Abdominal & pelvic trauma

Linda H. Warren
EdD RN MSN CCRN
NUR 335

Liver damage = most common, large size & location.
Kidney injury: flank (retroperitoneal) injury.
Pancreatic injury: vague S&S r/t posterior position.
Splenic injury = most often result of BLUNT trauma.

• Always maintain a HIGH
SUSPICION of serious
intra-abdominal injury in
the trauma pt...
• Particularly those who
exhibit signs of SHOCK.

Blunt:
 MVA
 Falls
 Pedestrian event
 Assault
 Crush injury
 Explosion
Penetrating:
 Gunshot
 Stab wounds

Compression-injuries occur as a result of a…
“Direct blow” against a fixed object (lap
belt, spinal column, steering wheel)
Penetrating object.
These crushing forces cause tears & sub-
scapular hematomas to solid organs.
 Spleen, liver
Increased intra-luminal pressure to
hollow organs  rupture!
 Intestines (small or large)
 Stomach (perforation or rupture)

Deceleration forces btwn.
relatively fixed & free objects
cause shearing & tearing injuries.
Longitudinal shearing: usually
rupture supporting structures to
solid and hollow organs.
• Hepatic artery tear
• Renal artery tear

Guarding & splinting of
abdominal wall
Rigid abdomen
(perforation)
Decreased or absent
bowel sounds
Abrasions, contusions or
bruising over abdomen
Pain over scapula (referred
pain) Kerhs sign—
indicative of splenic injury
Hematemesis, hematuria
Signs of hypovolemic
shock

Assessment for Abdominal Trauma:
INSPECTION: Presence of external signs of injury.
 Note patterns of abrasions, bruising.
 Note injury patterns that predict the
potential for intra-abdominal trauma.
 Seat-belt sign, airbag burns, etc.
• Observe respiratory patterns.
• Bradycardia  may have concurrent SCI.
• Cullen sign (peri-umbilical ecchymosis)
AUSCULTATION: Abdominal bruits.
 While auscultating, GENTLY PALPATE the
abdomen noting the patient’s reaction.

PALPATION: entire abdomen
 Note masses, tenderness, deformities.
 Rectal and bimanual vaginal pelvic examines
(secondary survey to assess for other injuries)
 Pelvic instabilities
 Sensory examination (SCI, TBI)
 Abdominal distention:
- Gastric dilation secondary to assisted
ventilation or swallowing air.
 Peritonitis (rupture), however often not seen
until 24-48hrs after injury.
PERCUSSION: Tenderness

Management of Intra-Abdominal Injuries:
 Abdominal trauma can cause massive life-threatening
blood loss into abdominal cavity  HYPOVOLEMIA.
ASSESSMENT:
 Obtain history
 Assess abdomen & other body systems for injuries that
frequently accompany abdominal injuries.
 Assess for referred pain: may indicate spleen, liver, or
intraperitoneal injury.
 Labs (H+H, CBC), CT scan, abdominal ultrasound (FAST),
diagnostic peritoneal lavage (invasive).
 Stab wound—sonography.
 Ongoing assessment is essential!!
 Abdomen can hide blood, slow bleeds may occur.

Diagnostic Peritoneal Lavage (DPL):
WHEN IS DPL PERFORMED?
 When intra-abdominal bleeding
secondary to trauma is suspected.
 When CT or ultra-sound are not
readily available.
 When pt is too unstable for CT scan
or ultrasound (TIME IS VALUABLE!!)

STEP-BY-STEP APPROACH TO DPL:
 Using local anesthesia, the surgeon makes a small
incision in the abdomen just below the umbilicus.
 A cannula is inserted in the incision and is used to
penetrate the midline fascia of the abdominal wall.
 During insertion, a sudden give or "pop" can be
felt as the cannula passes through the fascia.
 A catheter is introduced through the incision into
the abdomen.
 Saline is infused into the abdomen through the
catheter, and then removed.
 If blood or intestinal contents are present in the
saline after removal….it is highly probable of a
serious intra-abdominal injury.
• Assess for returning contents.
• Blood or intestinal contents =
evidence of injury

Positive DPL:
 Bloody Lavage Fluid
 RBCs >100,000 cells/mm
 WBCs >500 cells/mm
 Amylase >175 U /100 ml
 Bacteria
 Fecal Material
 Bile
 Food Products
**can help to locate where the injury is.

