Transcript Bleeding and Shock - Adirondack Area Network

Abdominal Pain
AMY LITTLE, MD
ALBANY MEDICAL CENTER
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GOALS
 Review the anatomy of the abdomen
Quadrants
Peritoneal vs. Retroperitoneal
Solid vs. Hollow organ
Vascular structures
 Assessment (History and Physical Exam)
 Management
 Abdominal trauma
 Special situations
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The Abdomen
 Everything between
diaphragm and pelvis
 Injury and illness can
be very difficult to
assess because of
large variety of
structures
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Abdominal Anatomy
 Abdomen divided into
four quadrants by
body mid-line,
horizontal plane
through umbilicus
 Organs can be
located by quadrant
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Abdominal Anatomy
 Right Upper Quadrant
Liver
Gall Bladder
Right Kidney
Ascending Colon
Transverse Colon
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Abdominal Anatomy
 Left Upper Quadrant
Spleen
Stomach
Pancreas
Left Kidney
Transverse Colon
Descending Colon
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Abdominal Anatomy
 Right Lower Quadrant
Ascending Colon
Appendix
Right Ovary (female)
Right Fallopian Tube
(female)
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Abdominal Anatomy
 Left Lower Quadrant
Descending Colon
Sigmoid colon
Left Ovary (female)
Left Fallopian Tube
(female)
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Abdominal Anatomy
Periumbilical area
Located around (peri) the navel (umbilicus)
Small bowel lies in all quadrants in periumbilical
area
Suprapubic area
Located just above pubic bone
Urinary bladder, uterus lie in this area
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Abdominal Cavity
 Peritoneum =
abdominal cavity
lining
 Divides abdomen into
two spaces
Peritoneal cavity
Retroperitoneal space
(retro=behind)
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Abdominal Anatomy
 Peritoneal
Spleen
Liver
Stomach
Gall bladder
Bowel
 Retroperitoneal
Pancreas
Kidney
Ureter
Inferior vena cava
Abdominal aorta
Urinary bladder
Reproductive organs
NOTE: Disease or injury of
retroperitoneal organs often causes
back pain.
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Abdominal Anatomy
REVIEW: Organs are classified by
Quadrant, periumbilical, or suprapubic
Peritoneal or retroperitoneal
Organs can also be classified as:
Solid
Hollow
Major vascular
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Solid Organs
Liver
Spleen
Kidney
Pancreas
NOTE: When solid organs
are injured, they bleed
heavily and cause shock.
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Solid Organs
Liver
Largest abdominal organ
Most frequently injured
Fractures of ribs 8-12 on right side
Bleeding can be either:
Slow, contained under capsule
Free into peritoneal cavity
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Solid Organs
 Spleen
Frequently injured with
trauma ribs 9-11 on left side
Bleeds easily
Capsule around spleen tends
to slow development of shock
Rapid shock onset when
capsule ruptures
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Solid Organs
 Pancreas
Lies across lumbar
spine
Sudden deceleration
produces straddle injury
Very little hemorrhage
Leakage of enzymes
digests structures in
retroperitoneal space,
causes volume loss,
shock
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Solid Organs
 Kidney
Retroperitoneal
Vulnerable to trauma
(blunt & penetrating),
infection, obstruction,
chronic disease
Tenderness: Lower ribs,
upper L-spine, flank
Pain: groin, shoulder,
back, flank
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Hollow Organs
Stomach
Gall bladder
Large, small intestines
Ureters, urinary bladder, urethra
Rupture causes content
spillage & inflammation of
peritoneum.
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Hollow Organs
 Stomach
Acid, enzymes
Immediate
peritonitis
Pain, tenderness,
guarding, rigidity
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Hollow Organs
Colon
Spillage of bacteria
May take 6 hrs to develop peritonitis
Small Bowel
Fewer bacteria
May take 24-48 hours to develop peritonitis
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Hollow Organs: Urinary System
 Ureters
 Penetrating injury
 Bladder
 Blunt injury (seatbelts, pelvic fracture)
 Urethra
 Straddle injury
Signs and Symptoms
 Abnormal urination (Urgency, Inability, Dysuria,
Hematuria)
 Blood at external meatus
 Perineal bruising (butterfly bruise)
 Scrotal hematoma
 Shock
 Abdominal distension
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Major Vascular Structures
Aorta
Inferior vena cava
Major branches
Injury can cause severe
blood loss; exsanguination
(bleeding out).
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QUESTIONS about Abdominal Anatomy?
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ASSESSMENT of Abdominal Pain
History
LOCATION
Where do you hurt?
Know locations of major organs
But realize abdominal pain
locations do not always correlate
well with source
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ASSESSMENT of Abdominal Pain
QUALITY
What does pain feel like?
Steady pain - inflammatory process
Crampy pain - obstructive process
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ASSESSMENT of Abdominal Pain
ONSET
Was onset of pain gradual or
sudden?
Sudden = perforation, hemorrhage,
infarct
Gradual = peritoneal irritation,
hollow organ distension
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ASSESSMENT of Abdominal Pain
RADIATION
Does pain radiate (travel) anywhere?
Right shoulder, angle of right
scapula = gall bladder
Left shoulder = spleen, stomach
Around flank to groin = kidney,
ureter
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ASSESSMENT of Abdominal Pain
DURATION
> 6 hour duration = ? surgical significance
ASSOCIATED SYMPTOM:
Nausea &/or vomiting? Bloody? “Coffee
Grounds”?
