and welcome to chapter 31 abdominal and genital urinary injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand how to manage a patient with abdominal and genital urinary trauma you will learn how to recognize life threats associated with these injuries and the need for immediate intervention the curriculum includes detailed anatomy and physiology as well as pathophysiology complications assessment and management of abdominal and genital urinary injuries the assessment section is very comprehensive and follows the primary and secondary model specific injuries discussed include blunt versus penetrating mechanisms eviscerations impelled objects injuries to external genitalia vaginal bleeding secondary to trauma and sexual assault emergency care skills include management of blunt abdominal injury penetrating abdominal injury and abdominal evisceration okay so let's get started the abdomen extends from the diaphragm to the pelvis and contains the organs that make up digestion urinary and geniturinary systems specific trauma to the abdomen can occur from blood trauma penetrating trauma or both injuries to the abdomen that go unrecognized and are not repaired in surgery are the leading cause of traumatic death let's talk about the abdomen the anatomy and physiology of that so you have abdominal quadrants and the abdomen is divided into four quadrants the quadrant location of bruising or pain can tell you which organs are possibly involved in the traumatic injury and so let's take a look at these four quadrants the right lower quadrant is common location for swelling and inflammation and that's because of the appendix as a source of infection if it ruptures so first we're going to talk about hollow and solid organs so the hollow organs of the abdomen include the stomach intestines ureter and bladder and when ruptured or lacerated the contents spill into the peritoneal cavity causing inflammation and possible infection and we call this infection peritonitis severe abdominal pain tenderness and muscle spasms happen when you when the patient has peritonitis intestinal blood supply comes from the mesotenary it's a fold of tissue that connects the small intestines to the abdominal wall patients with injuries to the mesotenary can bleed significantly into the peritoneal cavity signs of this include abdominal rigidity and periumbilical bruising so these figures show the hollow and the solid organs of the abdomen the solid organs of the abdomen include the liver spleen pancreas and kidneys these organs perform the chemical work of the body which include enzyme production blood cleansing endocrine function and energy production because of the rich blood supply hemorrhage of the solid organs can be severe now the retroperitos peritoneal space is the posterior aspect of the abdomen and behind the peritoneum this includes the kidneys ureters urinary bladder and the majority of the pancreas so let's talk about injuries to the abdomen abdominal injuries are considered either open or closed and can involve solid or solid organs closed abdominal injuries can be from blood trauma to the abdomen so there's many mechanisms of injury that are capable of causing closed injuries they could include motor vehicle crashes motorcycle crashes falls blast injuries pedestrian versus bicycles rapid deceleration or compression injuries they may initially appear as abrasions on the surface of the skin and it may take several hours for the contusion or hematoma to become more visible you could have injuries from seatbelts and airbags and when worn properly the seatbelt lies below the anterior superior iliac spine of the pelvis and against the hip joints if the bulb is too high it can squeeze the abdominal organs or create vessels against the spine when the car decelerates or stops and can also cause can cause bladder injuries in pregnant patients who adjust the lap belt for comfort so remember to inspect beneath the airbag for signs and damage to the steering column so this figure shows the correct and correct placement of the seat belts next we're going to talk about open abdominal injuries and so injuries in which a foreign object enters the abdomen and opens the peritoneal cavity to the outside open wounds can be deceiving therefore you should maintain a high index of suspicion for unseen injuries internal damage to organs and potential life-threatening injuries so there's three different types of velocity injuries and we're going to talk about those next so the velocity of an object can help predict the amount of damage to the tissue low velocity injuries caused by hand-held or hand powered objects such as knives or other edged weapons then you have medium velocity injuries and this can caused by small caliber handguns and shotguns then there's high caliber and that's caused by larger weapons such as high powered rifles or higher powered handguns high and medium velocity injuries have temporary wounds channels in addition to exit and entrance wounds cavitation occurs as the pressure away from the projectile is transferred to the tissues the higher the velocity of the projectile the larger the cavity it produces and then when you talk about low velocity penetrations also have a capacity to damage underlying organs internal injury may not be as apparent during the physical exam and any time a patient has an injury at or below the zyphoid process it should be assumed that the thoracic and peritoneal cavities have been violated when it comes to an evisceration bowel protrudes from the peritoneum it can be extremely painful and also visually shocking do not push on the patient's abdomen only perform a visual assessment when there is any suspicion of this type of injury cut clothing close to the wound and never pull on any clothing stuck to or in the wound channel when you talk about hollow organs they often have delayed signs and symptoms commonly they spill the contents into the abdomen infection develops and that may take hours or days both blunt and penetrating trauma can cause hollow organ injuries blood trauma causes the organ to pop and this releases fluids and air and penetrating trauma causes a direct injury such as lacerations or punctures the gallbladder and urinary bladder are hollow organs whose contents are potentially irritating and damaging if ruptured these fluids move loose spaces and voids in the peritoneal cavity eventually leading to infection free air in the