Abdominal

Trauma
By Beka Aberra
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Outline
Introduction
Background Anatomy
Mechanisms and Pathophysiology
Clinical assessment
Conclusion

INTRODUCTION

Trauma is the commonest cause of death in

young people.

ABDOMINAL TRAUMA STANDS THIRD NEXT

TO HEAD INJURY AND CHEST INJURY

25% of all major trauma victims require

abdominal exploration.
Abdominal evaluation is the challenging
component of evaluating trauma.
Penetrating torso injuries b/n nipple & perineum
is a potential intra abdominal injury.
Mechanism, Force & Location of injury &
Hemodynamic status determine the priority &
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best method of assessment.

75% OF ALL BLUNT TRAUMA TO ABDOMEN

INVOLVES ROAD TRAFFIC ACCIDENT

60% OF INJURY OCCUR IN MALES (14-30)

Trauma related deaths form 3 Peaks

First Peak accounts 50% die instantly or
very soon.
Second Peak accounts 30% in hours of
injury due to severe blood loss.
Third Peak accounts 20% in days to
weeks due to infection/multi organ failure.
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Background Anatomy

Anterior abdomen
Flank
Back
Intraperitoneal space contents
Retroperitoneal space contents
Pelvic cavity contents
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 Anterior

abdomen:

Trans-nipple line, Anterior axillary lines,

Inguinal ligaments and Symphysis pubis.
Flank:

Anterior and posterior axillary line;

Sixth intercostal to iliac crest.
Back:

Posterior axillary line; Tip of scapula to

Iliac crest.

Upper Peritoneal cavity

Covered by lower aspect of bony thorax. Includes Diaphragm, Liver,

Spleen, Stomach, Transverse colon.

Lower Peritoneal cavity:

Small bowel Ascending and Descending colon, Sigmoid colon

Retroperitoneal space:

A Potential space Behind true abdominal cavity

Abdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas,
kidneys, Ureters and posterior aspects of Ascending and Descending
colons

Pelvic cavity:

Rectum, Bladder, iliac vessels and Internal genitalia in women.

The Abdomen
Everything between diaphragm and
pelvis
Injuries very difficult to assess
because of large variety of structures

Abdominal Anatomy
Abdomen divided into four quadrants
by body mid-line, horizontal plane
through umbilicus
Organ located by quadrant

Abdominal Anatomy

Right Upper Quadrant

Liver
Gall Bladder
Right Kidney
Ascending Colon
Transverse Colon

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Abdominal Anatomy

Left Upper Quadrant

Spleen
Stomach
Pancreas
Left Kidney
Transverse Colon
Descending Colon
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Abdominal Anatomy

Right Lower Quadrant

Ascending Colon
Appendix
Right Ovary (female)
Right Fallopian Tube (female)

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Abdominal Anatomy

Left Lower Quadrant

Descending Colon
Sigmoid colon
Left Ovary (female)
Left Fallopian Tube (female)

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Abdominal Anatomy

Organs can be classified as:

Hollow
Solid
Major vascular

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Solid Organs
Liver
Spleen
Kidney
Pancreas

When solid organs are

injured, they bleed heavily
and cause shock
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Hollow Organs
Stomach
Gall bladder
Large, small intestines
Ureters, urinary bladder

Rupture causes content

spillage, inflammation of
peritoneum
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Major Vascular
Structures
Aorta
Inferior vena cava
Major branches

Injury can cause severe

blood loss ; exsanguination
(bleeding out)
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1. Abdominal Aorta
2. Common Iliac
Artery

Vascular Anatomy 3. Internal Iliac

4. External Iliac
5. Superior Gluteal
6. Obturator Artery

Can you tell me

What are the top 3 most commonly

injured organs in the abdomen?

Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)

Mechanisms

Blunt trauma:

Motor Vehicle Accident

Seat belt injury

Penetrating injuries:

Stab wounds
Gun Shot wounds

Blast
Bomb
Crush
Building collapse
Thermal

Blunt Trauma

Motor vehicle collisions

Motorcycle collisions

Pedestrian injuries

Falls

Assault

Blast injuries

Penetrating Trauma

Stab wounds

Gun Shot wounds

Surgical Incisions

Blunt Abdominal trauma is the

commonest cause of death in younger
population with Polytrauma in RTA.
Blunt abdominal injuries carry a
greater risk of morbidity and
mortality than penetrating
abdominal injuries.
Mostly due to
Inadequate diagnosis
Delayed resuscitation
Delayed surgery

Mechanism of Injury:
Blunt
Motor Vehicle Accident
Seatbelt injury

Pathophysiology

1.Compression/Concussive forces
Direct blow
External compression vs. fixed object (e.g. lap belt, spinal
column)
Cause

Tears & Sub capsular hematoma to solid

viscera.
Deform hollow organs & transiently Inc.
intraluminal pressure.

