ABDOMINAL ABDOMINAL TRAUMATRAUMA

Prepared by Prepared by

Samah Samah Ishtieh Ishtieh

MSN. MangementMSN. Mangement

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OBJECTIVESOBJECTIVES::

Identify the common mechanisms of Identify the common mechanisms of injury associated with abdominal injury associated with abdominal trauma.trauma.

Describe the pathophysiologic Describe the pathophysiologic changes as a basis for signs and changes as a basis for signs and symptoms.symptoms.

Identify selected abdominal injuries Identify selected abdominal injuries (S &S ).(S &S ).

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OBJECTIVESOBJECTIVES

Discuss the NURSING of patients Discuss the NURSING of patients with abdominal trauma.with abdominal trauma.

Identify appropriate nursing Identify appropriate nursing diagnosis.diagnosis.

Plan appropriate interventions for Plan appropriate interventions for patients with abdominal trauma.patients with abdominal trauma.

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INTRODUCTIONINTRODUCTION

Abdominal injuries are common in patients who sustain major trauma.

Unrecognized abdominal injuries are frequently the cause of preventable death.

Approximately one-fifth of all traumatized pt requiring operative intervention have sustained trauma to the abdomen.

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Abdominal traumaAbdominal trauma

Abdominal traumaAbdominal trauma is an injury to the is an injury to the abdomen. It may be . It may be blunt or or penetrating and may involve damage to the abdominal and may involve damage to the abdominal organs. .

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TYPES OF INJURIESTYPES OF INJURIES

Blunt abdominal trauma is a leading cause of is a leading cause of morbidity and mortality among all age groups.morbidity and mortality among all age groups.

Blunt trauma: liver …spleen (most common).Blunt trauma: liver …spleen (most common).

Penetrating: liver, small bowel and stomach.liver, small bowel and stomach.

Penetrating: present with single or multiple Penetrating: present with single or multiple injuries injuries

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Penetrating abdominal trauma (PAT) (PAT) is usually diagnosed based on clinical signs, blunt abdominal trauma is more likely to be missed because clinical signs are less obvious.

Penetrating trauma is further subdivided into stab wounds and bullet wounds, which have different treatments.

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Multiple injuries, abdominal trauma can

lead to hemorrhage, hypovolemic shock, and death. Yet even a serious, life-threatening abdominal injury may not cause obvious signs

and symptoms, especially in cases of blunt trauma.

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Key responses to decrease mortality and morbidity include :

- aggressive resuscitation efforts, - adequate volume replacement,- early diagnosis of injuries, and- surgical intervention if warranted

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ORGANSORGANS

Solid Solid OrgansOrgansLiverLiver

SpleenSpleen

KidneysKidneys

PancreasPancreas

Hollow Hollow OrgansOrgansStomachStomach

Small bowelSmall bowel

Large bowelLarge bowel

BladderBladder04/18/2304/18/23 1010

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Mechanisms of injuryMechanisms of injury

The most common mechanism of blunt injury The most common mechanism of blunt injury is MVC (motor vehicle crash).is MVC (motor vehicle crash). Firearm , stabbings, are associated with Firearm , stabbings, are associated with Penetrating trauma.Penetrating trauma. Injuries result from acceleration, deceleration, Injuries result from acceleration, deceleration,

or both forces.or both forces. Crushing forces compress the duodenum Crushing forces compress the duodenum Or Or the pancreas against the vertebral column.the pancreas against the vertebral column.

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Mechanisms of injuryMechanisms of injury

Forces applied to solid organ can rupture a surrounding capsule & injury the

parenchyma as well. Structures attached by ligaments or blood vessels may be stressed at their attachment points

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Mechanisms of injuryMechanisms of injury

Belts if improperly positioned cause

deceleration injuries to the lower abdomen , Frontal impact crashes with a bent steering

wheel associated with spleen & liver injuries as

well as head &chest trauma.

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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Blood loss: (mesenteric attachments of the intestines ) semi fixed by ligaments, stressed, tears , bleeding.

Liver & spleen ( rich blood supply) & capsulated , compression, rupture, hemorrhage.

Pain: rigidity, spasm, rebound tenderness

Irritants(blood or gastric contents or enzymes)

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Pancreatic & duodenal injury: diffuse

abdominalabdominal, tenderness and pain radiating from

epigastric to the back.

Splenic injury: referred shoulder pain (Kehr`s

sign) . Because of: stress, blood in the abdominal

cavity and direct bowel injury

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Spleen injury is usually associated with blunt trauma. Fractures of ribs 10 to 12 on the left should raise your suspicion of spleen damage,which ranges from laceration of the capsule or a nonexpanding hematoma to ruptured subcapsular hematomas or parenchymal laceration.

