welcome back everybody we're going to cover chapter 31 which is abdominal and genital urinary injuries we're going to talk about the recognition management of blunt versus penetrating mechanisms and filterations and impaled objects talk about the assessment management pathophysiology of solid and hollow organs blunt trauma versus penetrating evisceration injuries to external genitalia vaginal bleeding due to trauma and sexual assaults so the abdomen extends from the diaphragm which we just got done talking about the pelvis it contains organs that make up your digestive your urinary and your genital urinary systems significant trauma to your abdomen can occur from blunt trauma penetrating trauma or both just like the chest and injuries to your abdomen that go unrecognized or not repaired in surgery can be a leading cause of traumatic death so your abdomen is divided up into four general quadrants you need to know what organs are located within those four general quadrants your right upper is your liver gallbladder duodenum in your pancreas your left upper is your stomach and spleen left lower descending colon transverse colon and right lower is your large and small intestines and your appendix the right lower quadrant is common location for swelling and inflammation that's where your appendix is a lot of times you'll talk about having pain in your right lower quadrant typically it can be your appendix it can be other things but again it's typically your appendix in your right lower you have hollow organs such as your stomach your intestines your bladder in other words they're not full of blood they're not they're not like your liver they're not like your spleen which is really vascular full of blood these are empty and they're hollow but they do can have um contents in there that can spill into your peritoneal cavity once they are ruptured or lacerated or whatever happens to them and that when that rupture happens and those contents spill into your peritoneal cavity that's when you get infections such as peritonitis intestinal blood supply comes from your mesentery artery it connects the small intestine to the abdominal wall and patients with injuries to the mesentery can bleed into the peritoneal cavity so you can have abdominal cavity bleeding from that mesentery artery which is the blood supply for your intestines here's another good amp review for you for your abdomen you can see what's in your right upper your left upper those are typically your vascular solid organs your hollow organs are typically in your lower abdominal cavities solid organs are going to be your liver your spleen your pancreas your kidneys again they do the chemical work of your body they produce enzymes they clean your blood they produce energy and again because they are very vascular they can bleed very severely so your spleen is the number one injured organ in most motor vehicle collisions if you haven't heard that before but it's typically your spleen that you actually lacerate [Music] so injuries to your abd abdominal area could be either open or closed and it could involve hollow solid or both organs blunt trauma motor vehicle collisions motorcycle crashes falls blast injuries car versus uh pedestrian or pedestrian versus bicycle uh rapid deceleration injuries and compression injuries so blood in the peritoneal cavity has acute pain in your entire abdomen so when you assess do your patient assessment we're going to assess all four quadrants and if all four quadrants hurt maybe the reasoning for the pain is going to be blood in the abdominal cavity distension is usually a result of fluid blood or organ spilling into the peritoneal cavity now the peritoneal cavity has a cut in it and your abdominal organs are starting to kind of push through that that lining if you will and it might have abdominal bruising discoloration besides distension seat belts they can cause abdominal injuries especially if you wear your seat belt too high for comfort and set it down where it should be it can cause bladder injuries especially to our pregnant patients because they want to make sure the seat belt doesn't hurt the baby so they'll wear the seat belt improperly here's the correct position to wear your seat belt see how it is lower on the number c it's down on on your pelvic your iliac spines or your pelvis for uh if you have an open abdominal injury something enters into your abdominal cavity and it opens your peritoneal cavity to the outside world again even though these wounds can be deceiving we think about a high index of suspicion for an acute injury low velocity knives arrows uh i've seen a samurai sword a man killed his mom with a samurai sword uh i medium velocity that's the handguns and shotguns and then your high velocity rifles are excuse me high velocity injury are high powered hunting rifles and assault weapons and even some handguns are considered high velocity so speed just like in motor vehicle collisions speed kills so the higher the velocity the more damage that can occur high and medium velocity injuries they have temporary wound channels in other words when the bullet goes into your body it creates a pressure cavity so it opens up this big cavern like in your body and as the pressure wave goes through the tissue it creates damage because of this pressure wave in your your abdominal cavity so it's almost like it goes in like an opening to a cave and all of a sudden the cave opens up really big that's what a bullet does and as it opens up really big that cavity it creates that big cavity it creates injuries to your organs with low velocity you don't really have that that cavity uh and again internal injuries might not be apparent because maybe it just nicked an organ or it nicked an artery or nicked a vein it didn't blast through a vein or artery again assume that your thoracic and peritoneal cavities have been injured if it's below the xiphoid process an evisceration that's really where part of your bowel protrudes from the peritoneum so it kind of