2. Deceleration forces
Stretching & Linear shearing b/n relatively fixed & free object.

In BAT, Organs that cant yield to impact by elastic

deformation are most likely to be injured i.e. solid
organs

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Rapid deceleration
Shearing Force created that cause solid, visceral
organs and vascular pedicles to tear at relatively fixed
points of attachment. Differential movements of fixed
and non-fixed structures
(e.g. liver and spleen laceration at sites of supporting ligaments)
Crushing effect
B/n anterior abdominal wall and vertebral
column/posterior cage
(e.g. direct blow to the epigastrium with crushing of the pancreas

over the spine)

Compressive effect
Sudden dramatic rise in Intra-abdominal pressure due
to external compression, hollow viscus ruptures
(e.g. direct blow to liver or blowout of the bowel)

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Motor Vehicle
Accidents
The
most common cause of blunt trauma
is the motor vehicle Injuries

Major global public health challenge but

most of it occurs in low- and middle-income
countries including Ethiopia.

Every year about 1.2 million people

are killed and more than 20 million
are injured or disabled
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Contributing Factors

Poor road network

Absence of knowledge on road traffic safety
Mixed traffic flow system
Poor legislation and failure of enforcement
Poor conditions of vehicles;
Poor emergency medical services

Traffic accident compulsory insurance law is in effect Recently.

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Seatbelt injuries
Although seatbelts reduce mortality overall, they
cause a specific pattern of internal injuries.
Patients

with seatbelt marks have been found to

have a fourfold increase in thoracic trauma and
an eightfold increase in intra-abdominal trauma
compared with those without seatbelt marks
The

three-point shoulder-lap belt is the most

effective restraining system and is associated with
the lowest incidence of abdominal injuries.

Use of seatbelts is thought to reduce the risk

of death or serious injury for front-seat
occupants by approximately 45%.
Unbelted rear-seat occupants are also at
increased risk of serious injury in motor vehicle
accidents (MVAs); they may be ejected or
thrown forward into the back of the front seat;
the impact from unbelted rear-seat
passengers on front-seat occupants can be a
major determinant of injury.
It is estimated that, when rear seatbelts are
worn, the risk of death for belted front-seat
occupants is reduced by 80%.
In direct frontal MVAs, airbags provide a
reduced risk of fatality of approximately 30%. 32

Compression
Of the bowel between the belt and the
vertebral column, an acute short closed-loop
obstruction occurs along with perforation
secondary to the sudden generation of high
intraluminal pressures.

Clinically, two symptom patterns emerge.

~1/4 of pt. develop evidence of a hemoperitoneum

secondary to mesenteric lacerations.

In the remainder 3/4 of pt. the intestinal injury most

commonly involves the jejunum contusion or
perforation.

Rare cases of acute abdominal aortic dissection

with incomplete or complete occlusion have also
been described, and injuries to the lumbar spine are
not uncommon.

Mechanism of Injury:
Penetrating
Kinetic Energy imparted to body
Low velocity: Knife
Ice pick
Medium velocity: Gunshot wounds
Shotgun wounds
High velocity: High-power hunting rifles
Military weapons

Pathophysiology
Depends on the
Type of weapon
Velocity of bullet
Distance b/n assailant & victim
Typically follow the tract/trajectory of the
inflicting instrument & thus involve
contiguous structures.

Stab Wounds

Multiple in 20% of cases

Involve the chest in up to 10% of cases

Most stab wounds do not cause an

intraperitoneal injury

The incidence varies with the direction of

entry into the peritoneal cavity

The liver, followed by the small bowel, is the

organ most often damaged by stab wounds.

Knives are not the sole implement

used in stabbings.

Ice picks, pens, coat hangers,

screwdrivers, and broken bottles.

Most

commonly in the upper

quadrants, the left more commonly
than the right???

Gunshot Wounds

Handguns, Rifles, and Shotguns

crush Bones

The degree of injury depends on

Amount of kinetic energy imparted by the

bullet to the victim
Massstretch
of the bullet
and the square of its
Tissues
velocity
Distance

General Principles of GSW

Low-velocity injury (<1000ft/sec), damage is

confined to missile tract.
High-velocity injury (<2000ft/sec), blast effect &
cavitation occur in addition to damage by missile
tract.
85% of ant. GSW violate the peritoneum; of these
95% require repair of intra abdominal injury.
Organs occupying the most space are more often
injured
Small bowel(29%)
Liver(28%)
Colon(23%)
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Type I wounds : long range (>7 yards) , a

penetration of subcutaneous tissue and
deep fascia only.

Type II wounds : distance of (3 to 7 yards)

and may create a large number of
perforated structures.

