Thoracoabdominal Trauma Instructor Name: Title: Unit:

OBJECTIVES ABDOMINAL TRAUMA Anatomy & Physiology MOI Patient Assessment General Treatment Specific Injuries Thoracic Trauma

Abdominal Trauma: Facts 7%-15% of all trauma deaths Penetrating – Most Common; 5% mortality Blunt – Most difficult to diagnose; 10%-30% mortality 75% of blunt abd blunt trauma is caused by high speed motor vehicle crashes (MVC’s)

ABDOMINAL A&P Abdominal cavity bounded by pelvis, diaphragm, anterior abdominal muscles, vertebral column and ribs, flank muscles Peritoneum Parietal Visceral Mesenteries Peritoneal cavity Potential space between visceral and parietal pleura Abdominal Cavity – Divided into 2 spaces: Retro peritoneal space – Kidneys, ureters, bladder, reproductive organs, inferior vena cava, aorta, pancreas, duodenum colon, & rectum Peritoneal space – bowel, spleen, liver, stomach, & gall bladder

MECANISM OF INJURY (MOI) Solid organs bleed Hollow organs – discharge contents into the peritoneum which leads to peritonitis Fx ribs/sternum – usually injures liver/spleen Fx pelvis – injures bladder, reproductive organs, intestines

MOI (CONT’D.) Steering wheel impacts may rupture abdominal cavity w/ herniation of left diaphragm Stab wounds – possible to predict path of object, less able to predict injuries with GSW Compression injuries – organs sheared at impact with other objects (ex: Liver)

PATIENT ASSESSMENT Observe MOI and maintain index of suspicion Suspect intrabdominal bleeding when: Echymosis Distention Hematuria Blood return in NG Tube Pain Abd. Tenderness Abd. Rigidity Unexplained shock Testicular pain = retroperitoneal injury L shoulder pain = Spleen R Shoulder pain = Liver

PT. ASSESSMENT (CON’D) Difficult to assess pain (abd. Vs. ribs) Pain may be masked by drugs, head injury, ETOH Observation Distention Contusions Cullens sign – echymosis around umbilicus = spleenic injury Grey Turners sign – Flank echymosis Kehrs sign – referred pain to shoulders from abd. Injury, worse when lying flat = diaphragm and phrenic nerve)

PT. ASSESSMENT (CON’D) Observation (con’d) Penetration Evisceration Impaled object Obvious bleeding Scaphoid abdomen – Sn of herniated diaphragm Encapsulating Injury – bleeding into itself without rupturing. (Ex. Spleen or Liver)

PT. ASSESSMENT (CON’D) Palpation Avoid deep palpation Abdominal wall defects Tenderness Pelvic instability

GENERAL TREATMENT Remember ABC’s!!! Rapid assessment, packaging, and Transport High flow O IV Lines –Up to 3 L on way to ER (PHTLS) MAST (no abd. Section) Treat other injuries

THORACIC TRAUMA-FACTS Second leading cause of trauma deaths Accounts for 25% of all trauma deaths 85% can be managed outside of the operating room Major causes of Blunt Thoracic Trauma: Steering wheel, bicycle handlebars, baseball Major causes of Penetrating Trauma: GSW and Stabbings

THORACIC A&P Cavity is bounded by ribs, spine, and diaphragm Pleura Parietal Visceral Potential space can hold 3 liters on each side Right lung – 3 lobes Left lung – 2 lobes Mediastinum - Heart Great vessels Esophagus trachea Mainstem bronchi

PHYSIOLOGY Respiration Requires intercostal muscles and diaphragm Operates on pressure gradient During exhalation, diaphragm elevated to 4th intercostal space Driven by PCO2 levels (chemoreceptors in brainstem) COPD patients driven by PO2 receptors in aortic arch and carotid arteries

PATIENT ASSESSMENT Signs & Symptoms Dyspnea Puncture wounds Pleuritic chest pain Splinting Echymosis Cyanosis Lacerations Asymmetrical chest Crepitus Flail segment Puncture wounds Neck vein distention Tracheal deviation SQ emphysema Sucking chest wound Deformity Paradoxical chest Tenderness +/- lung sounds

RIB FRACTURES Most commonly fx are 3-8 (thin) 8-12 assoc. with spleen, kidney or liver injuries 1&2 have high mortality because of the forces necessary to fx these ribs – produce serious injuries Pain upon movement Crepitus Deformity Local tenderness Hypoventilation Potential for: Pneumo/hemothorax Atelectasis/pneumonia

SIMPLE PNEUMOTHORAX Air in the pleural space Affected lung begins to collapse as pleural space expands Caused by puncture wound, rib fx, or lung defect Simple pneumo usually well tolerated in young, healthy adult S&S: dyspnea, pleuritic chest pain, tachypnea, decreased lung sounds Treatment: anticipate development of tension, semi-sitting position unless contraindicated, O2, assist ventilations PRN, IV, EKG, treat other injuries

