Abdominal Trauma for the EMT

Abdominal trauma is extremely common and its basic management follows the principles of the ABCs and basic wound care. There are two special situations involving the abdomen that will be discussed in this section, eviscerations and impaled objects. This section will also review the basic anatomy of the abdomen and the concept of "abdominal quadrants." The next section will address the types of abdominal trauma: open abdominal trauma and closed abdominal trauma. 

 

Before we get into the trauma, let's look at the abdominal area and what it encompasses.

Anatomical Areas

A basic understanding of anatomy is important to target and inform the remainder of your assessment and assist you in identified co-dominant injuries. The abdomen is divided into quadrants with the belly button (umbilicus) being the center. They are named the upper right, upper left, lower right, and lower left quadrants.

UPPER QUADRANTS: Injury to the upper quadrants can result in damage to the

• diaphragm,
• liver,
• spleen, and
• stomach.

This can result in significant blood loss extremely quickly, and/or may compromise the patient's ability to breathe in the case of diaphragm injury.

LOWER QUADRANTS: Mostly occupied by the

• intestines,
• ovaries, and
• blood vessels.

These injuries can still be serious but are usually less so than injuries to the upper quadrants.

Types of Abdominal Trauma

Abdominal trauma is one of the most common complaints that lead to serious EMS activations. There are many organs, blood vessels, and spaces in the abdomen that can all be injured, leak blood, and hide large amounts of hemorrhage. This section will divide abdominal trauma into closed trauma (which often is from blunt impacts) and open trauma (which often follows violent attacks).

Closed Abdominal Trauma

MECHANISMS OF INJURY that frequently lead to closed abdominal injuries are motor vehicle accidents, assaults, and falls from significant heights. 

SIGNS AND SYMPTOMS of closed abdominal injury include pain, discoloration of the skin, and distention of the abdomen which may or may not be associated with rigidity and guarding. The last two are symptoms of a more severe injury that is generally referred to as an "acute abdomen."

You should use your assessment of the mechanism of injury and the signs on the body of trauma to make educated guesses as to what underlying organs may have been affected and what potential pitfalls lie ahead in the treatment of your patient.

ASSESSMENT: When assessing a patient with closed abdominal trauma, be sure to note the position you find the patient in, the presence of pain that increases in intensity with movement/palpation, and the presence of any blood from the mouth/rectum.

(Auscultating epigastric sounds has not proven to be a valuable use of prehospital time in the acute trauma setting.)

If the assessment of a trauma patient does not reveal significant injury, the signs of unexplained shock should lead you to suspect serious abdominal/thorax trauma, that is, loss of significant blood somewhere. 

MANAGEMENT: Closed abdominal trauma is mainly treated by closely managing the ABC's, providing early treatment for any developing shock, and rapid transport to a trauma center.

In the case of pelvic fracture, compromise of the large blood vessels in the area is common, so consider the application of Pneumatic Anti-Shock Garment (PASG) for stabilization and prevention of further injury. NOTE: the use of PASG is controversial, due to conflicting data in the literature. 

 

Open Abdominal Trauma

Open abdominal trauma is a penetrating trauma from an object applied at a force at which an open hole or wound results.

• A low-velocity puncture with a knife will cause a different injury pattern than a high-velocity gunshot wound.
• With any puncture wound, make sure to examine the opposite surface of the body for exit wounds. It does not do as much good to stop the bleeding on the anterior abdomen if a larger exit wound on the posterior is not also addressed.
• Control abdominal bleeding with bulky dressings and direct pressure.

Firearms, stabbings, and physical assaults are associated with penetrating abdominal trauma. The organs of the abdomen are vulnerable to penetrating injury not only through the anterior abdominal wall, but through the back, flank area, and even the lower chest. Patients with penetrating abdominal injuries may present with single or multiple wounds.

The liver, small bowel, and stomach are the most commonly injured organs from penetrating trauma. Always remember that the path of the projectile or penetration does not always go straight in from the entrance wound. Consider many trajectories and arcs and their associated potential for injury.

PNEUMOTHORAX: A penetrating injury with an upward or indirect tract from the outside world (air in) through the abdomen into the thoracic cavity can cause a pneumo- or hemothorax as easily as a direct path through the thorax. Any injury to the diaphragm from below it or from above it can cause a pneumo- or hemothorax. 

DAMAGE TO THE ABDOMEN VIA THE THORAX: Any penetrating trauma to the chest may cross the diaphragm, either as a direct path or as high-impact radiant injury (such as cavitation, e.g.  GSW). 

EVISCERATION: An abdominal evisceration occurs when organs protrude out of a penetrating wound. It can be a small loop of the intestine leaking out of a stab wound or an entire open abdomen with many exposed organs. In the case of eviscerations, do not attempt to replace organs back inside the body. Instead, cover all exposed abdominal contents with moist, sterile towels and cover with an occlusive dressing.

The intestines, liver, spleen, and stomach are commonly involved in eviscerations. These injuries are dangerous as they expose the organs to the outside environment--unprotected--risking injury due to dehydration and infection.

MANAGEMENT: Management of these injuries is focused on keeping the exposed organs as moist and sterile as possible.

• Make sure to remove all clothing and roll your patient to make sure you have found all of the injuries including exit wounds.
• Control bleeding
• Cover wounds with sterile gauze or abdominal pads should be irrigated with sterile saline and draped gently over the wound.
• Do not attempt to push the abdominal contents back into the body cavity: this risks further injury and is unlikely to succeed.

The most important factor in survivability is the time from the onset of injury to the arrival at definitive care. In test questions, The clock is ticking when it comes to evisceration: 

• time of exposure to pathogens in the outside world;
• possible torsion of the blood supply to the eviscerated organs.

Impaled Objects

IMPALEMENT: A foreign object protruding from the body is managed the same way as evisceration, regardless of the location.

• Impaled objects should never be removed.
• The clothing should be cut away from around the object,
• the area irrigated and dressed with a bulky dressing to control bleeding,
• seal the wound entrance from further contamination, and
• anchor the object in place.

The only modification to this rule is if the patient requires CPR and an impaled object prevents chest compressions on the sternum.

 

Vaginal Bleeding

VAGINAL BLEEDING: Vaginal bleeding may be secondary to penetrating or blunt trauma.

• Find out if the patient is pregnant,
• determine any mechanism of injury, and apply
• sterile vaginal pads en route.

Do not insert fingers or instruments into the vagina.

• In sexual assault calls, make sure to secure and process all evidence properly, treat wounds as you would any other soft tissue injury, and provide confidential emotional support to the patient during transport.