looks i know it sounds kind of weird but it kind of looks like a sausage or a bratwurst on the outside of your abdominal cavity it's painful it it's gross looking it's shocking looking to you and the patient so we never push down in the abdomen we never push it back into the abdomen um and we never um try to like play with it or move it or anything because again we could damage that bowel as it protrudes it's used to a very moist environment and outside now it's starting to dry out and we may push it in and that actually cracks and opens up hollow organ injuries signs and symptoms well when you have an injury to a hollow organ whatever's within that hollow organ is what we're worried about spilling into your abdominal cavity so if it does spill in let's say something happens and it does build it could take hours or days before an invec infection occurs and it's really bad stuff that's going to be leaking into your abdominal cavity so think about what's in your intestines what's in your stomach and if that were to leak out into your belly what it's going to do blunt penetrating trauma sometimes blood trauma causes an organ to pop when it releases fluid and air so that hollow organ pops penetrating trauma causes a direct injury to it and it tears through it your gallbladder and your urinary bladder that's going to dump whatever's into there into your body air in your peritoneal cavity causes pain so you just might have air in the peritoneal cavity and again uh death and ischemia of muscle tissue or organs that's what's going to occur when you have solid organ injuries bleeding is the obviously the thing we worry about the most but it can be hard to see how hard excuse me it could be hard to determine where that bleeding is coming from it could be an artery it could be a vein so it could be oozing or could be squirting internally so it could be a rapid or a slow blood loss the liver is obviously your largest organ in your abdomen and it's very vascular and so when that is cut lacerated or damaged it could lead to hypoperfusion and again your lower right rib might penetrate that injury so you even though you're not shot with something you might have a rib injury where the rib breaks and punctures your liver referred pain to the right shoulder is common with an injured liver so you might have pain in your right shoulder if you have a liver injury so let's think about this for one second let's say you're a passenger in a motor vehicle accident you're the front seat passenger after the motor vehicle accident has occurred you tell uh the emts and paramedics and firefighters and everybody that your right shoulder hurts could it be a liver problem not just the seat belt on your right shoulder we have a high index of suspicion when we have a right shoulder injury where the shoulder belt is we shouldn't just um mark it off and say oh that's a seat belt injury don't worry about it it could i mean seriously it could be a liver injury we have to be suspicious of that you know that that has referred pain now the spleen the pancreas heavy bleeding spleen is often injured in motor vehicle collisions i talked about that steering wheel trauma fall from heights bicycle motor vehicle accidents involving the handlebars where your abdomen strikes the handlebars your diaphragm can become injured especially with penetrating or when it's ruptured and parts of your bowel can actually go through a tear in your diaphragm and that bowel will actually end up in your thoracic cavity so now the person's having trouble breathing but the reason they're having trouble breathing is part of the bowel is into their chest and you can actually hear if you put your stethoscope on your stomach tonight and listen to bowel sounds you hear that gurgling sound if you suspect a bowel in the thoracic cavity you're going to hear that gurgling sound in their chest cavity kidneys obviously they're very vascular uh the common finding is blood in the urine uh blood visible in the urinary meters that signifies trauma to the genital urinary so maybe when we inspect the uh the uh the pelvic area we the the boy and girl parts if you will and we see blood in their underwear maybe that's an indication that they've had a kidney injury assessment of the abdominal injuries is really difficult there's so many things that can go wrong your patient might be overwhelmed you know just because they have pain one area maybe their entire stomach hurts i'm it's really difficult to assess abdominal injuries so we'd start bsi scene say make sure the scene's safe for you additional resources if needed mechanism of injury trauma consider spinal precautions and again all of the injuries that mechanisms or injury could have produced so we think about the hollow and solid organs general impression note any severe external hemorrhaging and then we assess the abcs make sure they have a paid airway make sure that their circulation is going good make sure that we assess for signs and symptoms of shock and we treat that aggressively and then we transport to the highest level of trauma center that's available we don't take them to the local uh basic hospital they gotta have surgery they're gonna go to a trauma center think about their chief complaint what are they talking about what are they complaining about what is the mechanism of injury com in it compared to what is uh their their complaint sample history opq rst again nausea vomiting go with everything in ems but diarrhea that's a different one now is there any chance or excuse me any appearance of it bowel movements and urinary output so was there stool dark and tarry because that indicates blood was there bright red in their in their stool was their blood in their urine those are really good trauma assessments on a patient with a possible um abdominal injury your secondary assessment we've talked about this before you may not have time to do this because you're too worried about the ex abcs but if you have time we inspect for bleeding we loosen clothing to expose