhans Insulin, glucagon, and somatostatin secretion

Pancreas (2 of 2) : 

Pancreas (2 of 2) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc.

Other Abdominal Structures : 

Other Abdominal Structures Spleen Vascular structures Inferior and superior mesenteric arteries Mesenteric, splenic, gastroepiploic, and gastric veins

Pathophysiology : 

Pathophysiology

Types of Abdominal Trauma : 

Types of Abdominal Trauma Blunt Penetrating

Blunt Trauma : 

Blunt Trauma Abdominal organs most often injured in blunt trauma: Liver Spleen Large intestine Small intestine

Penetrating Trauma (1 of 3) : 

Penetrating Trauma (1 of 3) Abdominal organs most often injured in gunshot wounds: Small bowel Mesentery structures Liver Colon Diaphragm

Penetrating Trauma (2 of 3) : 

Penetrating Trauma (2 of 3) Abdominal organs most often injured in stab wounds: Liver Colon Small bowel Stomach

Penetrating Trauma (3 of 3) : 

Penetrating Trauma (3 of 3) Injury may not be immediately apparent outwardly Lack of skeletal structures protecting the abdominal compartment Leaves unobstructed pathway for transmitting energy from the vehicle of trauma to the intra-abdominal organs Rapid transport to emergency department decreases risk of mortality

Common Abdominal Injury Presentation : 

Common Abdominal Injury Presentation Abdominal pain Hypoperfusion Devascularization

Specific Abdominal Organ Injuries : 

Specific Abdominal Organ Injuries

Liver (1 of 3) : 

Liver (1 of 3) Extremely vulnerable to both blunt and penetrating mechanisms of injury Tough, fibrous outer capsule can split when energy is introduced via trauma mechanisms Organ “fractures”

Liver (2 of 3) : 

Liver (2 of 3) Trend toward hemodynamic instability from liver injuries Of patients with liver trauma, 60 percent present to the emergency department unstable Result of: Significant blood flow Up to 25 percent of cardiac output Dense vascular anatomy

Liver (3 of 3) : 

Liver (3 of 3) American Association for the Surgery of Trauma (AAST) Liver Injury Scale Injuries assigned a grade of I through VI Grade I and II injuries Subcapsular hematomas that are nonexpanding and represent less than 50 percent of surface area or Lacerations of the capsule that are at most bleeding lightly and are less than 3 cm deep or less than 10 cm long Grade III injuries Hematomas involving more than half the liver surface area and Lacerations more than 3 cm deep Grade IV–VI injuries Total avulsion of the liver from the hepatic artery and vein

Gall Bladder (1 of 2) : 

Gall Bladder (1 of 2) Gall-bladder, bile-duct, and cystic-duct injuries almost never present as isolated Structures in protected locations Factors that predispose individuals to biliary injuries include gallbladder distension and alcohol abuse

Gall Bladder (2 of 2) : 

Gall Bladder (2 of 2) Mechanism of injury Penetrating trauma is a common cause Compression injuries sustained when structure is crushed between the liver and spine account for most of trauma Biliary injury diagnosed on clinical grounds alone can prove quite challenging, if at all possible Lack of specific symptomatology

Spleen (1 of 3) : 

Spleen (1 of 3) Mechanism of injury Second most commonly injured abdominal organ in blunt trauma Motor vehicle collisions the most frequent mechanism of injury Mechanisms sufficient to cause splenic injury can be so unimpressive that patients may not recall them Delayed rupture of the spleen occurs in about 5 percent of blunt trauma splenic injuries Most cases (80 percent) present within 2–3 weeks of injury

Spleen (2 of 3) : 

Spleen (2 of 3) AAST Spleen Injury Scale Grade I injuries Include small subcapsular hematomas and shallow capsular lacerations Grade II injuries Hematomas involving up to 50 percent of surface area and capsular lacerations up to 3 cm and hemorrhaging Grade III injuries Subcapsular hematomas covering more than 50 percent of surface area or are expanding and Lacerations more than 3 cm or involving trabecular blood vessels in the spleen parenchyma

Spleen (3 of 3) : 

Spleen (3 of 3) AAST Spleen Injury Scale Grade IV injuries Ruptured, hemorrhaging, interparenchymal hematomas and deep laceration resulting in devascularization of more than 25 percent of the spleen Grade V injuries Completely shatter or devascularize the spleen

Stomach : 