Any blood in GI tract =
Emergency until proven otherwise
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ASSESSMENT of Abdominal Pain
Change in urinary habits? Urine
appearance?
Change in bowel habits? Diarrhea?
Appearance of bowel movements?
Melena?
Regardless of underlying cause vomiting
or diarrhea can be a problem because of
associated volume loss.
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ASSESSMENT of Abdominal Pain
Females
Last menstrual period?
Abnormal vaginal bleeding?
In females, abdominal pain =
Gynecological problem until proven
otherwise.
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PHYSICAL EXAM
General Appearance
Lies perfectly still inflammation = peritonitis
Restless, writhing obstruction
Abdominal distension?
Ecchymosis around umbilicus, flanks?
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PHYSICAL EXAM
Vital signs
Tachycardia = Early shock &/or
pain (more important than BP)
Rapid shallow breathing =
peritonitis
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PHYSICAL EXAM
Palpate each quadrant
Work toward area of pain
Warm hands
Patient on back, knee bent (if possible)
Note tenderness, rigidity, involuntary guarding,
voluntary guarding, masses
Bowel sounds (?)
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Management
Airway
High concentration O2
Anticipate vomiting
Anticipate hypovolemia
Need PIV, IVF
Nothing by mouth except medications
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Management
Consider referred cardiac pain:
 Adults > 30
 Diabetics
 History of cardiac problems
In females, consider gynecological
problems, especially ruptured ectopic
pregnancy (surgical emergency)
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QUESTIONS about general assessment
or management?
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REVIEW: GOALS
 Review the anatomy of the abdomen
 Quadrants
 Peritoneal vs. Retroperitoneal
 Solid vs. Hollow organ
 Vascular structures
 Assessment (History and Physical Exam)
 Management
NEXT:
 Abdominal trauma
 Special situations
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Abdominal Trauma
Most survive to reach hospital
Most common factors leading to death
Failure to adequately evaluate
Delayed resuscitation
Inadequate volume replacement
Inadequate/missed diagnosis
Delayed surgery
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High Index of Suspicion in Trauma
Mechanism
Unexplained hypovolemic shock
Signs of injured abdomen
Management
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Mechanism
Look for signs of injury
Bruises
Tire marks
Obvious open injuries
Trauma to lower chest, back, flank,
buttocks, and perineum
Injury above umbilicus also involves chest
until proven otherwise
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Unexplained Shock
Assess vital signs; skin color, temperature;
capillary refill
Tachycardia; restlessness; cool, moist skin
In trauma, signs of shock suggest
abdominal injury if no other obvious
causes present
Assume any abdominal injury is serious
until proven otherwise!
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Signs of Injured Abdomen
 Diffuse tenderness
 Pain
Pain referred to shoulder =
Organ under diaphragm
involved (?spleen)
Pain referred to back =
Retroperitoneal organ
involved (?kidney)
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Abdominal Trauma Management
Less important to diagnose exact injury
Treat clinical findings (open wounds,
hypotension/tachycardia)
Management same regardless of specific
organ(s) injured
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Abdominal Trauma Management
Airway
C-Spine if mechanism indicates
High flow O2
Assist ventilations if needed
Give nothing by mouth
(?) MAST may be helpful in slowing
intraabdominal bleeding with shock
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Special situations in Abdominal Pain
Impaled objects
Evisceration
Trauma to the reproductive system
Sexual assault
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Impaled Object
Leave in place
Shorten if necessary for transport
Leave part of object exposed
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Evisceration
With large laceration abdominal
contents may spill out
Do NOT try to replace
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Evisceration
Cover exposed organs with saline
moistened multi-trauma dressing
Do NOT use 4 x 4s
Cover first dressing with second DRY
dressing or aluminum foil
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Reproductive System Trauma
 Can occur to both external and internal
reproductive systems
External
 More common
 Pain, extensive bleeding
Internal
 Less frequently injured
 Treat like blunt or penetrating soft tissue
injuries elsewhere on body
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Male Genitalia Trauma
 Usually NOT
life-threatening
 Very painful
 Great source of
concern to
patient
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Male Genitalia Trauma
 Avulsion of skin of
penis, scrotum
Cover with a moist,
sterile dressing
 Complete
amputation of penis
Treat as any
amputated part
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Male Genitalia Trauma
Blunt trauma to penis, scrotum
Apply ice pack
Urethral foreign bodies
Do NOT remove
Penis entrapped in zipper
If 1 or 2 teeth involved, try to unzip
If more involved, cut zipper out of trousers,
transport
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Female Genitalia Trauma
 Internal
Rarely injured
 External
Can cause pain,
extensive bleeding
Usually not lifethreatening
 Treat with
compresses,
pressure
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Sexual Assault
Avoid examining genitalia unless
obvious bleeding present
Ask patient to NOT wash, douche,
urinate, defecate
Ask patient NOT to change clothes
Record history, but avoid extensive
questioning about incident
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SUMMARY: Abdominal Pain
Consider the anatomy
In general abdominal pain, note HISTORY
In trauma, think about mechanism
ManagementANTICIPATE!
Vomiting=airway
Hypovolemiaresuscitation
Appropriate transport
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THANK YOU FOR YOUR ATTENTION!
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