1. Thoracoabdominal Trauma
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2. OBJECTIVES ABDOMINAL TRAUMA Anatomy & Physiology MOI
Patient Assessment
General Treatment
Specific Injuries
Thoracic Trauma

3. 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)

4. 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

5. 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

6. 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)

7. 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

8. 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)

9. 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)

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. ABDOMINAL TRAUMA
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24. OVERVIEW Review anatomy Review types of injuries
Blunt
Penetrating
Evaluation of abdominal trauma
Management of abdominal trauma

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

26. Intrathoracic Abdomen
ANATOMY
Intrathoracic Abdomen
True Abdomen

27. ANATOMY RETROPERITONEAL ABDOMEN

28. TYPES OF INJURIES
Blunt trauma
Penetrating trauma

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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 systolic

37. 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

38. 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

39. QUESTIONS?