Bleeding remains the leading cause of preventable traumatic death. With all the vascular structures contained in the abdomen, identification of internal bleeding is imperative for proper treatment.
- Mechanism of injury / Clinical history
- Identify bleeding
- Cullen Sign
- Grey-Turner Sign
- Kehr’s Sign
- Concurrent Injuries
- Hollow or Solid Organ injury (tear vs rupture)
- Small Bowel
- Large Bowel
- Reproductive Organs
- Attempt to identify what is bleeding
- Visable signs
- Previously mentioned signs (Cullen, Grey-Turner, Kehr)
- Abdominal Distention
- Seatbelt Sign
- Guarding (intentional or involuntary)
- Referred Pain
- Blood at the Urinary Meatus
- FAST exam
- Visable signs
- For all suspected abdominal trauma
- Anticipate blood transfsuions
- Hemodynamic monotoring
- NO FOLEY!
- Specific Organ injuries
- Non-op if stable
- High grade injuries – monitor, serial abd exams
- Hemodynamicaly unstable – OR
- Trend towards non-op mamagement
- Serial abd exams and H&H
- Low grade injuries
- OR for those who have concurrent injuries or severe splenic injuries
- Post-op consideration
- Trend towards non-op mamagement
- Rarely injured by itself
- Usually result of being squished
- Trend towards non-op management
- Bowel rest
- Serial CT’s
- Monitor for S&S of infection
- Suspicion of injury with MOI
- 90% non surgical
- Nephro consult
- Anatomy & Physiology
- Know the organs in the abdominal cavity
- The increased vasculature contained in the abdomen adds to the concern for life threatening hemmorhage
- Fluid & Electrolyte Balance
- With the loss and replacement of blood products, the fluid and electrolyte shift can be severe. Make sure we monitor the levels.
- Blunt abdominal injuries are very common in teenage contact sports. Be aware of signs of internal injuries.
- Always wear seatbelts!
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Greetings everyone and welcome to today’s lesson about Blunt Abdominal Trauma. So let’s get started.
So this is so true. There are so many different organs in the abdomen and given enough force, any one of them can pop, or perforate. We need to know where everything is located in order to help us figure out all the possible injuries.
As always, we want to try to get a good history, specifically focusing on the mechanism of injury.
Once we have that information we can focus on the damage. We want to keep the type of organ in mind. Is it a solid organ, like the liver or spleen, or is it hollow like the stomach or intestines. How the blunt force impacted the abdomen will have an effect on the severity of damage and which organ is injured will help to determine the severity of blood loss.
When assessing blunt abdominal trauma, we perform our usual ABCs. As with any abdominal assessment, we inspect, auscultate, percuss and palpate…in that order. Don’t start mashing on our guys belly and then listening for the result.
With our abdominal injuries, there are some specific signs to be aware of. Cullen sign is bruising around the umbilicus and is indicative of an intraperitoneal hemorrhage. It can also lead us to injuries of the pancreas or in females, the fallopian tubes.
Grey-Turner sign is bruising to the flanks and is a sign of retroperitoneal bleeding.
And Kehr’s sign is pain to the tip of the shoulder. When it comes to abdominal trauma, pain in the left shoulder is usually a sign of a ruptured spleen,. I know it seems weird to have an injury so low causing pain so high but it is due to the irritation of the diaphragm and the phrenic nerve which causes that shoulder pain.
Of course, with our bleeding concerns, we want to watch for hypotension and use our radiology resources to check for free fluid in the abdomen. The FAST exam, or focused assessment with Sonography in Trauma is a great tool for quickly determining if there is blood in the belly.
I want to also mention here the use of DPL or diagnostic peritoneal lavage. This is a procedure that is done in the ED where an incision is made in the abdomen and a catheter inserted to see what comes out. If nothing comes right out, then saline is infused and then drained to see what comes out. They are looking to see if any, and how much fluid is in the belly. This procedure is done less and less as the FAST exam has taken its place and has been found to be an equal of not better diagnostic tool.
We want to get an idea of how bad our patient is bleeding. We can use our eyes and look for abdominal distention, the signs we just talked about on the last slide, and checking for a seatbelt sign. Seatbelt sign is a reddened mark across the abdomen that is due to the force of the seatbelt keeping our patient in place.
We talked about referred pain but we want to assess all pain. What quadrant is he having pain. Is it in the front or back. Is it dull, or sharp, or god forbid…tearing. A conscious patient is a fountain of information if we just ask the right questions.
Blood at the urinary meatus is bad. It is a usually a sign of a bladder injury, or an injury to the urinary tract. Either way…do not try to insert a foley into these patients.
