ABDOMINAL &GENITOURINARY TRAUMA

Peritoneum
Smooth, serous membranes that provides cover to abdominal structures
Solid organs

 Liver:-largest organ in the abdomen

 Located in the right upper quadrant
 Extremely vascular- circulation is through the hepatic artery and portal vein
and represents about 30% of cardiac output
 Releases bile that aids in the emulsification and absorption of fatty acids
 Stores up to 500ml of blood at any given time
 The size and anterior location of the liver makes it an easy target for blunt and
penetrating forces
 One of the most commonly injured organs
25% of circulating blood is in the liver
Mortality for liver injury -10%

Spleen: large vascular organ located in the left upper quadrant

 Important in the body’s immune function for its clearance of bacteria

 It stores and filters up to 200ml of blood
 Splenic 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
 The most serious types of injury are a severely fractured spleen or vascular tear
that causes splenic ischemia and massive blood loss
 The manifestations of major hemorrhage, including hemorrhagic shock,
abdominal pain, and distention, are usually clinically obvious
 Lesser hemorrhage causes left upper quadrant abdominal pain, which
sometimes radiates to the left shoulder(Kher’s sighn)

Gallbladder: saclike organ located on the lower surface of the liver that acts as a
reservoir for bile

 Gallbladder injuries following trauma are rare and are associated with other
abdominal injuries
Kidneys:-retroperitoneal organs

 Lie on the level of 12 thoracic vertebra to the third lumbar vertebra

 Posterior to the stomach, spleen colonic flexure and small bowel
 Enclosed in a capsule of fatty tissue and a layer of renal fascia
 They filter blood and excrete body wastes in the form of urine
 Renal injuries:

 Occur in up to 10% of all abdominal trauma

 80% of all GU injuries
 Majority of renal injuries are due to blunt trauma
Assessment :

 Abdominal pain and tenderness over the kidneys (denoting significant force
transfer)
 there may be a large flank ecchymosis, palpable mass or hematoma
 Sometimes injuries may be significant with no physical findings
 urinalysis, complete blood count and chemistry panel to assess for hematuria,
baseline hematocrit and renal function
 Ct scan can also reveal other abdominal injuries
 Penetrating injuries result in higher renal loss, evidence obvious on inspection
 Gunshot trajectories can have entry points not involving the flank and still
involve the kidney: urologist and trauma surgeon

The pancreas:- located behind the stomach along the posterior wall in the
retroperitoneum

 Produces insulin, glucagon, somatostatin, which are involved in carbohydrate

metabolism
 Produces enzymes, electrolytes and bicarbonate to assist in the digestion and
absorption of nutrients.
 The pancreas:- Protected by the liver and stomach
 Most injuries are due to penetrating trauma
Assess for:
Epigastric or back pain
Cullen’s sign: (bluish discoloration around the umbilicus sometimes occurring in
intraperitoneal hemorrhage) discoloration is seen in acute hemorrhagic pancreatitis
Investigation

 Serum amylase levels ( unrealiable- 40% NORMAL levels)

 Assay of pancreatic fraction
 Surgery must make every effort to preserve pancreatic function due to exocrine
and endocrine functions
 Note : patient with pancreatic injuries usually has other injuries associated
with hemorrhage being the major cause of death

Hollow organs
The stomach:- located in the LUQ between the liver and the spleen at level of the 7th
and 9th ribs

 Entry controlled by cardiac sphincter

 Exit controlled by pyloric sphincter
 Stores food
 Secretes acidic gastric secretions , mixes with food and propels mixture into
duodenum
 Can be easily displaced: rarely injured with blunt trauma
 Gastric and esophageal injuries occur more with multi-organ and multisystem
injuries and are most commonly associated with penetrating trauma because
of their size and anterior location

Signs and symptoms

 LUQ pain and tenderness
 Diagnosis is based on patient assessment , aspiration of blood via gastric tube
 Free air in abdominal radiograph
 All patients with gastric injuries require surgical exploration
Small bowels: connects to pyloric sphincter and fills most of the abdominal cavity

