Blunt Abdominal Trauma Author: Kristi Hudson RN MSN CCRN Pathophysiology There are two primary mechanisms of injury

when it comes to blunt abdominal trauma, and they are either compression or deceleration injuries. Compression injuries are those that occur from direct blows against a fixed object (lap belt, spinal column, steering wheel) or a penetrating object. It is the transient pressure from these crushing injuries that cause tears and sub-capsular hematomas to the solid organ viscera (Liver and Spleen). These forces can also cause an intra-luminal pressure increase to hollow organs causing them to rupture (Small Bowel). Deceleration forces between relatively fixed and free objects cause more of a shearing or tearing type of injury. Classic longitudinal shearing injuries usually rupture supporting structures to solid and hollow organs and include; a hepatic tear (along the ligamentumteres), injuries to the renal arteries and mesenteric tears. Common Abdominal Injuries After Blunt Trauma Liver Injuries The liver may be lacerated by either blunt or penetrating trauma. Clinical findings include pain or tenderness in the upper right quadrant (rebound tenderness is often present). The source of pain is often due to blood ( it only needs to be present for two hours) in the abdominal cavity that causes peritoneal irritation. Liver laceration should be suspected when penetrating trauma involves the right lower chest or right upper abdomen, or when right upper quadrant tenderness accompanies blunt trauma. Diagnosis of a liver laceration can be obtained by CT (for stable patients). If the patient is exhibiting signs of shock or has other urgent injuries, a diagnostic peritoneal lavage (DPL) to confirm intra-peritoneal hemorrhage is more appropriate. Treatment for large liver lacerations or penetrating wounds will require surgical intervention to either pack or repair the injury. For smaller injuries close observation, frequent assessment including labs to monitor hemoglobin will be required. The following liver laceration grading scale is used to determine the severity of injury and as a guide for treatment. Spleen Injuries The spleen is the most commonly injured organ in blunt abdominal trauma. Clinical findings include tachycardia, hypotension (the most common presentation), and upper left quadrant pain. Rib fractures (9th and 10th), on the left side is also a common clinical finding. If injury to the phrenic nerve is present, the patient may complain of left shoulder/scapular pain as well. Peritoneal signs such as rebound sensitivity and guarding will be delayed until the blood has had time to cause local irritation to the peritoneum. Diagnosis of a spleen injury can be made by obtaining a CT (for stable patients). If the patient is exhibiting signs of shock or has other urgent injuries, a diagnostic peritoneal lavage (DPL) to confirm intra-peritoneal hemorrhage is more appropriate, however; any patient with tachycardia or hypotension and left upper quadrant tenderness is assumed to have a ruptured spleen until proven otherwise. Treatment for large spleen injuries will require either a splenectomy or over-sewing to repair the injury. For smaller injuries close observation, frequent assessment including labs to monitor hemoglobin will be required.

Kidney Injuries Injuries to the Kidney are more commonly seen with falls, automobile accidents and other blunt trauma usually to the lower back. When there are fractures to the 11th and 12th ribs or complaints of flank pain or tenderness, an injury to one or both kidneys should be suspected. Clinical findings include complaints of pain on inspiration, hematuria (of any degree) and complaints of abdominal or flank pain. Flank discoloration (bruising) is a late finding. Differentiating between the lacerated kidney and the contused kidney requires IVP examination or CT scan. The lacerated kidney will show leakage of dye, whereas the contused kidney will either be normal or show a blush of dye in the kidney stroma. Observation is appropriate for a kidney contusion however; surgical consultation is necessary for a lacerated kidney or any type of kidney injury that shows extravasation of dye during IVP or CT. Ruptured Bowel It is penetrating injuries that most commonly cause the bowel to rupture. The small bowel is most frequently injured, followed by the stomach and then the large intestine. Though penetrating injury is the most common source of injury, crushing injuries (steering wheel, lap belts) are also a common sources of injury (in these cases it is the duodenum that most often becomes injured). Clinical findings include complaints of abdominal pain (most likely due to intestinal contents rather than blood in the peritoneum. Description of the pain from stomach or intestinal rupture is described as a vague generalized pain or epigastric burning. Back pain may be a complaint if there is duodenal injury. Diagnosis of a ruptured bowel is determined by visualizing free air in the peritoneal cavity either with x-ray or CT. Diagnostic peritoneal lavage (DPL) will show WBCs and intestinal contents. Surgical intervention for a patient with a ruptured bowel is required. Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage (DPL) is performed when intra-abdominal bleeding secondary to trauma is suspected. The procedure is performed when CT or ultra-sound are not available or when the patient is too unstable and time is of the essence. The following is a step by step approach to performing a 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 that there is a serious intra-abdominal injury. Positive DPL findings include:

Bloody Lavage Fluid Red Blood Cells > 100,000 cells/mm White Blood Cells > 500 cells/mm

Amylase > 175 U/100 ml The presence of any of the following is considered a positive DPL: Bacteria Fecal Material Bile Food Products

Nursing Assessment/Documentation of the Patient with Blunt Abdominal Trauma Includes:

Appearance (distention, ecchymosis, lap belt signs, abrasions, wounds) Auscultation (bowel sounds, bruits) Tenderness (guarding, rebound pain) Palpation (organomegaly, pulsating masses)

Signs of Peritonitis include:

Abdominal pain (that increases with movement) Abdominal rigidity Abdominal guarding Abdominal distention Diminished or absent bowel sounds Fever Chills Nausea/Vomiting Anorexia Shallow respirations (associated with pain) Tachycardia

Nursing Care and Management of the Patient With Blunt Abdominal Trauma Includes:

Monitor Vital signs/Respiratory status/Pain assessment Routine Labs (notify physician of trends/abnormal values) CBC (special attention to WBCs and HgB/Hct) Electrolytes Foley Catheter (can be used for intra-abdominal pressure monitoring) Urine output (check for hematuria with kidney injury) Complete and ongoing abdominal assessment Pt. should remain NPO until surgical intervention is ruled out NG to low continuous suction IV or nutritional support Sequential or Ted hose

Post-op patient family education:

Incision site care (signs and symptoms of infection)

Pain Management Work/Exercise/Rest balance Diet Prescriptions Follow-up care

Nursing Diagnosis:

Alteration in Comfort: Pain Alteration in Nutrition Potential for Infection Altered Breathing Pattern Immobility Knowledge Deficit

Author: Kristi Hudson RN MSN CCRN References Marini, J., J. & Wheeler, A., P. (2006). Critical care medicine: the essentials. (3rd ed.). Lippencott, Williams and Wilkes. Philadelphia Salomone, J., A. MD. (2006). Abdominal trauma, blunt. Retrieved on December 9, 2006 at: http://www.emedicine.com/emerg/topic1.htm Cohen, S., S., RN, MSN, CEN, CCRN. (2003). Trauma Nursing Secrets.Hanley and Belfus.Philadelphia Diagnostic Peritoneal Lavage (2001). Retrieved on February 20, 2005 at: www.shands.org/health/surgeries/100159.html Lozen, Yvonne., RN, MS, CCRN (1999). AACN Clinical Issues Advanced Practice. Vol. 10.Number 1. Retrieved on December 10, 2006 at: www.aacn.org