Stomach Mechanism of injury Blunt trauma to stomach is extremely rare Accounts for about 1 percent of all blunt intra-abdominal injures Compressive force to full stomach Penetrating trauma more frequent

Duodenum : 

Duodenum Duodenum is well protected, accounts for rather low percentage (3 to 5 percent) of all abdominal injuries Duodenal injuries almost never occur in isolation Other organs commonly injured include, in decreasing frequency, the liver, pancreas, small intestine, and colon Duodenal rupture usually contained in the retroperitoneal space Patients often initially present as asymptomatic High index of suspicion based on appreciation of mechanism of injury usually needed to suspect duodenal injury

Jejunum and Ileum (1 of 2) : 

Jejunum and Ileum (1 of 2) Mechanisms of injury Penetrating trauma Accounts for vast majority of small bowel injury About 80 percent of gunshot wounds and 30 to 50 percent of stab wounds include small bowel insult Blunt trauma Injuries most commonly sustained by the proximal jejunum and terminal ileum

Jejunum and Ileum (2 of 2) : 

Jejunum and Ileum (2 of 2) Injuries Mesenteric vasculature Often involved, contributes to intra-abdominal hemorrhage Spilling of bowel contents Bowel contents, including digestive enzymes and partially digested chyme, can spill into the peritoneal cavity Results in gastrointestinal contamination, possible infection, autodigestion, and eventual peritonitis Bowel evisceration Occurs when the abdominal wall is violated Allows abdominal contents to protrude through the insult to the extra-abdominal environment Most often mesentery and small bowel

Pancreas (1 of 2) : 

Pancreas (1 of 2) Pancreatic trauma uncommon About 7 percent of all traumatic abdominal injuries Mechanism of injury Injury is secondary to penetrating trauma about 70 to 75 percent of the time Blunt trauma Midbody of the pancreas is often crushed against the vertebral column by crushing force to the anterior thoracic and abdominal wall Driver of a car may collide with a steering wheel

Pancreas (2 of 2) : 

Pancreas (2 of 2) Over 90 percent of patients with pancreatic injuries have injuries to other abdominal organs Mean number of additional injuries about three per patient Liver, stomach, and abdominal vascular structures Hemorrhage, leaking of digestive enzymes

Large Intestine (1 of 2) : 

Large Intestine (1 of 2) Mechanism of injury Almost 96 percent of injuries to these structures are secondary to penetrating trauma Gunshot wounds are the most frequent cause of colon and rectal injury Stab wounds account for less than 10 percent of all injuries Blunt force trauma accounts for 3 to 10 percent of all traumatic colorectal injuries

Large Intestine (2 of 2) : 

Large Intestine (2 of 2) The colon and rectum account for 5 percent of all intra-abdominal injuries Colorectal trauma is often also complicated by the introduction of fecal material into the abdominal or pelvic compartments Results in peritonitis and sepsis Mortality from colon injury is between 2 and 12 percent

Vascular Injuries (1 of 2) : 

Vascular Injuries (1 of 2) Injuries to abdominal vascular structures are associated with some of the highest mortality rates of abdominal injuries Between 30 and 60 percent combined Mortality by specific vessel: Aorta: 50 to 70 percent Iliac artery: 40 to 53 percent Inferior vena cava: 30 to 53 percent Portal and splenic veins: 40 to 70 percent Iliac vein: 38 percent

Vascular Injuries (2 of 2) : 

Vascular Injuries (2 of 2) Penetrating trauma responsible for 97 percent of abdominal vascular injuries Abdominal compartment can expand and accommodate significant amount of blood Outward evidence of massive internal bleeding can be occult CCP must suspect intra-abdominal bleeding secondary to the mechanism of injury and clinical exam findings suggesting developing hypovolemic shock

Assessment of Abdominal Injuries(1 of 5) : 

Assessment of Abdominal Injuries(1 of 5) Abdominal trauma patient must be assessed rapidly Initial attention paid to the patient’s airway, breathing, and circulatory status CCP must try to record accurate history of the events resulting in injury Take information from prehospital providers

Assessment of Abdominal Injuries(2 of 5) : 

Assessment of Abdominal Injuries(2 of 5) Interfacility transfer Staff at the transferring facility should provide full patient report at the time of CCP arrival Repeat initial assessment before CCP arrival Do not rush through the exam Be deliberate, systematic, and thorough every time

Assessment of Abdominal Injuries(3 of 5) : 