 Has three sections duodenum, jejunum and ileum

 Releases enzymes that aids in digestion and absorption
Large bowel: connects with the ileum proximally and ends distally at the rectum
Consists of the ascending colon, transverse colon descending colon and sigmoid colon

 Absorbs water and nutrients and store fecal matter until it can be eliminated
 The anterior location and lack of protection make intestines them vulnerable to
blunt and penetrating injuries
 Examine back
 penetrating trauma can eviscerate the bowel or omentum
 Establish IV access and prepare for surgery
 Must be covered with sterile saline soaked pads
 Then covered with occlusive dressing
 Can occur when seatbelts are inappropriately worn
 Rupture can cause bacterial and chemical spillage into the peritoneum
Assess for:

 Tenderness and rigidity

 Later: fever elevated WBC, abdominal distension, hypoactive bowel sounds

Urinary bladder:-extraperitoneal organ that stores urine

 pelvic cavity-When empty
 Abdomen :-when full
Large blood supply from branches of the iliac artery
Urethra: female-short/ male 20cm long mostly outside the body

 Bladder injuries vary by the severity of the mechanism of injury and the
degree of bladder distension at the time of the injury event
 The fuller the bladder the greater the opportunity for injury
 Associated with pelvic injuries which perforate the bladder
 Signs and symptoms are non -specific but may present as:
 Gross hematuria, supra pubic pain and tenderness, difficulty voiding, bruising
and ecchymosis around the bladder/thigh and abdominal distension, guarding
or rebound tenderness
Exploratory lap, layered closure
Antibiotic to prevent long term complications such as strictures, fistulas, infections
and delayed healing

Reproductive organs:
 Female: contains the uterus
 The non pregnant uterus is in the pelvis
 the gravid uterus lies in the lower abdomen
 Male: contains the penis and testis
Urethral injuries

 Most urethral injuries occur as a result of blunt trauma and occur mostly in
men because the male urethra is longer and found mostly outside the body-
female urethra shorter and more protected
 Injury are usually high impact or straddle mechanism and should be
considered with any pelvic fracture
 Evaluate for blood at the urethral meatus( a contraindication for insertion of
urinary catheter) a high riding prostate or pain and swelling ecchymosis in the
penis or perineum
 Minor injuries can be managed with the passage of a catheter
 Most injuries require suprapubic cystostomy and delayed repair of the urethral
injury

Penile injuries
 Penile injuries usually occur during vigorous sexual intercourse where the
penis is misdirected or may be self inflicted
 On physical examination the penis is swollen and ecchymotic
 The fracture line in the tunica is often palpable

Testicular injuries
 The testicles may be injured by direct blow, MVA’s or sports related activities.
Findings include significant pain, swelling and ecchymosis in the scrotal area.
  Ice and adequate analgesia should be used while obtaining urologic
consultation
Vascular structures:

 Abdominal aorta: lies left of the midline and bifurcates into the iliac arteries
which supply blood to the lower extremities
 The inferior vena carva is the major vein in the abdomen
 Blood vessels can be injured by blunt or penetrating mechanisms- injury of the
major abdominal vessels occurs in 5% to 10% of patients with blunt abdominal
trauma.
 Disruption of vascular structures causes severe hemorrhage and death if
damage is not repaired.
 Hemorrhage shock for intra-abdominal hemorrhage often leads to metabolic
acidosis accompanied by coagulopathy and hypothermia- often referred to as
the lethal triad of trauma
 Identification of injuries is often made in surgery particularly in an unstable
patient
 Emergency management includes establishing IV access and providing rapid
transport to the surgery

PATIENT ASSESSMENT

 HISTORY
 MECHANISM OF INJURY
 INSPECTION
 PERCUSSION
 AUSCULTAION
 PALPATION
HISTORY

 History and the mechanism of injury will reveal if the abdominal injury was an
accidental or forcibly inflicted
 A rapid scan of the patient will help you identify and manage life threats
 Determine the priority of care based on the general impression and the MOI
 Assess the patient's level of consciousness using the AVPU scale

