1. CHAPTER 28: ABDOMINAL & GENITOURINARY INJURIES
PATIENT ASSESSMENT & CARE II
EMS 246
Dr.Bushra Bilal

2. ABDOMINAL CAVITY
Abdomen is major body cavity extending from diaphragm to pelvis.
Contains organs that make up digestive, urinary, and genitourinary systems.

3. ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (1 OF 5)
Abdominal quadrants
Right upper quadrant (RUQ)
Liver
gallbladder,duodenumpancreas
Left upper quadrant (LUQ)
Stomach,
Spleen
Right lower quadrant (RLQ)
Large and small intestine,the appendix
Left lower quadrant (LLQ)
Descending colon ,left half of transverse colon

4. ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (2 OF 5)
RLQ is a common location for swelling and inflammation.
The appendix is a source of infection if it ruptures.

5. ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (3 OF 5)
A hollow organ is a visceral organ that forms a hollow tube or pouch
Stomach, intestines, ureters, bladder
Most of these contain digested food, urine, or bile.
When ruptured or lacerated, contents spill into peritoneal cavity and can cause infections such as peritonitis.

6. ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (4 OF 5)
Small intestine
Duodenum, jejunum, and ileum
Large intestine
Cecum, colon, and rectum
Intestinal blood supply comes from mesentery.

7. ANATOMY AND PHYSIOLOGY OF THE ABDOMEN (5 OF 5)
Liver, spleen, pancreas, kidneys
Solid masses of tissue
Perform chemical work of the body: enzyme production, blood cleansing, energy production
Because of rich blood supply, hemorrhage can be severe.

8. INJURIES TO THE ABDOMEN
Injuries to the abdomen are considered either open or closed.

9. CLOSED ABDOMINAL INJURIES (1 OF 2)
Blunt trauma to abdomen without breaking the skin
MOIs:
Steering wheel
Bicycle handlebars
Motorcycle collisions
Falls
Compression
Poorly placed lap belt
Deceleration
Fast-moving vehicle strikes an immoveable object.

10. CLOSED ABDOMINAL INJURIES (2 OF 2)
Signs and symptoms
Pain : Diffuse, may be referred to another body location (such as the Kehr sign)
Blood in peritoneal cavity
Guarding: stiffening of abdominal muscles
Abdominal distention: result of free fluid, blood, or organ contents spilling into peritoneal cavity
Abdominal bruising and discoloration

11. OPEN ABDOMINAL INJURIES (1 OF 3 )
Foreign object enters abdomen and opens peritoneal cavity to outside.
Also called penetrating injuries example stab wounds, gunshot wounds
Injury depends on velocity of object.

12. OPEN ABDOMINAL INJURIES (2 OF 3)
Evisceration: bowel protrudes from peritoneum.
Can be painful and visually shocking
Do not push down on abdomen.
Only perform visual assessment.
Never pull on clothing stuck to or in the wound channel.

13. Evisceration

14. OPEN ABDOMINAL INJURIES (3 OF 3)
Signs and symptoms
Pain
Tachycardia
Heart increases pumping action to compensate for blood loss
Later signs include:
Evidence of shock
Changes in mental status
Distended abdomen

15. HOLLOW ORGAN INJURIES
A hollow organ is a visceral organ that forms a hollow tube or pouch, such as the stomach or intestine, or that includes a cavity, like the heart or urinary bladder Often have delayed signs and symptoms
Spill contents into abdomen. Infection develops.
Both blunt and penetrating trauma can cause hollow organ injuries
Blunt: causes organ to “pop”
Air in peritoneal cavity causes pain, ischemia and infarction.

16. SOLID ORGAN INJURIES (1 OF 3)
Liver is the largest organ in abdomen.
Vascular, can lead to hypoperfusion
Often injured by fractured lower right rib or penetrating trauma
Kehr sign is common finding with injured liver.
is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated.
Spleen and pancreas
prone to heavy bleeding

17. SOLID ORGAN INJURIES (3 OF 3)
Diaphragm
When penetrated or ruptured, loops of bowels invade thoracic cavity.
May cause bowel sounds during auscultation of lungs
dyspnea.
Kidneys
blood loss
blood in urine (hematuria).

18. PATIENT ASSESSMENT OF ABDOMINAL INJURIES
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

19. SCENE SIZE-UP Scene Safety
Standard precautions of gloves and eye protection should be a minimum
Be sure scene is safe for you

20. PRIMARY ASSESSMENT (1 OF 2)
Evaluate patient’s ABCs.
Form a general impression.
Check for responsiveness using AVPU scale
Airway and breathing
Ensure airway is clear and patent.
Clear airway of vomitus (note the nature)

21. PRIMARY ASSESSMENT (2 OF 2)
Circulation
Superficial abdominal injuries usually do not produce significant external bleeding.
Internal bleeding can be profound specially trauma to liver, kidneys and spleen.
Transport decision
Abdominal injuries generally indicate a quick transport to the hospital.

