ABDOMINAL &

GENITOURINARY
TRAUMA
INDAH D. PRATIWI

DEPARTMENT OF EMERGENCY NURSING

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
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
Abdominal Boundaries
Diaphragm
Anterior abdominal wall
Pelvic skeletal structures
Vertebral column
Muscles of the abdomen and flanks
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
Pathophysiology
Hemorrhage
Limited external signs
Rapid blood loss possible
Hypovolemic shock
Blood does not result in peritonitis
Solid Organ Injuries
Death usually because of hemorrhage
May due to blunt or penetrating mechanism
Solid Organ Injuries
Spleen
Frequently injured solid organ
Usually due to blunt trauma
Often 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
Liver
Largest organ in abdomen
Frequently injured organ
May be due to blunt or penetrating trauma
Often trauma to ribs 8-12 on right side
Bleeding
Slow and contained under capsule
Enters peritoneal cavity
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
Death may result from hemorrhage and/or content spillage
May result from penetrating or blunt trauma
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
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
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
Genitourinary
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
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
Less than 2% of GU trauma
Usually secondary to penetrating trauma
Rupture
Extraperitoneal
Intraperitoneal
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
Urgency to void, inability to void
Shock
Abdominal distention
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
Usually due to pelvic fracture, deceleration or straddle injuries
Blood at external meatus
Perineal bruising
Scrotal Hematoma
Urethra
Urinary catheters 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
Accidental or Intentional Injury
Highly vascular with rich sensory nerve supply
Pain
Psychological issues
Hemorrhage
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
Usually intentional due to 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
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
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
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
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
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 Evisceration
Do not replace organs into abdomen
Cover exposed bowel with saline moistened multi trauma dressing
Cover first dressing with second dry dressing
Abdominal Trauma
Management
Leave impaled objects in place
Shorten if necessary for transport
Leave part of object exposed

NPO
Caution with
Sedatives
Narcotic Analgesics
Question???