injuries put them in a position of comfort typically if an abdominal injury has occurred they're going to like to sit with their legs flexed or their knees flexed examine the entire abdomen you have to take your clothing off to visualize your abdomen you have to palpate and inspect their abdomen check for decaf btls palpate look for contusions abrasions punctures penetration burns tenderness is this is the tenderness localized to one quadrant of their abdomen that tells a lot that tells a lot what could be injured is there swelling palpate the quadrant away from the part that hurts so if they say their right upper hurts we're gonna go left lower first reason being if my right upper hurts and you touch that first everywhere else you touch is gonna hurt so we always do that last we're still gonna have to palpate but we may not do it so aggressively if you find a life threat stop and treat it we don't just note it and go on if there's a life threat life threat we treat it right away inspect and palpate the kidneys for tenderness bruising swelling hollow organs will spill the contents into the peritoneal cavity the entire peritoneal cavity is going to heart vital signs again you might have a rapid pulse with a low blood pressure you're in shock the body's trying to compensate it may not be able to compensate anymore check your o2 saturation as well uh that's really one of the only monitoring devices we're going to have that's going to help us if they have an isolated abdominal injury we look for penetrating wounds a gunshot wound if you will if the wound is found see if there's an exit wound now the difference between an entrance and an exit is the entrance wound is usually smaller the exit wound is bigger and it kind of blows out of the body don't remove any impaled objects like if they were shot with an arrow we're not going to remove that arrow reassess vital signs reassess your interventions reassess your treatment communicate and document whether to the hospital or the paramedic service that you intervene or intercept with closed abdominal injuries so care we treat for shock again be ready for your patient to be nauseous and vomit oxygen if they're unconscious or in shock maybe we even need to bag them if they're unconscious consider als for a gastric tube placement now so what that is is basically a tube that is passed through their nose down into their stomach to relieve any air or fluid or whatever is in their abdomen not a lot of paramedic services can do that open abdominal injuries if they have an open dominant injury with penetrating we're looking for that obvious wound that external bleeding and again just because they have very little bleeding on the outside doesn't mean they won't have bleeding on the inside inspect their back their sides we're looking for exit wounds just because a bullet entered my stomach right above my belly button doesn't mean it's going to go straight back through my body it may ricochet ricochet off my spine and whatever and come back out the front who knows what they're going to do bullets are really weird dry sterile dressing to all open wounds if the penetrating object is still there we stabilize it bandage around it we'd never remove it obviously so this is what an abdominal invisceration looks like and it really truly is it looks really bad doesn't it it typically looks worse than it is but again you might have the organs protruding through that wound if you will never put them back in keep them moist and warm cover them with a moist sterile dressing secure that in place and tape it in place so you want to keep those organs moist and protected see how he kind of covers this with a a dry or moist sterile dressing and then they put an occlusive dressing over top of that and then secure it in place so it's basically moist dressing right on the organs and then a occlusive dressing an occlusive dressing on top of that controls reproductive functions and waste discharge so basically that's what your genital urinary system does reproduction functions and waste discharge boy that sounds like a job doesn't it so the male genitalia and the female genitalia that's really kind of what we're thinking about this is uh both the amp of excuse me the amp of the male genita uh reproductive system again we do have those external if you will um organs that could be damaged women have the internal organs that can be damaged but we both have you know a lot of the same systems we think about the kidneys okay so the kidneys are not uncommon and rarely occur in isolation kidney injuries because they're really protected but the problem with kidneys is if you get you know the kidney shot in your back with a blunt trauma it could create bleeding within your kidneys or the release of the contents so if you have an abrasion laceration or contusion on your flank it's kind of on your back side is what we're talking about you might have a penetrating wound in your flank or upper abdomen fractures of your ribs can cause genital urinary system or kidney damage and then a hematoma or that pooling of blood in the flank those might be signs of a suspected kidney damage patient urinary bladder might rupture urine spills into the tissues uh in males a sudden deceleration can tear the bladder from the urethra in later trimesters of pregnancy bladder injuries occur so people are and can have bladder injuries um with motor vehicle accidents this is a fractured pelvis can perforate the bladder and then you're going to have urine leaking into your pelvis and urine is is a waste product so think about having that waste product leak into your pelvis with males and external genitalia injuries they're basically soft tissue wounds they're very rarely life threatening um although they can be very vascular very and and bleed a lot priority should be given over more severe wounds and then pain might be referred to your lower abdomen with females what we think about is their internal genitalia is rarely damaged unless it's a massive massive