22. HISTORY TAKING Investigate chief complaint, focus on MOI
SAMPLE history
If patient is not responsive, obtain history from family or friends.
Ask if there is nausea, vomiting, diarrhea and appearance of any bowel and urinary output.

23. SECONDARY ASSESSMENT Physical examinations Inspect for bleeding.
Evaluate the bowel sounds.
Hypoactive = cannot hear sounds
Hyperactive = lots of gurgling and gas moving about
Use DCAP-BTLS
Perform full-body scan to identify injuries, beginning with head
Vital signs
Many abdominal emergencies can cause a rapid pulse and low blood pressure.

24. REASSESSMENT Repeat the primary assessment and reassess vital signs.
Interventions
Manage airway and breathing problems.
Provide spinal stabilization, treatment for shock
Cover wounds
Communication and documentation
Communicate all relevant information to staff at receiving hospital.

25. EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (1 OF 4)
Closed abdominal injuries
Patient requires immediate transport.
Apply high-flow oxygen.
Treat for shock.
Patient with blunt abdominal injury should be log rolled to a supine position on a backboard.
Monitor vital signs

26. EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (2 OF 4)
Open abdominal injuries
Patients with penetrating injuries
Inspect patient’s back and sides for exit wound.
Apply dry, sterile dressing to all open wounds.
If penetrating object is still in place, apply stabilizing bandage around it.

27. EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (3 OF 4)
Evisceration: Severe lacerations of abdominal wall may result in internal organs or fat protruding through wound.

28. EMERGENCY MEDICAL CARE OF ABDOMINAL INJURIES (4 OF 4)
Open abdominal injuries (cont’d)
Never try to replace a protruding organ.
Keep the organs moist and warm.
Cover with moistened, sterile gauze or occlusive dressing.
Secure dressing with bandage.
Secure bandage with tape.

29. ANATOMY OF THE GENITOURINARY SYSTEM (1 OF 3)
Controls reproductive functions and waste discharge
Male genitalia lie outside pelvic cavity.
Except prostate gland and seminal vesicles
Female genitalia lie within pelvic cavity.
Except vulva, clitoris, labia

30. ANATOMY OF THE GENITOURINARY SYSTEM (2 of 3)

31. Anatomy of the Genitourinary System (3 of 3)

32. INJURIES OF THE GENITOURINARY SYSTEM (1 OF 4)
Kidney injuries
Suspect kidney damage if:
Abrasion, laceration, contusion in the flank
Penetrating wound in region of flank or upper abdomen
Fractures on either side of lower rib cage
A hematoma in the flank region

33. INJURIES OF THE GENITOURINARY SYSTEM (2 OF 4)
Urinary bladder injuries
Blunt injuries to lower abdomen or pelvis can rupture urinary bladder.
In later trimesters of pregnancy, bladder injuries increase.

34. INJURIES OF THE GENITOURINARY SYSTEM (3 OF 4)
External male genitalia injuries
Soft-tissue wounds, painful but not life threatening.
Female genitalia injuries
Uterus, ovaries, fallopian tubes are rarely damaged, the exception is pregnant uterus
Uterus enlarges substantially and rises out of pelvis
Also keep fetus in mind.
In last trimester of pregnancy, uterus is large and may obstruct vena cava.

35. INJURIES OF THE GENITOURINARY SYSTEM (4 OF 4)
External female genitalia
Very rich nerve supply
Consider sexual assault and pregnancy.
If there is external bleeding, a sterile absorbent sanitary pad may be applied to the labia.
Do not insert anything into the vagina.

36. PATIENT ASSESSMENT OF THE GENITOURINARY SYSTEM (1 OF 2)
Potential for patient embarrassment
Maintain a professional presence.
Provide privacy .
Have EMT of same gender perform assessment.
Look for blood on patient’s undergarments.

37. PATIENT ASSESSMENT OF THE GENITOURINARY SYSTEM (2 OF 2)
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

38. SCENE SIZE-UP Scene safety Assess the scene for hazards and violence.
Mechanism of injury/nature of illness
Look for indicators of MOI.
Patient may avoid the discussion to avoid undergoing a physical exam.
Patient may also provide an MOI that seems less embarrassing than the actual MOI.

39. PRIMARY ASSESSMENT (1 OF 2)
Form a general impression.
Important indicators will alert you to the seriousness of the condition.
Is the patient awake and interacting?
Are there any life threats?
What color is the patient’s skin?
Is he or she responding appropriately or inappropriately?

40. PRIMARY ASSESSMENT (2 OF 2)
Airway and breathing
Ensure the patient has a clear and patent airway.
Circulation
Genitourinary system can be a significant source of bleeding.
Assess pulse rate and quality.
Determine skin condition, color, and temp.
Check capillary refill time.
Transport decision

41. HISTORY TAKING Investigate chief complaint.
Common associated complaints are:
Nausea and vomiting, Diarrhea
Blood in urine
Vomiting blood
Abnormal bowel and bladder habits
SAMPLE history
Ask about pain, output especially blood in urine allergies, past medical history, last intake of food and fluid.