Assessment of Abdominal Injuries(3 of 5) Inspect Fully expose abdomen Inspect for obvious signs of trauma DCAP-BTLS Kehr’s sign Cullen’s sign Grey-Turner’s sign Anterior, lateral, posterior abdominal wall

Assessment of Abdominal Injuries(4 of 5) : 

Assessment of Abdominal Injuries(4 of 5) Auscultate Presence and quality of bowel sounds

Assessment of Abdominal Injuries(5 of 5) : 

Assessment of Abdominal Injuries(5 of 5) Palpate Assess for tenderness, guarding, rigidity, masses, pulsations, or crepitus of the lower ribs Anterior, lateral, posterior abdominal wall Referred pain

Screening Exams for Abdominal Injuries:Imaging Studies : 

Screening Exams for Abdominal Injuries:Imaging Studies

Laparotomy (1 of 2) : 

Laparotomy (1 of 2) Considered the “gold standard” therapy for intra-abdominal injury Allows an unparalleled assessment of the abdomen and retroperitoneum Definitive Allows for immediate injury repair Usually reserved for those who present with findings that suggest the need for surgical repair Hemodynamic instability Penetrating abdominal injury

Laparotomy (2 of 2) : 

Laparotomy (2 of 2) Peritoneal findings Gross blood in the abdomen Intraperitoneal free air CT findings In hemodynamically stable patients, less invasive methods of assessing the abdomen such as CT, sonography, and diagnostic peritoneal lavage are usually considered

Diagnostic Peritoneal Lavage (1 of 5) : 

Diagnostic Peritoneal Lavage (1 of 5) Performed by inserting a catheter into the peritoneal space by opened or closed technique Once the catheter is in place, a syringe is used to attempt aspiration of any gross blood

Diagnostic Peritoneal Lavage (2 of 5) : 

Diagnostic Peritoneal Lavage (2 of 5) Aspiration of 10 ml of blood is considered positive Patient will often receive an explorative laparotomy If no blood in aspirated, 1 liter of normal saline is infused into the peritoneal cavity, allowed to diffuse for 5–10 minutes, then removed The fluid is then inspected in a laboratory and considered positive if: There is more than 100,000 RBC/mm3 for blunt trauma or 5,000 RBC/mm3 for penetration wounds There is more than 500 WBC/mm3 Bile or an amylase greater than serum amylase is present or if bacteria, fecal matter, or food particles are present

Diagnostic Peritoneal Lavage (3 of 5) : 

Diagnostic Peritoneal Lavage (3 of 5) Indications for procedure include a history of trauma and suspicion of intra-abdominal injury Relative contraindications include pregnancy and previous abdominal surgery Procedure is rapid and sensitive but nonspecific Really reveals that blood is in the abdomen Site and severity of the hemorrhage remains unknown Often identies minor, normally inoperative injuries that result in unnecessary laparotomies

Diagnostic Peritoneal Lavage (4 of 5) : 

Diagnostic Peritoneal Lavage (4 of 5) Only a surgeon who will be making surgical decisions about the patient should perform this procedure Role of procedure in critical care transport is limited Technology for peritoneal fluid evaluation is unavailable for critical care transport Critical care transport team may be asked to finish a lavage that was started before their arrival In cases of transport from a facility that has performed this procedure, knowledge of the results could aid in decision-making before and during transport

Diagnostic Peritoneal Lavage (5 of 5) : 

Diagnostic Peritoneal Lavage (5 of 5) Edward T. Dickinson, MD

Sonography (1 of 4) : 

Sonography (1 of 4) Use of inaudible sound or ultrasound to produce in image of an organ or a tissue Ultrasonic echoes are recorded as they strike tissues of varied densities

Sonography (2 of 4) : 

Sonography (2 of 4) Focused assessment with sonography for trauma (FAST) Ultrasound assessment designed to detect blood in the pericardium or abdomen secondary to traumatic injury Advantages Performed in 3–4 minutes by experienced examiners Accurate From 96 to 98 percent accurate at detecting fluid in the peritoneal cavity Inexpensive Without complications, because it is noninvasive Repeatable as often as needed

Sonography (3 of 4) : 