 If the patient is able to communicate, obtain the chief complaint, the type of
injury that occurred, and when it occurred. Closed abdominal injuries may be
more severe than they appear
 Symptoms vary with the degree of injury and the organs damaged
 Penetrating trauma :penetration into the peritoneum cavity by moving foreign
bodies
 stab wounds
  gunshot wounds
Commonly injured : intestines, liver, and spleen( no bony protection)

 Patient is at risk for:

 hemorrhage and hypovolemic shock
 The loss of all or part of the function of organs
 sympathetic stress response
 Bacterial Contamination
 cell death

Blunt injuries
 no break in the skin
 often occur as multiple injuries
 spleen and liver are the most commonly injured organs
 Injury due to compression, concussive forces and deceleration forces.
 motor vehicle accidents, fights, falls from heights, and sports accidents.
 can cause tears and hematomas to the solid organs such as the liver and spleen
Seat belts

 Seatbelts have prevented many injuries and saved many lives.

 They occasionally cause blunt injuries of the abdominal organs.
 Seatbelts can squeeze abdominal organs or great vessels against the spine
when the car decelerates or stops.
 Any MVA victim who has ecchymosis in the imprint of a seat belt on his
abdomen should be evaluated for abdominal injuries
 Mesenteric hematoma, de-vascularization of the bowel, severe damage leading
to rupture of the bowel wall, bruising, and hemorrhage of the abdominal wall
that follows the belt pattern are the most common injury
 Signs and symptoms of seat belt injury usually develop slowly and may be
overshadowed by other injuries.
 Can cause bladder injuries to pregnant patients who adjust the lap belt for
comfort
 Air bags are a great advance in automotive safety
 Can be a lifesaver in head-on collisions
 Must be used in combination with safety belts
 Children or small adults may be at risk of injury if an air bag deploys on them.
Inspection

 pinpoints the type of abdominal injury and helps determine its severity
 reveals bruises, abrasions, contusions and, possibly, distention
 Depending on the severity of the injury, the patient may be pale, cyanotic, or
dyspneic.
  reveals the type of wound and associated blood loss e.g. Gunshots usually
produce both entrance and exit wounds, with variable blood loss, pain, and
tenderness
 Ecchymosis involving the flanks or the umbilicus : Indicates retroperitoneal
hemorrhage, but is usually delayed for several hours to days
Auscultation

 may disclose tachycardia, decreased breath sounds, absent or decreased bowel

sounds, or bowel sounds in the chest
 Auscultate all four abdominal quadrants to determine the presence of bowel
sounds
 Although the absence of bowel sounds can indicate underlying bleeding, their
absence does not always indicate injury
 Auscultation of bowel sounds in the thorax: May indicate a diaphragmatic
injury
 Abdominal bruit: May indicate underlying vascular disease or traumatic
arteriovenous fistula
Percussion

 Normally percussion elicits dull sounds over solid organs and fluid-filled
structures (such as a full bladder) and tympany over air-filled areas (such as
the stomach).
 Pain with light percussion suggests peritoneal inflammation.
 Fixed dullness in the left flank and shifting dullness in the right flank while the
patient is lying on his left side (Ballance's sign) signal blood around the spleen
or spleen injury.
 Dullness over regions that normally contain gas may indicate accumulated
blood or fluid.
 Loss of dullness over solid organs indicates the presence of "free air," which
signals bowel perforation.
Palpation

 Painful areas should be palpated last

 Palpation should follow one quadrant at a time while monitoring the patient for
involuntary guarding, splinting, tenderness, rigidity, spasm, and localized pain
 Local or generalized tenderness, guarding, rigidity, or rebound tenderness:
Suggests peritoneal injury
 Fullness and doughy consistency on palpation: May indicate intra-abdominal
hemorrhage
 Crepitation or instability of the lower thoracic cage: Indicates the potential for
splenic or hepatic injuries
 Signs and symptoms might not be present when there is competing pain from
another injury, a retroperitoneal hematoma, spinal cord injury, or decreased
level of consciousness or if he's under the influence of drugs or alcohol
Initial Stabilization
Initial stabilization: the patient with abdominal or genitourinary trauma follows the
same sequence as for any patient with major trauma:
securing airway, breathing and circulation