Type III wounds : occur at point-blank

range (<3 yards) and involve a massive
destruction of tissue
*1yard=0.9meter

Small bowel injury is the most

common injury resulting from ___
abdominal trauma.
penetrating
blunt

Small bowel injury is the most

common injury resulting from ___
abdominal trauma.
penetrating
blunt

CLINICAL ASSESSMENT

HISTORY

PHYSICAL EXAMINATION

Primary goal is to identify that an injury

exists, not necessarily making an accurate
diagnosis.

The patient's history may be unobtainable,

elusive, or temporarily abandoned while
resuscitative measures are carried out.

History from prehospital care team or

transferring hospital : the vital signs, physical
assessment, prehospital course, and
response to therapy should be obtained

Mechanism of injury is an important factor in

developing a high index of suspicion; thus a
detailed history is helpful if available.

Assessment: History
Mechanism
MVC:

Speed
Type of collision (Frontal, Lateral,
Sideswipe, Rear, Rollover)
Vehicle intrusion into passenger
compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle
Kehrs Sign???

In blunt trauma: MVA

Details about accident
Fatality at the scene
Vehicle type and velocity
Whether the vehicle rolled over
Patient's location within the vehicle
Extent of intrusion into the passenger compartment
Extent of damage to the vehicle
Steering wheel deformity
Whether seat belts were used and, if so, what type
Whether front or side air bags were deployed
All patients involved in deceleration injuries and
bicycle injuries should be suspected of having
intraabdominal injury

In penetrating trauma: GSW/MSW

No. of shots or stabs?
Type of weapon?
Number of shots heard?
Position of the patient when shot?
Distance of the patient from the gun?
What instrument was used?
How long and how wide was the instrument?
How was the patient positioned during the
stabbing?
What path did the implement travel?

Assessment: Physical
Exam

PHYSICAL EXAMINATION
General Examination : Relating to
hemodynamic stability (Vital Signs)
Abdominal findings:
Inspection :
For abdominal distension
For contusions or abrasions
Lap belt ecchymosis
Mesenteric, Bowel, and Lumbar spine injuries
Periumblical (Cullen sign) and
Flank (Grey Turner Sign) ecchymosis
Retroperitoneal hematoma

PHYSICAL EXAMINATION cont.

Palpation :
For tenderness, guarding and/or rigidity,
rebound tenderness
hemoperitoneum
Percussion :
Dullness/ shifting dullness
Intraabdominal collection
Auscultation : Where to auscultate &
What to listen for??? All four quadrants

The classical
seatbelt sign.
The bruising on
the left breast is
from the shoulder
belt and the low
bruising to the
abdominal wall is
from the lap belt.

PHYSICAL
EXAMINATION cont..
Rectal findings
Check for gross blood Pelvic fracture
Determine prostate position
High riding
prostate Urethral injury
Assess sphincter tone
Neurologic status
Distal pulses
- Assess for absence or asymmetry
Assessment of other associated injuries i.e.
multiple fractures, spinal injuries etc.

Associated with
fractures
Left lower six ribs
Right lower six ribs
Upper Lumbar
vertebra
Transverse
Process

Pelvis

Spleen
Liver
Pancreas and
Duodenum
Kidneys
Bladder
Urethra
Rectum

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Reliability of clinical
evaluation
Low sensitivity
Unreliable in 35/45% of pt.
Why??
Head Injury
Caution
Spinal
A missed abdominal
injury can cause a
Alcohol
preventable death.
Drug
Repeated physical examination is
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Mandatory.

The major findings with injury of the solid

abdominal organs are those of hemorrhagic shock.
Signs with solid organ injury include all of the
following EXCEPT:
abdominal

pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may result from
confined hemorrhage)

The major findings with injury of the solid

abdominal organs are those of hemorrhagic shock.
Signs with solid organ injury include all of the
following EXCEPT:
abdominal

pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may result from
confined hemorrhage)

High Index of Suspicion

Mechanism
Tachycardia early, hypotension, and
pale, diaphoretic skin late
Hypovolemic shock with no readily
identifiable cause
Diffusely tender abdomen
Pain in uninjured shoulder

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Blunt Abdominal Trauma

Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially

Blunt Abdominal Trauma

Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially

Blunt Abdominal Trauma

Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially

Blunt Abdominal Trauma

Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially

Blunt Abdominal Trauma

Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially

Conclusion
Abdominal trauma is often difficult
to evaluate in the prehospital
setting. Therefore the paramedic
must exercise a high degree of
suspicion based on the mechanism
of injury and kinematics.
Death from abdominal injury usually
results from hemorrhage and
delayed surgical repair.

The KEY to Saving

Lives

The abdomen is the Black Box

i.e, its impossible to know what specific
injuries have occurred at initial evaluation.

The Key to saving lives in abdominal

trauma is NOT to make an accurate
diagnosis, but rather to recognize that
there is an abdominal injury.
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