Blunt and penetrating abdominal injuries
Blunt and penetrating abdominal injuries: Excerpt from Professional Guide to Diseases (Eighth Edition)
Blunt and penetrating abdominal injuries may damage major blood vessels and internal organs. Their most immediate life-threatening consequences are hemorrhage and hypovolemic shock; later threats include infection. The prognosis depends on the extent of the injury and the specific organs damaged, but it’s usually improved by prompt diagnosis and surgical repair.
Causes and incidence
Blunt (nonpenetrating) abdominal injuries usually result from automobile accidents, falls from heights, or sports injuries; penetrating abdominal injuries, from stab and gunshot wounds.
The most commonly injured organs associated with penetrating abdominal trauma are the small intestine (29%), liver (28%), and colon (23%). Penetrating abdominal trauma affects 35% of those admitted to urban trauma centers and 1% to 12% of those admitted to suburban and rural centers.
Signs and symptoms
Symptoms vary with the degree of injury and the organs damaged. Penetrating abdominal injuries cause obvious wounds (gunshots commonly produce both entrance and exit wounds) with variable blood loss, pain, and tenderness. They commonly result in pallor, cyanosis, tachycardia, shortness of breath, and hypotension. (See Projectile pathway.)Blunt abdominal injuries cause severe pain (which may radiate beyond the abdomen to the shoulders), bruises, abrasions, contusions, or distention. They may also result in tenderness, abdominal splinting or rigidity, nausea, vomiting, pallor, cyanosis, tachycardia, and shortness of breath. Rib fractures commonly accompany blunt injuries. (See Effects of blunt abdominal trauma, page 300.)
In both blunt and penetrating injuries, massive blood loss may cause hypovolemic shock. Damage to solid abdominal organs (liver, spleen, pancreas, and kidneys) generally causes hemorrhage. Damage to hollow organs (stomach, intestine, gallbladder, and bladder) causes rupture and release of the organs’ contents (including bacteria) into the abdomen, which in turn produces inflammation and, possibly, infection.
Diagnosis
CONFIRMING DIAGNOSIS A history of abdominal trauma, clinical features, and laboratory test results confirm the diagnosis of blunt or penetrating abdominal injury and determine organ damage.
Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Laboratory studies vary with the patient’s condition but usually include:
❑ chest X-rays (preferably done with the patient upright to show free air)
❑ abdominal X-rays
❑ examination of stools and stomach aspirate for blood
❑ blood studies (decreased hematocrit and hemoglobin levels point to blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; type and crossmatch to prepare for a blood transfusion)
❑ arterial blood gas analysis to evaluate respiratory status
❑ serum amylase levels, which may be elevated in pancreatic injury
❑ aspartate aminotransferase and alanine aminotransferase levels, which increase with tissue injury and cell death
❑ excretory urography and cystourethrography to detect renal and urinary tract damage
❑ radioisotope scanning and ultrasound to detect liver, kidney, or spleen injury
❑ angiography to detect specific injuries, especially to the kidneys
❑ computed tomography scan to detect abdominal, head, or other injuries
❑ exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete
❑ other laboratory studies to rule out associated injuries
❑ peritoneal lavage with insertion of a lavage catheter to check for blood, GI content, vegetable fibers, and bile. In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.
Treatment
Emergency treatment of abdominal injuries controls hemorrhage and prevents hypovolemic shock through the infusion of I.V. fluids and blood components. After stabilization, most abdominal injuries require surgical repair; some patients, however, require immediate surgery. Analgesics and antibiotics increase patient comfort and prevent infection. Most patients require hospitalization; if they’re asymptomatic, they may require observation for only 6 to 24 hours.
Special considerations
Emergency care in patients with abdominal injuries supports vital functions by maintaining airway, breathing, and circulation. At admission, immediately evaluate respiratory and circulatory status and, if possible, obtain a history. Follow these guidelines:
❑ To maintain airway and breathing, intubate the patient and provide mechanical ventilation as necessary; otherwise, provide supplemental oxygen.
❑ Using a large-bore needle, start two or more I.V. lines for rapid infusion of normal saline solution, lactated Ringer’s solution, or blood. Then draw a blood sample for laboratory studies, and type and crossmatch blood. Also, insert a nasogastric tube and, if necessary, an indwelling urinary catheter. Monitor stomach aspirate and urine for blood.
❑ Obtain baseline vital signs, and continue to monitor them every 15 minutes.
❑ Apply a sterile dressing to open wounds. After assessing the patient, splint a suspected pelvic injury by tying the patient’s legs together with a pillow between them. Most trousers may be used to splint pelvic fractures. Try not to move the patient.
❑ Give analgesics as ordered. Opioids usually aren’t recommended, but if the pain is severe, give opioids in small, titrated I.V. doses.
❑ Give tetanus prophylaxis and prophylactic I.V. antibiotics as ordered.
❑ Prepare the patient for surgery. Have the patient or a responsible relative sign a consent form. Remove dentures.
❑ If the injury was caused by a motor vehicle accident, find out if the police were notified; if not, notify them. If the patient suffered a gunshot or stab wound, notify the police. Place the patient’s clothes in a paper bag, labeled with the patient’s name and the date and time he was brought to your facility; the police will require the clothing as part of their investigation into the circumstances surrounding the patient’s injury. Document the number and sites of the wounds. Contact the patient’s family and offer them reassurance.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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