Flashcards in Abdominal Trauma Deck (70):
Right Upper Quadrant Structures
Ascending and transverse colon
Left Upper Quadrant Structures
Left lobe of the liver
Left colonic flexure
Left Lower Quadrant Structures
Portion of descending colon
Portion of duodenum
Right Lower Quadrant Structures
Portion of ascending colon
Posterior to the "true abdomen". Contains aorta, inferior vena cava, pancreas, kidneys, ureters, ascending and descending colon and duodenum.
Types of Solid Organs
Liver, Spleen, Kidneys, and Pancreas
Types of Hollow Organs
Gallbladder, Stomach, Small intestine, Large intestine, Bladder
abdominal aorta, common iliac arteries, femoral arteries, renal arteries, portal vein, inferior vena cava
Contraindications to NG placement
nasal, midface or cribiform plate fracture
Contraindications to Foley placement
blood at urinary meatus, high riding prostate, perineal hematoma, concurrent pelvic injury or fracture
Inspection of abdomen includes
Observe for gross abnormalities, Contour, Symmetry, Visible Pulsations, Skin color/discolorations, back and flank, pelvic or perineal bleeding/drainage, general respiratory rate, pattern and depth; change in respiratory effort.
Rounded, flat, scaphoid, distended or pregnant if distended think of 6Fs.
Fluid, Fat, Flatus, Feces, Fetus, Fibroid.
Decreased and absent bowl sounds general indicate......
peritoneal irritation from enteric contents, bile, pancreatic juice, or intraperitoneal blood. May also cause ileus.
hyperactive bowel sounds
Bowel sounds in the chest
Vascular sounds in the abdomen
A bruit can be noted if artery is partially occluded
(Dull vs Tympanic)
Dull: Organ margins, accumulation of free fluid
Tympanic: Air, gas
shifting of dullness over LUQ when patient lies on left side; suggestive of splenic rupture.
Pulsatile/Palpable masses are emergent if found were?
Slightly left of umbilicus
Other tests for rebound tenderness
Cough tenderness, percussion, heel drop test,
Heel drop test AKA...
What is heel drop test
Have pt stand on their toes and drop their heels. If this aggravates the pain, consider it positive. Same test on a supine patient. Gently pick up the leg and tap the heel. If pt winces, suspect peritoneal inflammation
Prostate location can indicate...
presence of urethral tear
Peritoneal irritation signs
board-like abdomen described as increased rigidity of the abdominal wall or palpable rigidity.
Diminished or absent bowel sounds
Sever focal pain, rebound tenderness
Referred pain in the left shoulder suggest peritoneal or diaphragmatic irritation; usually noted with splenic rupture.
Bluish discoloration around the umbilicus suggests intra or retroperitoneal hemorrhage
Discoloration of the lower abdomen and flanks is believed to believed to be due to the infiltration of etraperitoneal tissues with blood. Seen in acute hemorrhagic pancreatitis or renal trauma.
On KUB, Loss of Psoas shadow suggests...
IDs BOTH intraperitoneal and retroperitoneal injuries. Both qualitative and quantitative (Id of injured organ as well as blood loss), can be repeated as often as necessary, not complicated by peritoneal irritation, not limited by intestinal gas, can assess vascular integrity with contrast
Need for contrast, potential for allergy, need for adequate hydration for tenal perfusion, need to move pt to radiology, time, cost. May miss GI injuries, diaphragm, and pancreatic injuries.
Diagnostic peritoneal lavage (DPL) Advantages
Rapid and simple, Accurate (highly sensitive for bleeding 98%), inexpensive, patient doesn't need to leave the unit
Diagnostic Peritoneal Lavage (DPL) Disadvantages
Invasive, Low specificity (cannot quantify hematomas or judge amount or location of bleeding)
Nursing Implications of DPL
ABCs take priority, Place gastric tube and urinary prior to insertion unless contraindicated. Get films prior to testing as free air can be introduced
Absolute indications for exploratory laparotomy
Persistent and/or recurring shock w/o an identifiable source (suspect abdominal injury), evisceration, peritonitis, frank blood per gastric rube or rectum, frank blood per gastric tube or rectum, free air or retroperitoneal air on XR, retained stabbing implement, positive ancillary tests, suspected diaphragmatic rupture, intraperitoneal bladder rupture, free fluid on CT scan without evidence of solid organ injury. S
Resuscitative Endovascular Balloon Occlusion of the Aorta.
Aortic occlusion temporarily controls distal bleeding until permanent hemostasis is provided. Used to increase SBP and augment perfusion to heart and brain.