42. SECONDARY ASSESSMENT Physical examinations Look for DCAP-BTLS.
Identify wounds and control bleeding.
Start with a full-body scan for significant trauma.
Vital signs
Obtain the patient’s vital signs
Tachycardia; tachypnea; low blood pressure; weak pulse; and cool, moist, pale skin indicate hypoperfusion.

43. REASSESSMENT Interventions Provide oxygen and maintain airway.
Control bleeding and treat for shock.
Communication and documentation
Communicate all concerns to hospital staff.
Describe and document all injuries and treatments given.

44. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (1 OF 7)
Kidney injuries
Signs of shock
Blood in urine (hematuria)
Treat for shock, transport promptly, monitor vital signs en route.
Urinary bladder injury
Blood at urethral opening
Signs of trauma to lower abdomen, pelvis, perineum
In presence of shock, transport promptly and
Monitor vital signs en route.

45. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (2 OF 7)
External male genitalia
General rules for treatment:
Make patient comfortable.
Use sterile, moist compresses to cover areas stripped of skin.
Apply direct pressure with dry, sterile gauze dressings to control bleeding.
Never move or manipulate foreign objects in urethra.

46. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (3 OF 7)
Laceration of head of penis
Associated with heavy bleeding
Apply local pressure with sterile dressing.
Skin of shaft or foreskin caught in zipper
If small segment of zipper is involved, try to unzip.
If long segment of zipper is involved, cut the zipper out of the pants with heavy scissors.

47. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (4 OF 7)
Urethral injuries
Straddle injuries, pelvic fractures, and penetrating wounds of the perineum
Important to know if patient can urinate and if there is blood in urine.
Foreign bodies protruding from urethra will have to be surgically removed.

48. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (5 OF 7)
Avulsion of the skin of the scrotum may damage scrotal contents.
Preserve avulsed skin in a moist sterile dressing.
Wrap scrotal contents or perineal area with a sterile moist compress; use local pressure for bleeding.
Direct blows to scrotum can result in rupture of a testicle or accumulation of blood around testes.
Apply ice to scrotal area.

49. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (6 OF 7)
Female genitalia
Treat lacerations and avulsions with moist, sterile compresses.
Use local pressure to control bleeding.
Do not pack dressings into vagina.
Leave any foreign bodies in place after stabilizing with bandages

50. EMERGENCY MEDICAL CARE OF GENITOURINARY INJURIES (7 OF 7)
Rectal bleeding
Possible causes include sexual assault, hemorrhoids, colitis, ulcers.
Acute rectal bleeding should never be passed off as something minor.

51. SEXUAL ASSAULT (1 OF 2) Sexual assault and rape are common.
Victims are generally women.
Do not examine genitalia unless obvious bleeding requires application of dressing.
Follow appropriate procedures and protocol.
Shield patient from curious onlookers.
Document patient’s history, assessment, treatment, and response to treatment

52. SEXUAL ASSAULT (2 OF 2) Follow crime scene policy of your EMS system.
Advise patient not to wash, douche, urinate, or defecate until after examination.
If oral penetration occurred, advise patient not to eat, drink, brush the teeth, or use mouthwash until after examination.
Handle patient’s clothes as little as possible.
Make sure EMT caring for patient is same gender as patient whenever possible.

53. SUMMARY
Abdominal injuries are categorized as either open (penetrating trauma) or closed (blunt force trauma).
Blunt force trauma that causes closed injuries results from an object striking the body without breaking the skin, such as being hit with a baseball bat or when the patient’s body strikes the steering wheel during a motor vehicle crash.
Penetrating trauma is often a result of a gunshot wound or stab wound. Other MOIs such as a fall on an object can also cause penetrating trauma to the abdomen.

54. SUMMARY
Always maintain a high index of suspicion for serious intra-abdominal injury in the trauma patient, particularly in the patient who exhibits signs of shock.
Assess the abdomen for signs of bruising, rigidity, penetrating injuries, and pain.
Never remove an impaled object from the abdominal region. Secure it in place with a large bulky dressing and provide prompt transport.
Be prepared to treat the patient for shock. Place the patient in the modified shock position, keep the patient warm, and provide high-flow oxygen.

55. SUMMARY
Never replace an organ that protrudes from an open injury to the abdomen (evisceration). Instead, keep the organ moist and warm. Cover the injury site with a large sterile, moist, bulky dressing.
Injury to the external genitalia of male and female patients is very painful but not usually life threatening.
In the case of sexual assault or rape, treat for shock if necessary, and record all the facts in detail. Follow any crime scene policy established by your system to protect the scene and any potential evidence. Advise the patient not to wash, douche, or void until after a physician has examined him or her.

56. UNIT ASSESSMENT
List three signs and symptoms associated with abdominal injuries
What is the displacement of abdominal organs outside of the body called?
What findings would suggest damage to the kidneys?