Sonography (3 of 4) FAST Involves assessing four areas of a supine patient First, the pericardium is assessed for fluid via a sagittal view from the subxiphoid area Second, a sagittal view of the abdomen is taken from the right midaxillary line between the eleventh and twelfth ribs and used to evaluate the hepatorenal space, or Morrison’s pouch, for blood Third, a sagittal view of the abdomen is taken from the left midaxillary line between the tenth and eleventh ribs and used to evaluate the spleen and kidney and assess the splenorenal space for blood Fourth, a coronal view superior to the pubis symphysis is taken and used to assess the pelvis for blood

Sonography (4 of 4) : 

Sonography (4 of 4) FAST Limitations Cannot reveal small amounts of blood (<200ml) False negative results have been reported in instances of diaphragmatic rupture Sensitivity for the presence of hemoperitoneum between 73 and 88 percent Specificity between 98 and 100 percent Is accurate 96 to 98 percent of the time Level of accuracy is independent of the level of the practitioner performing the study

Sonography: FAST : 

Sonography: FAST David Spear, MD

Computed Tomography (CT) (1 of 3) : 

Computed Tomography (CT) (1 of 3) Process by which transverse planes of tissues are swept by a pinpoint radiographic beam to create a computerized image Provides an excellent modality to screen for specific abdominal injury in stable trauma patients who may not require operative management of their intra-abdominal injuries

Computed Tomography (CT) (2 of 3) : 

Computed Tomography (CT) (2 of 3) Advantages Allows for specific diagnosis Allows for a greater number of intra-abdominal trauma patients to be managed nonoperatively Can diagnose retroperitoneal injuries Disadvantages Tends to miss injuries that do not introduce blood or other fluids into the abdominal cavity Pancreas, diaphragm, empty urinary bladder, mesenteric injuries, and small bowel Patient treatment delayed Used on stable patients only

Computed Tomography (CT) (3 of 3) : 

Computed Tomography (CT) (3 of 3) Kathy Altergott, BSN, MBA, CRA. Banner Good Samaritan Medical Center, Phoenix, AZ

Radiography (1 of 2) : 

Radiography (1 of 2) Abdominal radiographs of little use in blunt trauma Limited use in penetrating trauma Identify missiles, foreign bodies

Radiography (2 of 2) : 

Radiography (2 of 2) Kathy Altergott, BSN, MBA, CRA. Banner Good Samaritan Medical Center, Phoenix, AZ

Pertinent Lab Values : 

Pertinent Lab Values

ABG : 

ABG Serum pH indicates acid-base status Metabolic acidosis with a high lactate indicates that anaerobic metabolism is taking place secondary to tissue hypoperfusion PO2 and PCO2 to help determine oxygenation and ventilation status

Blood Chemistry : 

Blood Chemistry Most blood chemistry changes that occur secondary to abdominal trauma do not occur acutely Many hours or even days are required for many values to change Lliver function test

ASP (SGOT), GTT/Alkaline Phosphatase, and ALT (SGPT) : 

ASP (SGOT), GTT/Alkaline Phosphatase, and ALT (SGPT) May be elevated in liver trauma or incidences of “shock liver” Transient increase in serum bilirubin secondary to the lyses of red blood cells Crushing injuries

Bilirubin : 

Bilirubin Not elevated in acute liver trauma Will rise at about 0.8–1.0 per day in liver failure

Serum Lactate : 

Serum Lactate Good indicator of the perfusion status of tissue, especially tissue in the GI tract Elevated lactate indicates that VO2 fails to meet the metabolic demand

Serum Amylase and Lipase : 

Serum Amylase and Lipase Unreliable indicators for pancreatic trauma Positive predictive value of about 10 percent Increasing serum amylase and lipase indicates a need for further, more sensitive studies of the pancreas In cases of normal serum amylase after blunt trauma, 95 percent likely pancreas is uninjured In small bowel injury, the serum amylase will rise independent of lipase

Hemoglobin/Hematocrit (H&H) : 

Hemoglobin/Hematocrit (H&H) Low or decreasing serial hemoglobin/hematocrit (H&H) values after a traumatic mechanism of injury to the abdomen indicate intra-abdominal bleeding

Leukocytes : 

Leukocytes Levels above 15,000 u/L considered suggestive but not diagnostic for traumatic injury when a mechanism of injury has been identified Any stress on the body, physical or psychological, can elevate the white blood count Extremely nonspecific, questionable value White blood count could have been elevated before the traumatic event

HCG : 

HCG HCG screen to rule out pregnancy should be done on every female trauma patient of child-bearing age

BUN/Creatinine : 