In these cases, if we suspect the bleeding that we do, we are going to call for a massive transfusion protocol. The name at your facility may be different but it is the code for whatever gets you a lot of blood to the bedside for infusion very quickly.
As we are giving all this blood, we need to keep an eye on our guys hemodynamic status. He stays on monitor and we continue to trend the BP and the pulse and look for those changes that indicate that things are going south.
We want to always stay alert for signs of an acute abdomen. This is basically sudden severe pain and discomfort to really any part of the abdomen and sometimes the pain is diffuse and hard to localize. It’s usually due to peritoneal irritation and indicates severe bleeding or some sort of perforation. If the patient is showing signs like this, it’s most likely they need some soft of surgical intervention.
And like i said on the last slide….if we suspect those bladder or urinary tract injuries….No Foleys.
When it comes to liver injuries, they are graded 1-5. 1 is the most minor, like small laceration that requires no interventions. 5 is bad….like the liver has exploded. Very very bad. Instant OR for these guys.
If they have those low-grade injuries, like 1-3, we are probably going to admit and monitor. Some abdominal exams, maybe some blood work.
If they are hemodynamically unstable, if we think they are bleeding out… It’s time for the OR and someone needs to pack the liver. These are those high grade liver lacerations. We all know how we stop external bleeding, right. Direct pressure. It’s the same for the liver…packing the liver is basically putting pressure on these large lacerations until the surgeon can sow them closed.
The current trend with splenic injuries is monitoring. Abdominal exams, blood work for hemoglobin and hematocrit will guide their treatment or discharge.
If they have a severe splenic rupture or if there are concurrent injuries, they are most likely going to require surgery.
So…because the spleen plays a big role in fighting infection in the body, if we take it out..the risk for severe life threatening infection is always present. Because of this, itis of vital importance that these patients get certain vaccines. Pneumovax, Flu Vaccine and meningitis vaccine are three that should be given on a proper schedule and should not be missed. Patient education is really important for these patients.
We all know the pancreas is pretty small, right. Well we have to figure, if the pancreas is injured, something else is going to be injured too.
The pancreas usually gets injured after its been squished. This could be from car accidents, sports injuries, anything that can cause severe compression to the abdomen.
As with most non-lethal injuries, the trend here is for non-operative management. Rest the bowel, meaning don’t give oral foods or fluids, run serial CT scans and keep an eye out for signs and symptoms of infection.
When we think of the kidneys, we want to think of the mechanism. Just think if someone was hit in the flank with a bat, or tackled from the side in a football game and took a shoulder pad to the back. All of these could lead to a severe kidney injury.
Most kidney injuries, thankfully, are non surgical. If we suspect a more severe injury, or were unsure of a course of action, we can call in a nephrology consult and get the expert opinion.
A bowel perforation is a hole, somewhere in the bowel. In blunt trauma, it’s usually the result of compression of the air within the hollow intestine, causing a pop along some part. The problem here is that with that bowel torn open, stuff is going to leak. As those digestive contents invade the abdominal cavity, they begin to irritate the peritoneum and result in a condition called peritonitis. One of the common signs of which is severe and diffuse tenderness of the abdomen.
There is not much we can do in the ED for these patients except minimize their pain, do our best to keep them hemodynamically stable, and get them ready for the OR.
Abdominal compart syndrome is a massive buildup of fuid in the abdomen. It is usually associated with blunt abdominal trauma. If you think about it, our skin is pretty tough. If we have enough fluid building in the abdomen, there is only so many places it can go, and it’s not really gonna burst through the skin, although we have all zee movies like that.
Because of this, as that fluid builds, it literally starts to crush the internal organs. The bowel, kidneys, liver, all of the abdominal organs can be affected and the systemic result is lethal.
We need to open these patients up. The definitive treatment is to do a laparotomy in the OR and evacuate all of that fluid, and of course finding the source of the bleeding and stopping it.
Like we have said in all our trauma lessons, its imperative that you know your anatomy in order to anticipate how many injuries can result from the specific trauma.
Bleeding and clotting become serious concerns, especially when the liver is involved.
And with the possibilities for severe hemorrhage as well as the perforation of abdominal organs, the alterations in fluid and electrolyte balance can be lethal.
We talked about solid and hollow organs. Try to think… are they bleeding, are they leaking, are they both? For the ones that bleed…they bleed a lot. Lets get that blood back into our patients and quickly.
Keep an eye out for those specific abdominal signs, Cullen, Grey-Turner, and Kehr.
We always want to use what we have, our eyes, our ears..i will however say please don’t use your sense of taste, your patient and I will thank you.
With so many organs in the abdomen, keep thinking about all the other things that can be injured besides the obvious injuries.
Once again, thank you for joining me for this lesson and as always