motor vehicle collision the exception is the pregnant uterus so the uterus enlarges substantially and rises out of the pelvis so injuries can be serious and also not only to mom but to the fetus itself we think about the external female genitalia very rich in nerve so it's going to hurt and we think about the injuries here would be to from a sexual assault or the pregnancy if external bleeding we just give mom a sanitary pad and we're never going to pack anything we never insert anything into the vagina really is here's the big thing potential for embarrassment maintain privacy have an emt of the same gender perform the assessment if you can i know sometimes it can't happen i know there's always that chance but if we can we should have the same gender to the assessment scene size up we look for standard precautions mechanism of injury quickly oh i love this statement here patient may provide a mechanism of injury that seems less embarrassing than the actual mechanism of injury so how did you get hurt mike they might kind of uh tell you a different story quickly scan for life threats treat those life-threatening hemorrhaging airway and breathing abs we might need to bag them besides give them oxygen and again if they're unresponsive unconscious we might need to think about an opa circulation we're looking at the skin we're looking at the pulse rate and quality we're looking for cap refill we're going to treat for shock high flow oxygen put them on a blanket lay them down rapid transport to the hospital and again it's usually a trauma center when we deal with trauma they really should go to a trauma center those of you in bigger cities that's not i mean that's that's an option you can go to one level trauma one or level trauma two whatever but for some of us that are in the rural areas sometimes we don't have a choice where to go investigate the chief complaint nausea vomiting goes with everything in ems diarrhea doesn't blood in the urine doesn't vomiting blood does not go with everything in ems listen for those abnormal bowel and bladder excuse me abnormal bowel sounds maybe in the chest and then look at the abnormal bowel and bladder habits sample history o p q r s t we really need to talk about output which would be uh urine so do they have blood in the urine it might indicate a kidney injury ask about allergies food intake and fluid and what led up to the injury and again they might not tell you the the the right story because the right story might be embarrassing decap btls i love the first line genital urinary system injuries can be awkward to assess and treat yes indeed it can um you know it's it's very awkward if you have to assess someone of the opposite gender uh think about that interventions treat us i mean sorry repeat your primary assessment vital signs reassess your interventions and treatment adjust your interventions it's now we finally see this i think that's important we always do that but adjust our interventions as needed if you have them on a nasal cannula and their o2 saturation is low obviously we're going to switch them to a non-rebreather mask at a higher flow concentration communicate everything your of your assessment even your concerns to the hospital staff so with kidney injuries might not be so obvious we think about blood in the urine yep treat for shock urinary bladder injury so you have blood in your urethral opening signs of trauma to the lower abdomen or pelvis transport nothing really we can do external male genital speaking as a man we should make them feel comfortable use sterile moist compresses and cover areas stripped of skin apply direct pressure with gauze to control bleeding never move or manipulate foreign objects in the urethra why they're there i don't know people identify and take evolves parts in a bag to the hospital with a patient remember lorena bobbitt she cut her husband's penis off drove down the highway and threw it out the window that's what i think about uh manage blood loss you direct pressure sterile dressing and again if you can find the amputated body part we're going to reattach it when an erect penis is bent sharply the shaft can be severely damaged sometimes that's going to take surgical repair again it's intense pain bleeding and the fear the fear is that it's not going to function again properly lacerations to the head of the penis heavy bleeding very vascular direct pressure sterile dressing oh some of this is making me cringe skin of the shaft or foreskin caught in a zipper so they as a child they might be zipping up their pants without wearing underwear and they zip it up and they get their penis caught in the zipper ah you try to unzip it to get it free uh if there's a long segment of zippers involved cut the zipper out of the pants uh and transport the patient to the hospital with that zipper still attached to their penis urethral openings those aren't common excuse me those are not uncommon excuse me saddle injuries pelvic fractures penetrating wounds of the peritoneum it's okay it says important to know a patient can urinate in their blood in the urine because that's going to dictate a lot and tell them a lot about what's happening with the urinary bladder foreign bodies protruding from the urethra will have to be surgically removed yikes avulsion to the skin of the scrotum may damage global contents again sterile moist dressing because it's a moist area wrap the contents with a sterile moist compress direct blow so the scrotum can result in a rupture of the testicle or accumulation of blood around the testes and again apply ice female genitalia lacerations and avulsions we want to again treat with a moist sterile dressing control the bleeding with pressure hold dressings in place with a diaper type bandage in other words we're going to put that bandaging on the external vagina and then we're going to kind of secure it like a diaper would don't pack the vagina leave foreign bodies in place after stabilizing with bandages again they're gonna be painful but it's