P:What provokes or palliates the pain
Q: Quality of the pai
R: Region, radiation, recurrence
S: severity 0-10
T:Time- onset and duration
Classification of Liver Hematoma ( I - IV)
Grade I (subcapsular) to Grade IV (ruptured central hematoma)
Classification of Liver Laceration ( I - IV)
Grade I (capsular tear, nonbleeding) to Grade IV (parenchymal destruction of 25% - 75% of hepatic lobe)
Grade V Liver
Laceration: >75% of hepatic love destruction
Vascular: juxtahepatic venous injuries
Grade VI Liver
Clinical Presentation of Liver injuries
peritoneal irritation, RUQ guarding w/ radiation to right shoulder, right diaphragm elevation, lower right rib fx, volume deficit and shock, decreased HCT increased WBC, frequently associated with brain trauma.
Indications for laparotomy
Hemodynamically unstable patients who have sustained blunt abdominal trauma or who have diffuse peritonitis or evidence of ongoing hemorrhage should be taken urgently for a laparotomy
What is the most commonly injures organ in blunt abdominal trauma?
Classification of Spleen Hematoma (I - IV)
Grade I: subscapsular, nonexplandind; Grade IV: Ruptured, intraperitoneal bleeding
Classification of Spleen Laceration (I-IV)
Grade I: Noncapsular tear, nonbleeding; Grade IV: Segmental or hilar vessel that produces major devascularization.
Grade V Spleen Injury
Laceration: Completely shattered spleen
Vascular: Hilar vascular injury that devascularizes spleen
Management of blunt Splenic injuries
Non-operative management is indicated in 85% of pt with blunt splenic injuries. A routine laparotomy is not indicated in patient who have an isolated splenic injury and are hemodynamically stable and do not have peritonitis.
High risk patients for failure of non-operative management include...
patients with a vascular blush or pseudoaneurysm on CT scan.
Pts with non-surgical management should be educated for the possibility of?
delayed splenic rupture when discharged home.
Overwhelming Post-Splenectomy Sepsis
Greatest risk for this condition occurs within the first 2 years post splenectomy. Mortality is high unless early identification and aggressive treatment occurs.
Early goal directed therapy for sepsis is recommended along with administration of vancoymcin and ceftriaxone
Prevention of OPSS
Post-splenectomy patients are immunized with pneumococcal, meningococcal, and hemophilus influenza vaccines.
Additionally, the pt/family should be taught s/s of OPSS and a medic-alert bracelet should be worn
What organ is most injured in penetrating trauma
Rapid deceleration increases injury of what organ and why?
Pancreas because first portion if fixed in the peritoneum, anchor to posterior wall and small portion of the stomach. Rapid deceleration results in rupture between free and anchored portions.
direct blow to abdomen
fixed at one end; easily town in high speed deceleration. may crush against vertebrae causing sever contusion and laceration.
Management of colon/rectal trauma
Early use of antibiotics is essential!
Seen in less than 5% of trauma. Increases with age. Risk is increased in lateral impact. Left side is more commonly injured.
A rasping sound, synchronous with the heartbeat, occurring in pneumomediastinum. Associated with esophageal injuries
Most frequent truncal vascular injuries are...
injuries to the inferior vena cava
Clinical presentation of Vascular injuries
Pt may arrive alert with normal BP and HCT and crash.
Management of Vascular injuries
Rapid infusion of warmed blood products and crystalloids, avoidance of hypothermia, abdominal exploration: initial tamponade using manual compression and lap packs with hepatic inflow occlusion
refers to an abbreviated laparotomy to save trauma patients who have sustained abdominal vascular injury, massive shock, hypothermia, and acidosis. Has 3 phases
3 Phases of Damage Control
1: Resuscitative surgery for rapid control of hemorrhage
2: Transfer to ICU
3: re-exploration is done to provide definitive management
Abdominal compartment syndrome is....
Pressure is >20mmHg
Massive fluid resuscitation can lead to increased intra-abdominal pressure.
Open abdomen is mandated if
pulmonary deterioration on closure of abdomen, hemodynamic instability with closure of abdomen, massive bowel edema, selectively tight closure, planned reoperation or intra-abdominal packing
Leaving Abdomen open is discretionary if:
fecal contamination or peritonitis is present, massive transfusion has occurred, the pt is hypovolemic, had multiple intra-abdominal injuries, persistent acidosis, or coagulopathy
clinical indicators that should lead to suspicion of ACS
reduction in gastic pH, increased bladder pressure, persistent or worsening acidosis without other causes, increase in O2 requirements, increased airway pressures, reduced cardiac output, persistent or worsening oliguria.
Possible complication if ACS foes unrecognized
renal failure, abdominal wall ischemia/edema, respiratory failure, intracranial hypertension, intestinal hepatic ischemia
18-22mmHg is considered elevated