Abdominal injuries can be caused by penetrating and blunt trauma. For the paramedic, determining the exact structures injured is not as essential as being able to recognize that an abdominal injury has occurred. This section will talk very broadly about the abdominal examination and presentations of certain injuries. Finally, certain injuries that require treatment beyond just intravenous fluids and cardiac monitoring will be discussed. In addition, the abdominal anatomy is discussed in chapter 5 in the section titled Gastrointestinal Emergencies.
The abdomen is particularly susceptible to blunt and penetrating trauma. It is not protected with bone like the chest and pelvis to help mitigate some of the forces involved in either type of trauma. It is highly vascular, so bleeding can occur from just about anywhere in the abdomen in meaningful amounts to quickly lead to shock. Laceration of any hollow organ in the abdomen—the stomach, intestines, or bladders—can lead to not only massive hemorrhage but also sepsis if the contents leak out.
Abdominal injuries should, therefore, be treated as a potentially lethal and true emergency. At this time, nothing can be done in the prehospital world for an abdominal injury. These injuries require surgical intervention to repair the laceration or remove the organ in its entirety, such as might occur from a lacerated spleen.
Unlike pain from other trauma, abdominal pain often is diffuse throughout the abdominal cavity, making it difficult to confidently isolate the source of the injury. Furthermore, because so much is going on in any of the 4 quadrants, even if the pain can be narrowed down to 1 quadrant, it could still be from any of several organs. For example, in the URQ, pain could be from liver lacerations, kidney lacerations, a gall bladder rupture, large or small intestine trauma, or lacerations to the head of the pancreas. Any of these could result in significant hemodynamic instability from internal bleeding.
Assessment of the patient with the closed abdominal injury begins by exposing the area and evaluating for any bruising. Periumbilical bruising (the Cullen sign) or bruising to either or both flanks (the Grey Turner sign) are strong indicators of internal bleeding. They are somewhat late signs, however, and, if present, the person has either been bleeding for a while or is bleeding heavily.
Next, each of the 4 quadrants should be palpated firmly, compressing the abdomen 2–3 inches using the entire area of the fingers, not just the tips. The quadrant furthest from the painful quadrant should be palpated 1st, while the quadrant the patient identified as painful should be saved for last. This is done because if the painful quadrant is palpated 1st, it may hinder the patient’s ability to tell if the other quadrants are pain free during palpation. During palpation also note if the abdomen is rigid. This can be from blood in that area or muscular guarding of the area. Either of these are good indicators of an injury to that quadrant.
Management of the patient with a closed abdominal injury should largely be supportive, with an eye toward prophylactic shock prevention. Administer high-flow O2 as with any multisystem trauma patient. Initiate at least 1 large-bore intravenous line as soon as possible without delaying transport to the hospital; initiate a 2nd if time permits. Initiate continuous cardiac monitoring and treat any dysrhythmia found. Treat any external wounds.
An evisceration is a deep laceration to the abdominal cavity that results in the abdominal contents spilling outside. Needless to say, this is a very serious injury that requires rapid transport to the nearest trauma center. Do not palpate over the eviscerated abdomen or the contents. Do not attempt to push the contents back into the abdomen. Instead, cover all the exposed contents with a moist sterile dressing and then cover the entire area with another bandage to keep warm. Initiate at least 1 intravenous line and treat for shock.