Blunt Force Injuries of the Abdominal Viscera

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The abdominal organs are vulnerable to a variety of injuries from blunt trauma because the lax and compressible abdominal walls, composed of skin, fascia, and muscle, readily transmit the force applied to the abdominal viscera. If the victim anticipates the blow and tightens the abdominal muscles, this will disperse the force of impact and thereby reduce the probability of internal injuries. Thus, the boxer who has conditioned his abdominal muscles and is prepared to receive such blows will sustain no injury to his abdominal organs.

The type of injury an abdominal organ will sustain depends on the organ involved. The soft, compact, vascular liver and spleen may be lacerated or crushed; a distended hollow organ, such as the stomach or intestines, will burst due to the rapid increase in intraluminal pressure produced by the force of impact. The severity of trauma is relative to the size of the blunt object, the force of impact, the organ traumatized and its condition at the time of impact. It cannot be overemphasized that absence of external injury (contusions or abrasions) to the abdominal walls does not exclude injury, even massive injury, to one or more of the internal abdominal organs (Figure 5.6). The lack of external injuries is attributable to the lax and compressible abdominal walls and protection afforded by clothing. If a traumatized victim complains of abdominal pains, but lacks visible signs of injury to the abdomen, the emergency room physician or surgeon may fail to clinically detect

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Figure 5.6 (A) Complete transection of liver (B) without any evidence of external trauma to anterior abdominal wall.

the early signs of intra-abdominal injury, and thus delay a lifesaving operation. This is especially true of intoxicated victims and individuals on high doses of tranquilizer whose condition renders them insensible to pain and obscures the signs of peritoneal irritation.

A 21-year-old male, involved in a motor vehicle accident, was admitted to a local hospital with pain in the left abdominal region. Vital signs were normal; physical examination was essentially negative, except for severe tenderness in the periumbilical area. The patient's abdomen was flat and soft. Bowel sounds were normal. X-ray studies of the abdomen, in the flat and upright position, revealed no evidence of abnormality. The intestinal gas pattern was normal. The hepatic, splenic, renal, and psoas outlines were unremarkable. There was no evidence of free abdominal air or fluid. Approximately 28 h later, he was DOA at another hospital. At autopsy, 2000 mL of purulent material was found in the peritoneal cavity. Fifty centimeters from the duodenum, there was a 2 x 2-cm laceration of the proximal jejunum, with communication with the peritoneal cavity. The mesentery showed a 3 x 5-cm contusion and recent thrombi of the superior mesenteric veins.

Trauma to the abdomen may be generalized, involving the abdomen as a whole, as exemplified by an individual run over by a vehicle, or localized, such as would occur if an individual was kicked in the abdomen. Most homicides resulting from blunt force involve localized injuries to the abdomen. Possibly only through a thorough investigation of the circumstances surrounding the victim's death will one be able to determine whether the blunt force injury was of a homicidal or accidental nature.

Since many individuals receive cardiopulmonary resuscitation nowadays, it is extremely important to differentiate iatrogenic injuries of the abdominal organs from those due primarily to trauma. Thus, with vigorous, slightly misplaced cardiopulmonary resuscitation, the authors have seen lacerations of the liver where it overlies the vertebral column. Several hundred milliliters of blood were present in the abdominal cavity in some cases, even though these injuries were, in a sense, postmortem.

In 1983, Ducatman et al. described three cases of fatal rectus sheath hematoma.22 This entity is characterized by apparent spontaneous nontrau-matic hemorrhage into the rectus sheath, usually occurring after anticoagulant therapy. It may be either an immediate or contributory cause of death.

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