IV access via two large bore IV catheters for administration of crystalloids, blood
products and medications
Baseline lab results

 Urinalysis detects blood as a sign of urinary tract injury

 A urine toxicology screen is routine to check for substances that could mask or
mimic an injury
 A baseline complete blood cell count can help identify injury sites, the extent of
injuries, and complications. For example, an elevation in white blood cells may
indicate a ruptured spleen
 An increase in immature neutrophils may signal acute infection
 Even when the patient is bleeding, his initial hemoglobin and hematocrit results
may be normal due to volume loss and hemoconcentration. Once fluid
resuscitation is under way, hemoglobin and hematocrit values can decrease
significantly, so monitor serial measurements
 Pregnancy test for women of childbearing age
 Arterial blood gas analysis can reveal abnormalities such as metabolic acidosis
 Prothrombin time, international normalized ratio, and activated partial
thromboplastin time screen for coagulopathy
 Electrolyte, blood urea nitrogen, and creatinine levels screen for underlying
renal problems and provide a baseline
 A type and crossmatch may be needed for blood replacement
 Serum amylase and lipase levels, when persistently elevated, may indicate
injury to the pancreas or bowel
Medications
Analgesia: pain relief is appropriate for most injuries
Fentanyl/ morphine sulfate
Antibiotics:

Anaerobes and coliforms are the predominant organisms found in cases of intestinal
perforation. Antibiotrics active against these organisms should be given to decrease
the incidence of intra- abdominal sepsis
Urinary catheter:

A urinary catheter must be inserted to monitor urine output in all patients with major
trauma
If there is a suspicion of urethra as evidenced by the blood in the urethral meatus,
penile or perineal hematomas , a displaced prostate or a severe anterior pelvic
fracture, a retrograde urethrogram should be preformed before a urinary catheter is
inserted
Gastric decompression

 Early gastric decompression with a gastric tube is particularly important when

there is a possibility of intra-abdominal visceral damage or when the patient
may have eaten or drunk recently
 Assume that the stomachs of all trauma patients are full
 The gastric tube may also be useful in the diagnosing and revealing injuries of
the upper GI tract
 oral insertion of the tube is recommended for patients with head injury
 Patients resuscitated with bag mask device may also benefit from tube
placement to remove forced air from the stomach
 Air in the stomach increases the possibility of vomiting and aspiration
can displace the diaphragm upwards increasing the resistance to ventilation
Wound care
Penetrating wounds should be covered with sterile dressings
If abdominal organs extrude through the abdominal wall and are exposed to the
environment:-
Keep extruded organs moist at all times with sterile saline-soaked dressings

Never attempt to push the eviscerated organs back into the peritoneal cavity – this
may cause further injuries

Diagnostic Evaluation
Is based on the patient’s hemodynamic stability

If the patient becomes unstable secondary to intra peritoneal injury, transfusion with
fluids and blood must be initiated and the patient prep for surgery
If the patient’s condition allows it major diagnostic tools may be used.
These include:

 Radiology
 CT
 Focused assessment sonography for trauma (FAST)
 Magnetic resonance imaging (MRI)
 Diagnostic peritoneal lavage
 Laparoscopy
 Cystography
 Anteriography ( renal artery injury)
summary
 Abdominal trauma is very common but often missed because other injuries
distract attention from the abdomen
 The delay in the development of signs and symptoms further confounds the
ability to identify problems
 The majority of injuries occur in young people whose compensatory
mechanisms are high
 In order to evaluate abdominal injuries ultrasound as well as imaging studies
may be necessary
 All penetrating injuries will require laparotomy because of the high chance that
they may have caused internal injuries
 Blunt injuries are harder to recognize and require a higher level of suspicion
based on The MOI.
 An understanding of anatomy and pathophysiology as a basis for signs and
symptoms will contribute significantly to the effective management of the
patient with abdominal and GU trauma