not life-threatening rectal bleeding common complaint could be from sexual assaults uh the person inserting foreign bodies hemorrhoids colitis and even ulcers can result in rectal bleeding sexual assault and rape are common unfortunately and again it's generally women but it can be men and can be children so here's the big thing with this is again it's a crime uh this is where your compassion has to shine through you have to be compassionate when you're doing your transport we think about multi-system trauma and the need for shock treatment don't examine the genitalia unless it requires you to put some dressing on there for the bleeding shield the patient from onlookers this is common sense stuff document the patient's history assessment treatment in response to the treatment don't let the patient wash bathe shower douche urinate defecate until they've been examined unfortunately that's that's um evidence and we don't want to lose that evidence we don't want another woman to go through what this woman just went through if oral penetration occurred tell your patient not to eat drink brush your teeth use mouthwash uh and they'll do that at the hospital they'll help they'll help her as much as possible at the hospital and then handle their clothing as little as possible don't let them change your clothing don't let them shower um even their clothing is evidence make sure the emt caring for the patient is of the same gender there are people out there that think this is i'm just going to say this this is the craziest thing i ever heard in my life i had a fellow emt instructor tell the students that after a woman has been sexually assaulted that you should have a man in the back of that ambulance worth with her so that she learns to realize that not all men are bad i think that is the stupidest damn thing that i've ever heard in my entire life you should have same gender taking care of same gender in the back of the neighborhood she was just raped this is not a time to teach her anything oh i wish i knew who that person was treat medical injured injury support compassion peritonitis would most likely result from the thought and injury to the following uh liver spleen kidney or stomach peritonitis liver spleen kidney or stomach the only one that's not vascular is your stomach that's a hollow organ the rest are very vascular which of the following organs would be most likely to bleed profusely if injured liver kidney stomach gallbladder i would say a as well 40 of your total blood volume is contained in your liver that's crazy numbers which of the following statements regarding intra-abdominal bleeding is false intra-abdominal bleeding often causes abdominal distension intra-abdominal bleeding is common following blunt force trauma the absence of pain and tenderness rules out intra-abdominal bleeding bruising may not occur immediately following blunt abdominal trauma so which one of those statements is false about intra-abdominal bleeding i know which one i think i think it's c as well yep again the absence of pain and tenderness does not mean that there is not internal bleeding even when seat belts are worn properly and airbags deploy injury may occur to the chest extremities iliac crests or lower ribcage even when seat belts are worn properly and the airbags deploy injury may occur to yeah the iliac crest because again the seat belt goes across the iliac press when inspecting the interior of a wrecked automobile you should be most suspicious that the driver experienced an abdominal injury if you find deformed steering wheel airbags deployed crushed instrument panel or damage to the lower dashboard i agree steering wheel uh again even after the airbag's been deployed uh and when you get there get uh when you're taking your patient out of the car lift up the airbag and inspect the steering wheel other than applying a moisture dressing covering with a dry dressing to treat an abdominal evisceration an alternative form of management may include dry towels cleaning the exposed bowel applying the pneumatic anti-shock garment or lastly applying an occlusive dressing secured by trauma dressings yep it's d it's the occlusive dressing over the moist sterile dressings that's going to really help and secure that moisture in there as well you're transporting a patient with a possible with possible peritonitis following trauma to the abdomen which position will he most likely prefer to assume sitting up legs drawn up legs outstretched or on his right side i know for a fact i just said that a few minutes ago anytime your belly hurts you're going to feel much better with your legs drawn up you and you outstretch him um you're actually putting you're stretching on your abdominal muscles 16 year old boy playing football struck in the left flank during a tackle his vital signs are stable however he is in severe pain most you should be most concerned that he injured his what left flank is that liver spleen kidney or bladder left flank yep you think about your abdominal contents left flank is definitely going to be your kidney the term hematuria is described or can be defined as blood in the stool blood in the urine vomiting up blood or urinary bladder rupture hematuria and you can kind of see it in the word itself can't you blood in the urine hematiteuria uh bright red blood in your stool is called hemato hematico check zia i think is how you pronounce that i'm not really sure dark tarry schools are as melanoma and then vomiting up blood is hematoemesis and the last question when caring for a female with trauma to the external genitalia the emt should use local pressure to control bleeding carefully pack the vagina to reduce bleeding remove any impaled objects from the vagina or cover any open wounds with a moist sterile dressing this is to the external genitalia i know which one i think it is you get it yeah direct pressure never pack um it's always direct pressure um and local direct pressure sorry okay so that's the end of that chapter see at the next one