Assessment

HISTORY. For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by including a detailed report from the pre-hospital professionals, witnesses, or significant others. AMPLE is a useful mnemonic in trauma assessment: Allergies; Medications; Past medical history; Last meal; Events leading to presentation. Information regarding the type of trauma (blunt or penetrating) is helpful. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient was restrained, the patient's position in the vehicle, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a helmet. In cases of traumatic injuries from falls, determine the point of impact, the distance of the fall, and the type of landing surface. If the patient has been shot, ask the paramedics or police for ballistics information, including the caliber of the weapon and the range at which the person was shot.

8 Abdominal Trauma

PHYSICAL EXAMINATION. The patient's appearance may range from anxious but healthy to critically injured with a full cardiopulmonary arrest. If the patient is hemorrhaging from a critical abdominal injury, he or she may be profoundly hypotensive with the symptoms of hypovolemic shock (see Hypovolemic/Hemorrhagic Shock, p. 505). The initial evaluation or primary survey of the trauma patient is centered on assessing the airway, breathing, circulation, disability (neurological status), and exposure (by completely undressing the patient). Life-saving interventions may accompany assessments made during the primary survey in the presence of life- and limb-threatening injuries. The primary survey is followed by a secondary survey, a thorough head-to-toe assessment of all organ systems. The assessment of the injured patient should be systematic, constant, and with re-evaluation.

When you inspect the patient's abdomen, note any disruption from the normal appearance such as distension, lacerations, ecchymoses, and penetrating wounds. Inspect for any signs of obvious bleeding such as ecchymoses around the umbilicus (Cullen sign) or over the left upper quadrant, which may occur with a ruptured spleen (although these signs usually take several hours to develop). Note that Grey-Turner's sign, bruising of the flank area, may indicate retroperitoneal bleeding. Inspect the perineum for accompanying urinary tract injuries that may lead to bleeding from the urinary meatus, vagina, and rectum. If the patient is obviously pregnant, determine the fetal age and monitor the patient for premature labor.

Auscultate all four abdominal quadrants for 2 minutes per quadrant to determine the presence of bowel sounds. Although the absence of bowel sounds can indicate underlying bleeding, their absence does not always indicate injury. Bowel sounds heard in the chest cavity may indicate a tear in the diaphragm. Trauma to the large abdominal blood vessels may lead to a friction rub or bruit. Bradycardia may indicate the presence of free intraperitoneal blood. Percussion of the abdomen identifies air, fluid, or tissue intra-abdominally. Air-filled spaces produce tympanic sounds as heard over the stomach. Abnormal hyper-resonance can indicate free air; abnormal dullness may indicate bleeding. When you palpate the abdomen and flanks, note any increase in tenderness that can be indicative of an underlying injury. Note any masses, rigidity, pain, and guarding. Kehr's sign—radiating pain to the left shoulder when you palpate the left upper quadrant—is associated with injury to the spleen. Palpate the pelvis for injury.

PSYCHOSOCIAL. Changes in lifestyle may be required, depending on the type of injury. Large incisions and scars may be present. If injury to the colon has occurred, a colostomy, whether temporary or permanent, alters the patient's body image and lifestyle. The sudden alteration in comfort, potential body image changes, and possible impaired functioning of vital organ systems can often be overwhelming and lead to maladaptive coping.

Diagnostic Highlights

Test

Abnormality with Normal Result Condition

Explanation

Computed tomog- Normal and intact raphy (CT) scan abdominal struc tures

Injured or ruptured organs, accumulation of blood or air in the peritoneum, in the retroperi-toneum, or above the diaphragm

Provides detailed pictures of the intraabdominal and retroperitoneal structures, the presence of bleeding, hematoma formation, and the grade of injury

Provides rapid evaluation of hemoperi-toneum

Focused abdominal Normal and intact Accumulation of blood in the sonogram for abdominal struc- peritoneum trauma (FAST) tures

Diagnostic Highlights (continued)

Test

Normal Result

Abnormality with Condition

Explanation

Diagnostic peritoneal lavage (DPL)

Negative lavage without presence of excessive bleeding or bilious or fecal material

Direct aspiration of 15 to 20 mL of blood, bile, or fecal material from a peritoneal catheter. Following lavage with 1 L of normal saline, the presence of 100,000 red cells or 500 white cells per mL is a positive lavage. This is 90% sensitive for detecting intra-abdominal hemorrhage

Determines presence of intra-abdominal hemorrhage or rupture of hollow organs; contraindicated when there are existing indications for laparotomy

Other Tests: Serum complete blood counts; coagulation profile; blood type, screen, and cross match; drug and alcohol screens; serum chemistries; serum glucose; serum amylase; abdominal, chest, and cervical spine radiographs; excretory urograms; and arteriography

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