51 Abdominal trauma
Overview/pathophysiology
Abdominal trauma accounts for nearly 7 million emergency department visits in the United States annually and often causes serious injury to major organs. It is essential to understand the mechanism of the injury (blunt, penetrating, or combination) and the abdominal organs affected to avoid complications in the recovery period. Astute serial assessments in the posttraumatic period may prevent serious consequences and avoid life-threatening situations. Abdominal injuries often are associated with multisystem trauma. See also discussions in “Pneumothorax/Hemothorax,” p. 120; “Spinal Cord Injury,” p. 306; and “Traumatic Brain Injury,” p. 333.
Blunt trauma may be caused by falls, assaults, motor vehicle collisions, or sports injuries and involve direct transmission of energy to solid or hollow organs, most commonly affecting the spleen and liver. Splenic injury should be suspected in the presence of left lower rib fractures. Rupture may not be immediately obvious, reinforcing the need for ongoing assessments. Pain radiating to the left shoulder (Kehr’s sign) may indicate blood beneath the diaphragm from splenic bleeding. Pain radiating to the right shoulder may indicate injury to the liver. Other organs that may be affected by blunt trauma include the kidneys and, occasionally, the pancreas and small and large intestines. Bleeding is the most common complication, resulting in increased morbidity and mortality. Abdominal vessels are injured in about 10% of blunt abdominal trauma patients and can quickly lead to shock and death if not recognized. Signs of blood loss may not be evident initially. For example, young healthy patients may lose up to 50% of their blood volume and appear stable.
Gunshot, stabbing, or impalement may cause penetrating trauma, and the external appearance of the wound does not accurately represent internal damage. If the lower esophagus, stomach, or intestines are injured by penetration, complications from release of irritating gastric and intestinal fluids into the peritoneum and free air below the diaphragm may occur. Penetrating injuries to the solid organs may cause fatal damage if not identified early.
Assessment
As with all trauma patients, immediate life-threatening problems are identified and treatment is initiated before the more detailed secondary and focused assessments can be completed.
Caution: Recently injured patients should be evaluated for peritoneal signs (generalized abdominal pain or tenderness, guarding of abdomen, abdominal wall rigidity, rebound tenderness, abdominal pain with movement or coughing, abdominal distention, and decreased or absent bowel sounds) at hourly intervals. The health care provider must be notified immediately if the patient develops peritoneal signs, evidence of shock, gastric or rectal bleeding, or gross hematuria.
Vital signs (VS) and hemodynamic measurements:
VS should be assessed frequently to detect changes. Gradual or sudden changes may be the heralding signs of hemorrhage following trauma, with tachycardia, impaired capillary refill, and hypotension key indicators of bleeding or shock. Respiratory assessment is essential along with VS because ventilatory excursion may be diminished due to pain, thoracic injury, or limited diaphragmatic movement caused by abdominal distention, which may impede oxygenation.
Pain:
Mild tenderness to severe abdominal pain may be present, with pain either localized to the site of injury or diffuse. Blood or fluid collection within the peritoneum causes irritation and may cause guarding, distention, rigidity, and rebound tenderness.
Gastrointestinal symptoms:
Nausea and vomiting may be present following blunt or penetrating trauma secondary to bleeding or obstruction. Note: Absence of signs and symptoms, especially in patients who have sustained head or spinal cord injury, does not exclude presence of major abdominal injury.
Inspection:
Abrasions and ecchymoses are suggestive of underlying injury. For example, ecchymosis over the left upper quadrant (LUQ) suggests possible splenic injury. Ecchymotic areas around the umbilicus or flanks are suggestive of retroperitoneal bleeding. Erythema and ecchymosis across the lower abdomen suggest intestinal or bladder injury caused by lap belts. Ecchymoses may take hours to days to develop, depending on rate of blood loss. Abdominal distention may signal bleeding, free air, or inflammation.
Auscultation:
Bowel sounds should be auscultated frequently, especially in the first 24-48 hr after injury. Auscultate before percussion and palpation to avoid stimulating the bowel and confounding assessment findings. Bowel sounds may be decreased or absent with abdominal organ injury and intraperitoneal bleeding. However, the presence of bowel sounds does not exclude significant abdominal injury. Bowel sounds in the chest could indicate a ruptured diaphragm with small bowel herniation into the thorax. Absence of bowel sounds is suggestive of ileus or other complications, such as bleeding, peritonitis, or bowel infarction. Presence of an abdominal bruit (turbulent blood flow through vessels) could indicate arterial injury.
Note: Percuss and palpate painful areas last. If patient’s pain is severe, do not percuss or palpate because more advanced studies are indicated for evaluation.
Percussion:
Tympany suggests the presence of gas. Percussion may reveal unusually large areas of dullness over ruptured blood-filled organs (e.g., a fixed area of dullness in the LUQ suggests a ruptured spleen).