BUN/Creatinine Will gradually increase in patients who have sustained renal trauma and have limited or no kidney function

Blood Glucose Determination : 

Blood Glucose Determination Should be done on every patient as soon as the ABCs have been addressed

Urinalysis : 

Urinalysis Required in trauma patients to assess for hematuria secondary to GU insult Determination of gross blood can be made clinically by direct observing the urine after catheterization Urine reagent strips help rapidly assess urine

Sublingual Capnometry : 

Sublingual Capnometry Evaluation of the sublingual PCO2 is, in effect, an evaluation of the visceral PCO2 As the gut is among the first tissues to be affected by decreasing tissue perfusion, monitoring of its PCO2 can alert the care provider very early in the development of shock Insult to the bowel elevates PCO2 levels Sublingual capnometry can therefore help identify subclinical cases of blunt abdominal trauma

Management : 

Management End point for abdominal trauma management is surgical care CCP’s role is to: Correct all immediate life-threatening injuries and provide rapid, safe transport to a trauma center Keep patient warm Provide other supportive care as needed

CCP Priorities in Abdominal Trauma : 

CCP Priorities in Abdominal Trauma Control airway Ensure adequate ventilation and oxygenation Identify and control, if possible, hemorrhaging Controlling intra-abdominal hemorrhage by nonsurgical means is difficult Recognize developing hypovolemic shock and prevent decompensation and eventual cardiovascular collapse

Specific Treatment : 

Specific Treatment Secure airway and breathing Provide intravenous access Establish two large-bore IVs Ensure central venous access

Volume Administration : 

Volume Administration Goal is blood pressure of about three-quarters the patient’s normal blood pressure 250 mL crystalloid bolus, reassess, repeat if needed Large volumes may be needed in cases of extreme hemorrhage Consider coadministering blood products to prevent hemodilution

Blood Products : 

Blood Products Whole blood/packed red blood cells Should be considered with administration of large volumes of crystalloids Ideally, typed and cross-matched whole blood administered Type-specific or O- blood in the acute emergency Synthetic fluids with oxygen-carrying capacity

Foley Catheter : 

Foley Catheter Allows: Bladder drainage Evaluation of urine output, color, and consistency

Anatomy and Physiology : 

Anatomy and Physiology

Kidneys (1 of 4) : 

Kidneys (1 of 4) Location, size In the retroperitoneal space lateral to the spinal column between the twelfth thoracic and third lumbar vertebrae Each about 4 inches long Left kidney typically sits a bit higher in the abdominal cavity than the right

Kidneys (2 of 4) : 

Kidneys (2 of 4) Anatomy Renal capsule Renal fascia Layer of adipose tissue Together, the renal capsule, adipose layer, and renal fascia serve to suspend and protect the kidneys Receive 20 to 25 percent of total cardiac output via the renal artery Renal vein returns blood to the inferior vena cava All blood vessels, lymphatic structures, and the ureters travel through the hilus when entering or exiting the kidney

Kidneys (3 of 4) : 

Kidneys (3 of 4) A) From Essentials of Anatomy & Physiology, 2nd ed., by Frederic H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Reprinted by permission. B) From Ralph T. Hutchings.

Kidneys (4 of 4) : 

Kidneys (4 of 4) Physiology Major roles include: Regulate fluid and electrolytes Form urine Remove waste Produce red blood cells Achieve homeostasis

Ureters : 

Ureters Drain urine from kidney to bladder Pass through retroperitoneal space

Urinary Bladder : 

Urinary Bladder Expandable, muscular reservoir for urine in the pelvic cavity Exact position differs between men and women due to differences in reproductive anatomy

Urethra (1 of 2) : 

Urethra (1 of 2) Exits the bladder at the neck and travels to the terminus of the external genitalia Female urethra is about 1–1.5 inches long Male urethra is about 7–8 inches long

Urethra (2 of 2) : 

Urethra (2 of 2) In the male, is divided into three parts: Prostatic urethra Passes through the prostate gland Membranous urethra Travels through the urogenital diaphragm Penile urethra Travels the length of the penis

Female Reproductive System : 

Female Reproductive System Consists of the: Ovaries Fallopian tubes Uterus Vagina From Fig. 20-8, p. 556, from Essentials of Anatomy & Physiology, 2nd ed., by Frederic H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Reprinted by permission.