OPEN PNEUMOTHORAX (Sucking Chest Wound) Open chest wall injury Stab wounds usually self-sealing GSW more extensive damage Air passes through opening into pleural space and remains outside of lung S&S: gurgling sound during air movement, bubbling wound, dyspnea, tachypnea, diminished breath sounds. Treatment: anticipate tension, cover wound w/ occlusive dressing to form flutter valve, O2, assist ventilations PRN, IV, EKG, treat other injuries

TENSION PNEUMOTHORAX Air enters pleural space and becomes trapped – leads to pressure increase Increased pressure further collapses lung and shifts mediastinum to unaffected side Increased dyspnea and compressed heart and great vessels leads to decreased cardiac output and shock S&S & Treatment: Con’d on next slide

TENSION PNEUMOTHORAX CON’D Signs & Symptoms: Dyspnea Tachypnea Anxiety Cyanosis Diminished lung sounds Hypotension SQ emphysema Paradoxical pulse Asymmetrical chest JVD Tachycardia Narrow pulse pressure Tracheal deviation shock

TENSION PNEUMOTHORAX CON’D Treatment Remove dressing over open pneumo If no improvement, open the wound then reseal Needle decompression Assist ventilations PRN IV EKG Treat other injuries

DECOMPRESSING A TENSION PNEUMOTHORAX Ensure tension exists and determine which side 2nd or 3rd midclavicular ICS or 4th or 5th midaxillary ICS Prep site Insert 14 ga. Catheter on top of rib Prepare valve McSwain dart Condom Stopcock Water valve Latex glove – no longer recommended Secure in place Monitor patient closely

ABDOMINAL TRAUMA Instructor Name: Title: Unit:

OVERVIEW Review anatomy Review types of injuries Blunt Penetrating Evaluation of abdominal trauma Management of abdominal trauma

ANATOMY Three regions Thoracic abdomen True abdomen Retroperitoneal abdomen Bleeding into this area does not cause abdominal rigidity

Intrathoracic Abdomen ANATOMY Intrathoracic Abdomen True Abdomen

ANATOMY RETROPERITONEAL ABDOMEN

TYPES OF INJURIES Blunt trauma Penetrating trauma

BLUNT ABDOMINAL TRAUMA Mortality 10-30% Associated with injuries to other systems Internal bleeding may be severe Tenderness may not be present during early exam Early onset of signs & symptoms suggests severe injury Watch for development of shock

BLUNT FORCES CAUSE Fracture of solid organs Rupture of hollow organs Hemorrhage Rupture of hollow organs High risk of peritonitis Tearing of organs, blood vessels, and mesentery (attachments) Fractures of lower ribs associated with high incidence of liver or spleen injury

PENETRATING WOUNDS Gunshot wounds Stab wounds Have higher mortality (up to 15%) due to higher rates of damage to abdominal viscera Stab wounds Mortality 1-2% All penetrating abdominal wounds should be evaluated in the hospital

PENETRATING WOUNDS Causes of mortality Hypovolemic shock Injury to abdominal viscera Sepsis and/or peritonitis are late causes of death Internal path of penetrating object may not be apparent from external wound Stab to the chest may penetrate the abdomen and vice versa Stab to the buttocks has 50% chance of significant intra-abdominal injury

EVALUATION SCENE SIZE-UP Extremely important Provides clues to Type of injury Path followed Forces involved Important factors Weapon or object involved Distance Force applied

EVALUATION BTLS PRIMARY SURVEY Initial Assessment ABCs Rapid Trauma Survey Head, Neck, Chest Abdomen Look for wounds, bruises, distention Feel for guarding, tenderness, rigidity

EVALUATION BTLS PRIMARY SURVEY Signs of intra-abdominal injury usually develop late After arrival at the hospital Abdominal pain or tenderness present at the scene suggests severe injury Patients are likely to develop shock Penetrating wounds to the upper abdomen may cause chest injury

MANAGEMENT Treat problems found in the BTLS Primary Survey 100% oxygen If abdominal tenderness Load & Go Dress wounds Two large bore IVs en route NS or RL to maintain BP of 90-100 systolic

MANAGEMENT EVISCERATION Cover protruding organs with moist sterile dressing and/or nonadherent material Do not try to put organs back into the abdomen Load & Go

SUMMARY Second leading cause of preventable death from trauma Most deaths from delayed treatment Be alert to mechanisms of injury Maintain high index of suspicion Abdominal pain = impending shock Penetrating wounds of the abdomen or tender abdomen mean Load & Go

QUESTIONS?