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Spleen injury

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CT scan showing the Spleen

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Liver injury is common because of the liver’s size and location.Severity ranges from a controlledsubcapsular hematoma and lacerations of the parenchyma to hepatic avulsion or a severe injury of the hepatic veins. (( التمزيقالكبدي

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Because liver tissue is very friable and the liver’s blood supply and storage capacity areextensive, a patient with liver injuries can hemorrhage profusely and may need surgery to control the bleeding.

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Liver injury

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LIVER INJURYLIVER INJURY

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PANCERAS INJURYPANCERAS INJURY

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The most common kidney injury is a contusion from blunt trauma; suspect this type of injury if your patient has fractures of the posterior ribs or lumbar vertebrae.

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KIDNEY & BLADDERKIDNEY & BLADDER

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Other renal injuries include lacerationsor contusion of the renalparenchyma caused by shearingand compression forces; the deepera laceration, the more serious the bleeding.

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Deceleration forces may damage the renal artery; collateral circulation in that area is limited, so any ischemia is serious and maytrigger acute tubular necrosis.

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Hollow organ injuries, which can occur with blunt or penetrating trauma, most commonlyinvolve the small bowel. Decelerationwith shearing may tear the small bowel, generally in relatively fixed or looped areas

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Blunt forces cause most bladder injuries. The bladder rises into the abdominal cavity when full, so it’s more susceptible to injury. If a distended bladder ruptures or is perforated, urine is likely to escape into the abdomen.

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If the bladder isn’t full when ruptured, urine may leak into the surrounding pelvictissues, vulva, or scrotum.

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Genitourinary tract - Perinephric hematomas should be entered only after vascular control has been obtained. Repair of many renal injuries (including partial nephrectomy) is now possible. When nephrectomy is required, it is reassuring to know that the

contra lateral kidney is functioning..04/18/2304/18/23 4040

DIAPHRAGMDIAPHRAGM

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Diaphragmatic injuries are notoriously difficult to diagnose. Small diaphragmatic injuries on the right side may heal without incident, and the liver protects against potential hernias. Small injuries on the left side may result in symptomatic diaphragmatic hernias. Acute diaphragmatic defects are best approached through the diaphragm. 04/18/2304/18/23 4242

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Colon/Rectum - In contrast to military teaching, an increasing number of surgeons utilize primary repair for simple colon injuries without associated shock or significant fecal soilage. Even a small missed colon injury may be lethal

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NURSING CARENURSING CARE

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As always, your primary priorities are to maintain the patient’s airway, breathing, and circulation. Next, perform a rapid neurologic examination and assess him head to toeto identify obvious injuries and signs of prolonged exposure to heat or cold.

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Ask the patient (or his family, emergency personnel, or bystanders) about his history—allergies, medications, preexisting medical conditions, when he last ate, and events immediately preceding or related to hisinjury.

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If your patient sustained blunt trauma, as in a motor vehicle crash (MVC), keep his neck and spine immobilized until X-rays rule out a spinal injury. If his viscera are protruding,cover them with a sterile dressing moistened with 0.9% sodium chloride solution to prevent drying.

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The following interventionsare routine for a patientwith abdominal trauma:

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•Insert two large-bore intravenous(I.V.) lines to infuse 0.9% sodiumchloride or lactated Ringer’s solution,according to facility protocol.

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• Control the patient’s pain without sedating him, so you can continue to assess his injuries and ask him questions. Generally, I.V. analgesics such as morphine can adequately manage pain without sedation.

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Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. For example, bloody urine or a prostate glandfound to be in a high position duringa rectal exam could indicate damage to the urinary tract

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If the patient is to have a rectal examination, delay catheter insertion untilafterward

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• Draw blood specimens stat for baseline lab values.

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• Insert a gastric tube to decompress the patient’s stomach, prevent aspiration, and minimize leakage of gastric contents and contamination of the abdominal cavity. Thisalso gives you access to gastric contents to test for blood

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Administer tetanus prophylaxis and antibiotics as ordered.

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The FAST option Focused abdominal sonography for trauma (FAST) offers 98% to 100% specificity in blunt abdominal trauma, and is accurate 98% of the time. FAST is especially helpful for pregnant patients or those bleeding from multiple injuries. It’s also useful in identifying pericardialfluid in penetrating trauma.

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FAST can demonstrate the presenceor absence of pericardial fluid, abdominalfluid, and some parenchymal injuries via a 2- to 3-minute exam. A hand-held transducer is positioned on four key areas to evaluatefluid collection.

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Unstable patients with penetratingabdominal trauma, such as gunshotwounds, stab wounds, or otherimpalements, usually proceed directlyto the operating department withoutDPL or FAST.

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Thanks for good listening