Male Reproductive System : 

Male Reproductive System Consists of the: Testes Epididymis Ductus deferens Seminal vesicle Ejaculatory duct Prostate gland Urethra Penis From Fig. 20-06, p. 554, from Essentials of Anatomy & Physiology, 2nd ed., by Frederic H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Reprinted by permission.

Pathophysiology : 

Pathophysiology

Renal (1 of 3) : 

Renal (1 of 3) Vast majority (90 percent) of renal trauma is secondary to blunt-force trauma Renal ruptures are associated with severe hemorrhage and shock CT findings include extravasation of contrast material into the perirenal area, severe renal lacerations, and possible renal fragmentation Rupture that involve the renal pelvis will introduce urine to the perirenal space

Renal (2 of 3) : 

Renal (2 of 3) AAST Spleen Injury Scale Grade I injuries Include small subcapsular hematomas and small contusions with minimal hematuria Grade II injuries Include nonexpanding perirenal hematomas confined to the renal retroperitoneum and lacerations of the renal cortex less than 1 cm in depth and no urinary extravasation Grade III injuries Lacerations to the renal cortex more than 1 cm deep, without collection system rupture or urinary extravasation

Renal (3 of 3) : 

Renal (3 of 3) AAST Spleen Injury Scale Grade IV injuries Include parenchymal lacerations extending through the renal cortex, medulla, and collecting system and contained injuries to the renal artery and vein Grade V injuries Include a completely shattered kidney or hilar avulsion resulting in renal devascularization

Ureter : 

Ureter Ureteral injuries rare Often the result of: Penetrating trauma that transects the ureter Blunt-force injury as a result of hyperflexion of the spine Results in ureteral rupture at or just below the ureteropelvic junction Cavitation forces from the passing of a bullet through the pelvic cavity Can result in micovascular thrombosis and, over days, necrosis and perforation

Bladder : 

Bladder Can be intraperitoneal or extraperitoneal Intraperitoneal bladder rupture is most often the result of a full bladder and blunt force trauma to the abdomen CT or cystogram will reveal extravasation of urine into the bowel above the bladder Extraperitoneal bladder ruptures are associated with pelvic fracture and occur most often at the bladder neck CT and cystogram findings include extravasation of contrast material into the pelvic tissue “Flame-like” pattern

Urethra (1 of 2) : 

Urethra (1 of 2) In males, injuries to the urethra can be divided into those that occur to the posterior urethra (prostatic and membranous) and the anterior urethra (penile) Posterior urethra injuries are associated with pelvic fractures and additional abdominal, thoracic, and head injuries Anterior injures often result secondary to penile fractures and direct force to the penis (falls, straddle injuries)

Urethra (2 of 2) : 

Urethra (2 of 2) Female urethral injury is rare Most often occurs secondary to direct pelvic trauma and fractures Extravasation of contrast material into the surrounding tissue revealed on CT and cystogram are diagnostic for urethral injury

Reproductive (1 of 4) : 

Reproductive (1 of 4) Male Scrotal injury Overall frequency is low Most likely due to organ’s mobility Blunt trauma is the most common cause, with direct blow and impingement against the symphysis pubis most common Scrotal tissue can be avulsed secondary to shearing forces Injury can result in blood accumulation and engorgement of the scrotum, and the testicles can be avulsed, contused, crushed, or dislocated into the inguinal canal

Reproductive (2 of 4) : 

Reproductive (2 of 4) Male Penile injuries Include penile fractures, hematomas, lacerations, avulsions, and degloving injuries Vacuum-cleaner injuries can extensively damage both the glans and the urethra Penile fractures occur when an erect penis experiences excessive compressive force Results in extreme bending, fracturing the engorged corpus cavernosum and injuring the surrounding tissue Patient hears and remembers loud, cracking sound Urethral injury or occlusion due to swelling and developing hematoma

Reproductive (3 of 4) : 

Reproductive (3 of 4) Female Injuries to the female reproductive structures are rare but most often involve the external genitalia, vagina, and uterus Ovarian and fallopian tube injuries are extremely uncommon due to organs’ small sizes and mobility Most often include contusions, hematomas, and devascularization injuries

Reproductive (4 of 4) : 

Reproductive (4 of 4) Female Ovaries, as solid organs, can fracture or shatter Penetrating trauma is most frequent cause of injury to the uterus Devascularization injuries can result secondary to blunt trauma that severely moves the uterus and disrupts its vascular supply External genitalia injured as result of straddle injuries, aggressive consensual sex, sexual assault, and rape Injury types include hematomas, lacerations, and avulsions