 Ensure ABCs
 Immobilize cervical spine
 Document all wounds:
 contusions, abrasions, lacerations.
 If abdominal viscera are protruding…
 cover with sterile, moist saline dressing.
 NGT to aspirate stomach contents.
 Tetanus and ABX prophylaxis.
 Hold oral fluids (NPO), surgery likely.
 Emergent surgery if indicated
Management of Intra-Abdominal Injuries:

LIVER INJURY
 Due to blunt or penetrating trauma
 Highly vascular organ  hypovolemia
 10-15% mortality rate (higher with penetrating injuries)
CLINICAL PRESENTATION:
 Fractures of 7th to 9th ribs (overl liver area).
 RUQ tenderness
 Rebound tenderness
- Blood in abdomen  Peritoneal irritation
- 2hrs following injury, may not be immediately assessed.
 Ecchymosis to RUQ
 Suspect any kind of liver injury if pt has…
- R-lower-chest injury or RUQ injury.

LIVER INJURY: DIAGNOSTICS
 HX of blunt or penetrating trauma to right lower chest or RUQ.
 FAST
 Abdominal CT
 Peritoneal lavage  confirms intraperitoneal hemorrhage
 Serial Hgb/Hct q4-6h
DEGREE OF LIVER INJURY = I to VI GRADE SCALE
- Grade VI: COMPLETE RUPTURE  HIGH MORTALITY.
- Management of grade I-III injuries:
- closely monitored, STRICT bed rest, no commode privileges
- H&H, LFTs
- Assess for ↑ pain, distention, ↓ BP, ↓ SpO2

SPLENIC INJURY
 Spleen is a lymphatic, solid organ
 Filters 10-15% of total blood per min.
 Produces WBCs
 Removal of abnormal RBC’s
 Reservoir of platelets
 Blunt trauma is the most common injury (40%) 
damage or rupture
 Lacerations: most common cause of profound
HEMORRHAGE.
 More common in children secondary to accidents,
falls, and less protection.
Toddlers have protruding abdomens, large head,
unbalanced.
Contact sports injuries

 Fractured 9th and 10th ribs on left side
 LUQ pain
 Left shoulder pain / tenderness
 Kehr’s sign (left shoulder pain)
 Hypovolemic shock
 Hypotension
 Peritonitis
SPLENIC INJURY
Splenic laceration

FAST
Abdominal CT
MRI
MRA (vascular study)
Peritoneal lavage
Laboratory Studies
hemoperitonea
Splenic injury
SPLENIC INJURY: DIAGNOSTICS

CONSERVATIVE (grade I-III):
 Strict bedrest x5 days
 Limited physical activity x6 weeks
 No contact sports x6 months
SURGERY (grade IV & V): if conservative therapy fails or pt is hypovolemic & low Hct:
 30% of conservative therapy fails.
 Surgery usually performed in the first 72 hours following injury.
 Assess for rebleeding after 72 hrs.
Serial H&H:
 Closely monitored for signs of bleeding.
 Q4-6h
SPLENIC INJURY: MANAGEMENT
***Ruptured spleen
is life-threatening 
EMERGENCY
SURGERY!

PATIENT TEACHING AFTER SPLENECTOMY:
 ↑ risk for infection
 Assess surgical wound
 Monitor for S&S of systemic infection (less immune protection)
 Pneumococcal infections common:
 Pneumo-vaccine a few days after surgery is likely.
 Report any S&S of bleeding: weakness, dizziness, fatigue, SOB
 Monitor for overt symptoms of bleeding…return to ED.
SPLENIC INJURY: MANAGEMENT

RUPTURED BOWEL
Penetrating injury MOST COMMON:
 Small bowel
 Stomach
 Large intestine
Blunt trauma:
 Crush injury of steering wheel to spine.
 Ruptured duodenum most frequent.
 Increased intraluminal pressure  ruptured hollow organs

 Decreased or absent bowel sounds
 Painful, rigid abdomen (bleeding)
 Rebound tenderness
 Abdominal distension
 Fever, elevated WBCs
 Stomach rupture: burning epigastric pain
 Small bowel and colon injury:
 Initially vague, generalized pain
 Later on  peritonitis
 Duodenal injury: back pain
 Pain that radiates to the back: aortic dissection
or duodenal injury…assess further to ID cause.
RUPTURED BOWEL
Small bowel injury: RUQ pain

 Abdominal X-ray: shows free air
 FAST (always before peritoneal lavage)
 Peritoneal lavage: will have intestinal contents
 Surgical Intervention
RUPTURED BOWEL: DIAGNOSTICS

PANCREATIC INJURY
 History of mid-abdominal blow: motorcycle handlebars or steering wheel
Difficult to DX:
 Located behind other structures
 Higher mortality r/t subtle S&S and late DX.
 CT scan
 ERCP: endoscopic retrograde pancreatography
 Often requires surgical int. to DX
NO SPECIFIC S&S or LABS FOR PANCREATIC INJURY!!!
Be alert for vague S&S***

 Serum amylase is NOT reliable in acute phase.
 Vague upper & mid-abdominal pain radiating to back.
 Generalized peritonitis hours after injury.
PANCREATIC INJURY
Pancreatic injury: epigastric pain