Diagnostic tests
White blood cell (WBC) count:
Leukocytosis is expected immediately after injury. Splenic injuries in particular result in rapid development of a moderate to high WBC count. A later increase in WBCs or a shift to the left reflects an increase in the number of neutrophils, which signals inflammatory response and possible intraabdominal infection.
Platelet count:
Mild thrombocytosis is seen immediately after traumatic injury. Thrombocytopenia may be present following massive hemorrhage.
Glucose:
Glucose is initially elevated because of catecholamine release and insulin resistance associated with major trauma. Glucose metabolism is abnormal after major hepatic resection, and patients should be monitored to prevent hypoglycemic episodes.
Arterial blood gases:
Essential in respiratory distress to determine presence of hypoxemia, hypercapnia, and respiratory or metabolic acidosis or alkalosis.
Type and cross match:
If blood replacement is anticipated.
Note: A flow sheet for serial laboratory values will help pinpoint changes that might otherwise go unnoticed.
X-ray examination:
Initially, flat and upright chest x-ray examinations exclude chest injuries (commonly associated with abdominal trauma) and establish a baseline. Subsequent chest x-ray examinations aid in detecting complications, such as atelectasis and pneumonia. In addition, chest and pelvic x-ray examinations may reveal fractures, missiles, foreign bodies, free intraperitoneal air, hematoma, or hemorrhage. Plain abdominal films are not useful in blunt trauma because they cannot define blood in the peritoneum.
Ultrasound:
Ultrasound is a rapid, noninvasive assessment tool for detecting intraabdominal hemorrhage. The Focused Assessment Sonogram for Trauma (FAST) has a sensitivity, specificity, and accuracy rate of more than 90% in detecting 100 mL or more of intraabdominal blood or fluid. It can neither image the retroperitoneum nor determine etiology of the bleeding. A single negative FAST cannot absolutely exclude intraabdominal bleeding.
Computed tomography (CT) scan:
Reveals organ-specific blunt abdominal injury and quantifies the amount of blood in the abdomen. CT images the ureters and can detect extravasation of urine. Disadvantages are the expense and time required to perform the examination. Patients with positive CT scan require diagnostic laparotomy. Caution: A patient in unstable condition always must be accompanied by a nurse during the CT scan.
Diagnostic peritoneal lavage:
Involves insertion of a peritoneal dialysis catheter into the peritoneum to check for intraabdominal bleeding. This procedure is much less common since FAST and CT scan have become available. It may be indicated for confirmed or suspected blunt abdominal trauma for any patient with signs and symptoms of abdominal injury obscured by intoxication, head or spinal cord trauma, opioids, or unconsciousness. Diagnostic peritoneal lavage is unnecessary for patients who have obvious intraabdominal bleeding or other indications for immediate laparotomy.
Laparotomy:
The “gold standard” for intraabdominal injuries, this procedure enables complete evaluation of the abdomen and retroperitoneum. It is recommended in all patients with severe hypotension, penetration of the abdominal wall, peritonitis, air in the abdomen, and in most cases of organ-specific injury noted on CT scan.
Occult blood:
Gastric contents, urine, and stool must be tested for occult blood because bleeding can occur as a result of direct injury causing significant complications.
Angiography:
Performed to evaluate injury to spleen, liver, pancreas, duodenum, and retroperitoneal vessels. Caution: Ensure adequate hydration and monitor urine output closely for 24-48 hr following angiography because the large amount of contrast used may cause renal failure, especially in older adults or in patients with preexisting cardiovascular or renal disease. Decreased urinary output and increased blood urea nitrogen (BUN) and creatinine may indicate contrast-associated acute tubular necrosis.
Nursing diagnosis:
Ineffective breathing pattern
related to pain from injury or surgical incision, chemical irritation of blood or bile on pleural tissue, and diaphragmatic elevation caused by abdominal distention
Desired Outcome: Within 24 hr of admission or surgery, patient is eupneic with respiratory rate (RR) 12-20 breaths/min and clear breath sounds.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess quality of breath sounds, RR, presence/absence of cough, and sputum characteristics. | Individuals sustaining abdominal trauma are likely to be tachypneic, with the potential for poor ventilatory effort. If not reversed, this could result in atelectasis and pneumonia. |
| Monitor oximetry readings q2-4h; report significant findings. | O2 saturation 92% or less usually signals need for supplemental oxygen. |
| Administer supplemental oxygen as prescribed. Monitor and document effectiveness. | Supplemental O2 is delivered until patient’s arterial blood gas or oximetry values while breathing room air are acceptable. |
| Encourage and assist patient with coughing, deep breathing, incentive spirometry, and turning q2-4h. | These measures help prevent pneumonia and atelectasis. |
| Administer analgesics at dose and frequency that relieves pain and associated impaired chest excursion. | Reducing pain will enable full chest excursion for better oxygenation. |
| Instruct patient in methods to splint abdomen. | This information will help the patient reduce pain on movement, coughing, and deep breathing, which in turn will aid the respiratory effort. |
| For additional interventions, see “Perioperative Care” Ineffective Breathing Pattern, p. 46. |
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