GU Assessment (1 of 5) : 

GU Assessment (1 of 5) Should occur after assessment of airway, breathing, and circulation has identified and corrected any immediate life threats Abdomen and pelvic regions should be fully exposed for genitourinary exam Protect the patient’s dignity regardless of the patient’s level of consciousness GU assessment most often occurs with an abdominal exam Should proceed systematically to include the anterior, lateral, and posterior abdomen

GU Assessment (2 of 5) : 

GU Assessment (2 of 5) Inspection Identify obvious trauma (e.g., bruising, abrasions, lacerations, and penetrating injury) Recognize Grey-Turner’s sign Inspect the urethra for frank blood when GU trauma is suspected

GU Assessment (3 of 5) : 

GU Assessment (3 of 5) Palpate Include flanks and the inferolateral and inferoposterior wall of the ribcage Pain or crepitus to the posterior aspects of ribs 11 and 12 suggests rib fracture and potential injury to the kidneys Pelvic girdle should be assessed for stability Palpate the bladder, in the lower abdominal quadrants Classic triad indicating bladder rupture Abdominal pain Gross hematuria Inability to void

GU Assessment (4 of 5) : 

GU Assessment (4 of 5) Due to their occult nature, ovarian, fallopian, and uterine injuries will most likely go unrecognized in the emergent situation CT exam is the most frequently used diagnostic modality to identify these types of injuries Clinical exam may reveal vaginal bleeding, more so in cases of uterine rupture, but alone is not diagnostic for any of these injuries Urethra should be examined closely for blood in males and females

GU Assessment (5 of 5) : 

GU Assessment (5 of 5) Testicular injuries should be inspected for obvious injuries (e.g., lacerations, abrasions, avulsions, discoloration, or swelling) Penile injuries often present with severe pain and obvious bleeding, discoloration, swelling, avulsion, degloving, or amputation

Screening Exams for GU Injury: Imaging Studies : 

Screening Exams for GU Injury: Imaging Studies

Cystography : 

Cystography Method About 300–500 ml of contrast media is infused into the urethra and serial radiographs are taken Any extravasation of contrast from the urethra or bladder indicates perforation

Radiography : 

Radiography Plain radiographs cannot detect renal injury or function Limited value when assessing GU patient

Computed Tomography (CT) : 

Computed Tomography (CT) Spiral CT with contrast is the imaging modality of choice for diagnosing kidney injury Able to show enough detail to allow accurate grading of the renal injury CT cystogram

Sonography : 

Sonography No real role in evaluating genitourinary trauma

Pertinent Laboratory Values (1 of 2) : 

Pertinent Laboratory Values (1 of 2) Blood chemistry BUN/creatinine Will gradually increase in patients who have sustained renal trauma and have limited or no kidney function Comparing the blood urea with serum creatinine can help diagnose bladder rupture Disproportionate increase in the serum urea as compared to creatinine

Pertinent Laboratory Values (2 of 2) : 

Pertinent Laboratory Values (2 of 2) Urinalysis Hematuria secondary to GU insult Clinical determination of gross blood by directly observing urine after catheterization Urine reagent strips help rapidly assess urine

Management (1 of 2) : 

Management (1 of 2) Definitive treatment for serious and life-threatening GU trauma is surgery CCP care consists primarily of: Securing the airway Ensuring breathing adequacy and oxygenation Treating shock as needed Providing rapid and safe transport to the receiving facility

Management (2 of 2) : 

Management (2 of 2) Circulatory considerations for shock are the same as those for the GI patient Vaginal bleeding can be controlled by applying dressings and direct pressure to the vaginal area Vaginal canal should never be packed Penile bleeding can be controlled by applying direct pressure around the circumference of the penis base

Summary (1 of 2) : 

Summary (1 of 2) Evaluation of patients who have sustained abdominal trauma, particularly blunt trauma, may pose a significant diagnostic and management challenge for the critical care transport team Trauma produces a spectrum of injuries, from minor single-organ ones to devastating, multiorgan or multisystem ones

Summary (2 of 2) : 

Summary (2 of 2) In addition to a command of anatomy, physiology, and injury pathology, the critical care paramedic must be able to: Perform a thorough physical exam Use the diagnostic tools available in today’s emergency and critical care environment

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