Abdominal injuries
Abdominal injuries: Excerpt from Handbook of Diseases
Blunt and penetrating abdominal injuries may damage major blood vessels as well as 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 on the organs damaged, but it’s generally improved by prompt diagnosis and surgical repair.
Causes
Blunt (nonpenetrating) abdominal injuries usually result from motor vehicle accidents, falls from heights, or athletic injuries; penetrating abdominal injuries, from stab or gunshot wounds.
Signs and symptoms
Depending on the degree of injury and the organs involved, signs and symptoms vary as follows:
Penetrating abdominal injuries cause obvious wounds. For example, gunshots commonly produce both entrance and exit wounds, with variable blood loss, pain, and tenderness. These injuries can cause pallor, cyanosis, tachycardia, shortness of breath, and hypotension.
Blunt abdominal injuries can cause severe pain (such pain may radiate beyond the abdomen, for example, to the shoulders), bruises, abrasions, contusions, and 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.
With both penetrating and blunt injuries, massive blood loss may cause hypovolemic shock. Generally, damage to a solid abdominal organ (liver, spleen, pancreas, or kidney) causes hemorrhage, whereas damage to a hollow organ (stomach, intestine, gallbladder, or bladder) causes rupture and release of the affected organ’s contents (including bacteria) into the abdomen, which, in turn, produces inflammation.
Diagnosis
A history of abdominal trauma, signs and symptoms, and laboratory results confirm the diagnosis and help determine organ damage. Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Diagnostic studies vary with the patient’s condition but usually include:
chest X-rays (preferably done with the patient upright) to show free air
examination of stool and stomach aspirate for blood
blood studies (decreased hemoglobin levels and hematocrit point to severe blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; typing and crossmatching help prepare for blood transfusion)
arterial blood gas analysis to evaluate respiratory status
serum amylase levels, which are commonly elevated in those with 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
angiography to detect specific injuries, especially to the kidneys
peritoneal lavage with insertion of a lavage catheter, to check for blood, urine, pus, ascitic fluid, bile, and chyle (a milky fluid absorbed by the intestinal lymph vessels during digestion) (In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.)
computed tomography scan to detect abdominal, head, chest, or other injuries
exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete
other laboratory studies to rule out associated injuries.
Treatment
Abdominal injuries require emergency treatment to control hemorrhage and prevent hypovolemic shock, by infusion of I.V. fluids and blood components. Some abdominal injuries require surgical repair after stabilization, whereas others require immediate surgery. Blunt trauma to the spleen or liver may be treated with nonoperative management and close monitoring. 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 for a patient with an abdominal injury supports vital functions by maintaining airway, breathing, and circulation. Upon admission, immediately evaluate the patient’s respiratory and circulatory status and, if possible, obtain a history.
To maintain airway and breathing, intubate the patient and provide mechanical ventilation as necessary; otherwise, provide supplemental oxygen.
Keep the patient’s cervical spine immobilized, unless clearance is obtained.
Using a large-bore needle, start two or more I.V. lines for monitoring and rapid fluid infusion, using normal saline or lactated Ringer’s solution (or blood transfusions if the patient’s condition is hemodynamically unstable).
CLINICAL TIP: Draw off blood for laboratory studies while inserting the large-bore I.V. catheter.
Send a blood sample for laboratory studies. Also, insert a nasogastric tube and, if necessary, an indwelling urinary catheter; monitor stomach aspirate and urine for blood.
Obtain vital signs for baseline data; continue to monitor them every 15 minutes.
Apply a sterile dressing to open wounds. Assess the patient in a head-to-toe fashion; if pelvic fracture is suspected, keep the patient immobilized until evaluation by the orthopedic surgeon.
Give an analgesic for pain as indicated.
If necessary, give tetanus prophylaxis and prophylactic I.V. antibiotics.
Prepare the patient for surgery. Remove the patient’s dentures. Type and crossmatch blood. Make sure the patient or a responsible family member has signed an informed consent form.
CLINICAL TIP: A consent form is necessary unless surgery must be performed immediately to save the patient’s life. The patient may not sign a consent form if under the influence of narcotics or other agents.
If the injury was caused by a motor vehicle accident, find out whether the police were notified and, if not, notify them. If the patient suffered a gunshot or stab wound, notify the police, place all the patient’s clothes in a bag, and retain them for the police. Document the number and sites of the wounds. Contact the patient’s family, and offer them reassurance.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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