TERMINAL LEARNING OBJECTIVE
Given a standard fully stocked M5 Bag or Combat Medic Vest System.
You encounter a casualty who has suspected abdomen injury(ies) and/or complains
of abdominal pain. There is no spinal involvement. The casualty has been initially
assessed and injury(ies) prioritized. Performed appropriate treatment for life
threatening abdominal injury(ies).
Managed the associated effects of the abdominal injury.
INTRODUCTION
Abdominal injuries are difficult to evaluate in the MTF and even more so in the field. Immediate surgical intervention is needed for penetrating abdominal injuries; blunt injuries may be more subtle, but can be just as deadly. Whether the result of penetrating or blunt trauma, abdominal injury presents two life threatening dangers: infection and hemorrhage.
Anatomy and physiology of organs and structures related to abdominal injuries
Review of abdominal anatomy
(1) The abdominal cavity is below the diaphragm. Its boundaries include:
(a) Anterior abdominal wall
(b) Pelvic bones
(c) Spine
(d) Muscles of the abdomen and flanks
(2) The cavity is divided into 3 spaces
(a) Peritoneal
(b) Retroperitoneal
(c) Pelvic
(3) Right upper quadrant
(a) Liver
(b) Gallbladder
(c) Part of colon
(4) Left upper quadrant
(a) Stomach
(b) Spleen
(c) Part of colon
(5) Right lower quadrant
(a) Large intestine
(b) Appendix
(c) Small intestine
(6) Left lower quadrant
(a) Small intestine
(b) Large intestine
(7) Pelvic
(a) Bladder
(b) Uterus
Review of abdominal physiology
(1) Abdominal injury may be caused by blunt or penetrating trauma
(2) Multiple organ injury is common
(3) Intestinal injury can result in:
(a) Infection
(b) Peritonitis
(c) Shock
Determine the mechanism of injury
History should be obtained quickly - major cause of mortality or morbidity is delaying in diagnosis.
Index of suspicion
The primary factor in assessing abdominal trauma is NOT the accurate diagnosis of the injury, but rather that an abdominal injury exists. Based on mechanism of injury and visual assessment
(1) Did the casualty fall from a height or hit by a vehicle?
(2) Was there an explosion that hurtles the victim against immobile objects or transmitted blast pressure to organs inside the abdomen?
(3) Ask the victim if a weapon was used:
(a) Type of weapon i.e. gun, knife, etc.
(b) Distance from weapon
Blunt mechanisms
(1) Most common type of abdominal injury
(2) High probability of accompanying injuries to other parts of the body
(3) Injury may be from:
(a) Direct compression of the abdomen
(i) Solid organs being fractured
(ii) Blowout of hollow organs
(b) Deceleration: tearing of organs or their blood vessels
(4) Casualties may have little or no pain with minimal external evidence of injury
Penetrating objects: Energy imparted to the body
(1) Gunshot wounds: Potential injury to abdominal viscera
(a) Low velocity
(i) Knife/bayonet
(ii) Ice pick
(b) Medium velocity
(i) Gunshot wounds
(ii) Shotgun wounds
(c) High velocity
(i) High power hunting rifles
(ii) Military weapons
(iii) Ballistics
(iv) Trajectory
(v) Distance
(2) Stab wound
(a) Casualty may not initially appear to be in shock unless knife penetrates a major vessel or organ
(b) Life-threatening peritonitis can develop within a few hours
(3) The path of the penetrating object may not be apparent from the wound location
The location is also dependent on whether the patient is inhaling or exhaling. This could cause the injury to be an abdominal, lung, or heart injury.
(a) A stab to the chest can penetrate the abdomen
(b) The course of a bullet may pass through numerous structures in various body locations
(c) You must be aware of the possibility of intra-abdominal bleeding with hemorrhagic shock
(d) NEVER REMOVE AN IMPALED OBJECT
Provide emergency care for an abdominal injury
Assessment findings
(1) Perform a primary assessment to ensure airway, breathing, and circulation prior to assessing the abdomen
(2) Secondary survey (specific to abdominal injuries)
(a) Inspect for:
(i) Abrasions
(ii) Contusions
(iii) External blood loss
(iv) Wounds
(v) Impaled objects
(vi) Evisceration
(vii) Carefully logroll the casualty to inspect posterior abdomen for exit wounds, bruising
(b) Palpate for:
(i) Tenderness
(ii) Guarding/rigidity
(iii) Pelvic instability - indicates a pelvic fracture
(iv) Distention
(3) Severe hemorrhage would be associated with:
(a) Distension
(b) Tenderness or tenseness, though tenderness may not be a reliable indicator if causally presents with an altered mental status
(4) The diaphragm is the only muscle sheet separating the chest from the abdomen. Injury is common to both.
(5) Abdominal injuries may present with shoulder pain
(7) Absence of signs and/or symptoms does not rule-out abdominal injuries
(8) Assess for shock (See LP C191W004, Treat for Shock)
Provide emergency medical care for abdominal injury
(1) Ensure open airway
(2) Provide supplemental oxygen
(3) IV access - administer IV antibiotics (Ancef) 1-2 gm
(4) Manage abdominal injuries
(a) Expose wound
(b) Control bleeding
(c) Prevent further contamination
(d) Apply dry sterile dressing to the wound and bandage securely in place
(e) Keep casualty calm
(f) Treat for shock
(g) Apply oxygen if available
(5) Manage abdominal eviserations
(a) Do NOT touch or attempt to push abdominal contents protruding from a wound back into the abdomen.
(b) Cover any organ or viscera protruding from a wound with saline or water moistened gauze: Intestines may become irreversibly damaged if they are allowed to dry
(6) Manage impaled objects
(a) Do NOT remove a foreign body that is impaled in the abdomen
(b) Stabilize the object in place
(c) Expose the wound area
(d) Control bleeding: bulky dressing may also assist in stabilizing the object (Also see C191W003, Treat for Shock)
(e) No food or drinks
(5) Transport to a facility with surgical capability
SUMMARY
Bleeding and time are the enemies of the abdominal trauma casualty. In the field delays must be minimized to maximize the casualty's survival.