NURSING MANAGEMENT OF ABDOMINAL TRAUMA:
 MONITOR: VS, respiratory status, pain assessment
 LABS: (notify MD of trends or abnormal values)
- CBC (WBCs, Hgb, Hct)
- Electrolytes
FOLEY CATHETER:
 Can be used for IAP monitoring (with transducer).
- Assess for abdominal compartment syndrome.
- High reading  consider surgical int.
 Urine output: assess for hematuria with AKI.
 Complete and ongoing abdominal assessment
• Increased IAP  hypoperfusion, necrosis
• Abdominal compartment syndrome (ACS)

NPO until surgical intervention is ruled out.
NGT: Low continuous suction
IV fluids
Nutritional support
DVT prophylaxis (bedrest)

Post-op patient family education:
 Incision site care
 S&S of infection
 Pain management
 Work, Exercise, Rest Balance
 Diet
 Prescriptions
 Follow-up care

RENAL INJURY:
 80-90% blunt trauma
 10-20% penetrating
 Associated with rib fractures (11th or 12th rib)
Blunt renal trauma classified as…
 Contusion (most common)
 Minor laceration
 Major Laceration
 Vascular injuries
Sports injuries
Penetrating injuries (GSW, stabbings)

 Pain  CVA tenderness
 Renal colic (spasms) due to blood clots
that obstruct the collecting system.
 Hematuria- microscopic or gross
 Flank swelling (Turners sign)
 Ecchymosis
 Laceration or wounds
 Hemorrhage
 Hypovolemia/ shock
RENAL INJURY:

CONTROL…
 Hemorrhage
 Pain
 Infection
 Monitor urine output
 Assess for hematuria (gross or microscopic).
 Conservative measures: mild contusion = BEDREST
Surgery: Nephrectomy
 POST-OP: monitor for refractory HTN, abscesses, fistula
formation
RENAL INJURY: MANAGEMENT

Associated with other organ injuries:
• Liver, colon, small intestines
• Skin assessment for other possible injuries
• Close monitoring for complications
Patient education:
• Wear a medicalert bracelet
• Report HTN
• Activity restrictions (at least one month)
• Follow-up blood work w/ renal studies: BUN, creatinine, GFR
RENAL INJURY: MANAGEMENT

GU INJURY:
Major causes of ureteral trauma:
Penetrating trauma: 95% GSW
Unintentional complication
(secondary cause) from
gynecologic or urologic surgery.
Detection of injury:
IV urography
Exploratory surgery

Bladder trauma due to…
 Pelvic fractures
 Multiple trauma
 Blow to lower abdomen (esp. when bladder is full)
 Contusion or rupture (esp. when bladder is full)
 Complications: sepsis, hemorrhage, shock,
extravasation of blood into the tissue.
Urethral trauma due to…
 Blunt trauma to lower abdomen or pelvic area.
 S/S: Inability to void, distended bladder.
 Perform bladder scans
 Blood around meatus: DO NOT INSERT FOLEY, notify
HCP, perform a bladder scan to assess for distention.
GU INJURY:

MEDICAL MANAGEMENT:
 Control: bleeding, pain, infection, and maintain adequate U/O
 Monitor H&H
 Monitor for signs of shock and acute peritonitis.
SURGICAL MANAGEMENT:
 Suprapubic catheter insertion (esp. if r/t bladder injury)
- Allows for bladder & urethral repair.
 Monitor for complications: strictures (r/t scar tissue), incontinence, and impotence
 May require a Foley up to 1 month.
- Make sure anastomoses will hold.
- Ensure a good and healed anastomosis.
GU INJURY:

VASCULAR INJURY
 Aorta
 Inferior vena cava
 Iliac artery
 Hepatic veins
DX:
 CXR-Widened Mediastinum  aortic injury (causes blood to accumulate in mediastinum)
 EKG
 CPK Isoenzymes: cardiac damage, MI
 Echocardiogram
 Angiography
Most vascular injuries require
IMMEDIATE surgical int…will
be going to OR

PELVIC FRACTURES:
 50% MORTALITY RATE due to hemorrhage.
 Usually caused by major injuries.
 Results in severe damage to underlying structures.
Due to:
 High velocity MVC
 Pedestrian vs. vehicle
 Falls
Large vascular supply in pelvic basin
Location of CNS pathways
Articulation of hip joints

STABLE: minor fractures, no displacement, can bear weight
UNSTABLE: “OPEN BOOK”
 Both sides of ileus are fractured
 Serious fracture:
- Vascular
- Neurological
- Urological
PRIMARY INT: stabilize pelvis
- May require wiring
- Most pelvic fractures will go to research facilities with high orthopedic expertise.
PELVIC FRACTURES:

 Local swelling
 Tenderness
 Deformity
 Unusual pelvic movement (pelvic instability)
 Ecchymosis
 Neurovascular Changes:
 Assess dorsalis pedis & posterior tibial pulses, presence of paresthesia
 Hemodynamic instability
 Hypovolemic Shock
PELVIC FRACTURES:

History of trauma
MOI
Visual Inspection
CT scan
Radiography (XRAY)
Urinalysis
Open book fracture
PELVIC FRACTURES: DIAGNOSTICS

Airway
Maintain BP- fluids and blood products
Bedrest
Compression
Surgical fixation
Monitor H&H Pelvic belt—used for
STABILIZATION ONLY:
• Used by EMS when pelvic
injury is suspected to prevent
further displacement or
damage to pelvic organs.
PELVIC FRACTURES: MANAGEMENT

NURSING DX
 Acute pain r/t fracture, soft tissue damage, muscle spasm and surgery
 Impaired physical mobility
 Impaired skin integrity r/t surgical incision
 Risk for impaired urinary elimination r/t immobility and injury to GU organs.
 Hemorrhage
 Peripheral neurovascular dysfunction
 DVT
 Pulmonary complications
 Pressure ulcers
r/t surgery and immobility

Alteration in Comfort: Pain
Alteration in Nutrition
Altered Breathing Pattern
Immobility
Knowledge Deficit
Potential for Infection:
↑ RR, ↓ BP, ↓ U/O, fever  sepsis  septic shock
NURSING DX

Heart
Great Vessels
Lungs
FAST assessment

 Usually caused by penetrating trauma.
 Bleeding into pericardial space.
 Impairs pumping ability of heart:
 ↓ CO
 ↓ venous return
 pulsus paradoxus
 May be difficult to DX.
BECK’S TRIAD:
 Hypotension
 Muffled heart sounds (sound far away)
 Elevated venous pressure

Suspect in patient with symptoms of
↓ CO who DO NOT respond to TX.
TX: PERICARDIOCENTESIS
Often, only small amts. of fluid are
removed (30cc) bc pericardial sac
does not hold much fluid.

CARDIAC CONTUSION:
 Bruise of heart
 Blunt trauma to chest
 Dysrhythmias
 “Driver’s injury”  airbag deployment
can cause chest injuries.
 Monitor cardiac enzymes (troponin, BNP)
 12-lead EKG
 Monitor tele for 48-72 hours

AORTIC DISSECTION:
 Can lead to death at scene (r/t hemorrhage)
 Weak pedal pulses b/l (below level of injury)
 Dysphagia
 Dyspnea
 Dyspepsia, epigastric pain
 Hoarseness
 Pain
 Widened Mediastinum
 Immediate surgical repair required for survival

PNEUMOTHORAX:
 Tension pneumothorax: ↑ intra-thoracic pressure
 Hemothorax: blood in chest
 Open pneumothorax
 Flail chest

TENSION PNEUMOTHORAX:
 Life-threatening
 ↑ intrapleural and intrathoracic pressures:
 Causes compression of heart and great vessels.
 CV collapse
DX: based on clinical presentation
 Tachycardia
 Hypotension
 Difficulty breathing
 Tracheal shift to unaffected side
 Emergent treatment w. needle thoracostomy  2nd intercostal space, midclavicular line
 Chest tube insertion after needle decompression

HEMOTHORAX:
Blood in pleural space
Diminished breath sounds
Dullness on percussion on the affected side (r/t fluid)
Hypotension (blood loss)
Respiratory distress
Need a chest tube inserted  lateral & lower placement

OPEN PNEUMOTHORAX:
 Air (pneumo) in pleural space
 Resulting from penetrating trauma
 Hypoxia
 Hemodynamic instability
Three-sided occlusive dressing:
 Does not allow air to enter the chest.
 Allows small amount of air to escape from occlusive dressing.
 Chest tube insertion needed: placed ANTERIORLY & HIGH (air rises)

FLAIL CHEST:
 >3 adjacent rib fractures in more than one location.
- Flail segment “floats” freely.
 Asymmetrical chest mvmt
 Paradoxical chest movement:
- Chest moves IN during inspiration
- Chest moves OUT during expiration
 ↑ WOB
 Hypoxemia
 Tachypnea
 TX: Intubation, Mechanical Ventilation, Pulmonary Care, Pain Management

PULMONARY CONTUSION:
 Bruising of the lungs and pleural cavity .
 Blunt or penetrating trauma.
 Associated with rib fractures and flail chest.
 Chest wall abrasions and bruising present.
 Difficult to assess, CXR may be normal,
 Follow serial H&H bc hemorrhage is occurring.
 May need mechanical ventilation and pain relief.
Common cause of death after chest trauma:
predisposed to pneumonia and ARDS.

Abdominal & pelvic trauma

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