peritoneal cavity produces pain usually this indicates that a hollow organ or loop of the bowel has been perforated if not rapidly identified or repaired several infections of severe infections and septic shock may develop let's talk about the solid organ injuries so we talked we said solid organs can bleed significantly and cause rapid blood loss and like we said earlier it's hard to identify and so because the patient is not experiencing that much pain so solid organs can also ooze blood into that peritoneal cavity and this causes pain to increase slowly over time the liver is one of the largest organs in the abdomen it's very vascular and can contribute to hypoperfusion if injured often injured by a fractured lowered rib lower rib and or penetrating trauma common assessment findings is referred pain to that right shoulder the spleen and the pancreas are also very vascular both are prone to heavy bleeding when fractured lacerated or punctured referred left shoulder pain also occurs in some cases of splenectic injury the diaphragm is penetrated or ruptured loops of the bowel may herniate through the thoracic cavity the patient is going to have some dipsnia and change in position from upright to supine in a more abdominal can cause more abdominal contents to spill into that thoracic cavity and this could compress the lungs prohibiting the lungs from fully expanding the kidneys can also be impacted or penetrated by trauma this can cause significant amounts of blood loss common findings is blood in the urine hematuria and blood visible on inspection of the urinary miatis indicates significant trauma in the genituria system so let's do the patient assessment of these abdominal injuries okay so assessment findings in patients with potential abdominal injuries can be challenging to interrupt some are obvious however many are easily overlooked patients with patients may be overwhelmed with more painful injuries and some abdominal injuries develop or worsen over time so of course we're going to start that patient assessment with the scene size up and we have to be sure that the scene is safe we need to call for additional resources early if we need them the moi and noi we have to consider early spinal precautions and consider all of the injuries of that mechanism of injury and what they could be produced then we're going to do the primary assessment we have to quickly form that general impression and note the patient's level of consciousness severe external hemorrhage may be addressed before airway and breathing concerns ensure the patient has a clear and patent airway and then there's circulation we need to treat signs and symptoms of shock aggressively and transport decisions so patients with that abdominal injury should be evaluated at the highest level of a trauma center if available next of course is the history taking of our assessment we need to do the sample history and the opqrst which is the history of the current illness we have to ask the patient if they're experiencing any nausea vomiting or diarrhea ask them about the appearance of any bowel movements and urinary output ask about referred pain peritonitis can cause pain provoked by removal of pressure and we call this rebound tenderness and guarding occurs when the patient tenses up or stiffens his or her abdominal muscles so our secondary assessment may not have the time to perform this of course in the field and but physical exams you want to make sure that you remove loosened clothes to expose any injured bodies regions of the body and transport the patient in the con the position of comfort unless of course spinal injury is suspected examine the entire abdomen including all posterior anterior and lateral surfaces and then we're going to use d-cap btls to help identify specific signs and symptoms of injuries we want to palpate the abdomen when examining the region palpate the quadrant farthest away from that from the quadrant that is experiencing signs and symptoms of injury and pain and perform a full body scan to identify injuries other than abdominal injuries inspect and palpate the kidney area for tenderness bruising swelling or other signs of trauma and then is vital signs so we have to obtain and record vital signs early and we need to repeat them every five minutes in patients who we suspect have a serious injury hypotension is a late sign of shock okay and so with those isolated abdominal injuries we're going to visually inspect the abdomen for penetrating wounds if an entrance wound is found check for the corresponding exit wound do not remove an impaled object in our reassessment we want to repeat the primary and vital signs reassess the interventions and treatment you have provided and communication and documentation outline the patient's mechanism of injury injuries and relevant vital signs all right so let's talk specifically about emergency care of abdominal injuries when it comes to close abdominal injuries we want to monitor the patient closely to evaluate for progression into shock the patient may experience nausea and vomiting have suction available administer oxygen to patients who are unconscious or who are in shock keep the patient warm assist ventilations if necessary and consider calling advanced life support for placement of an oral or nasogastric tube and then there's the open abdominal injuries patients with penetrating injuries generally obvious wounds and external bleeding however significant external bleeding is not always present so maintain a high index of specific suspicion for serious unseen blood loss then follow the general procedures described previously for care of blood abdominal injury as well as inspect the patient's back and sides for the exit wound apply a dry sterile dressing to all open wounds and if the penetrating object is still in place apply a stabilizing bandage around it to control external bleeding and to minimize movement of that object so severe lacerations of the abdominal wall may result in what's called an evisceration an evisceration is basically fat or internal organs protruding from the wound you want to place a sterile dressing moist and with saline over the wound and apply bandage and transport never try to replace the protruding injury and keep the affected area warm okay so the figure shows the steps to apply a dressing to have abdominal injury now we're going to talk about the anatomy of the genital urinary system okay the genitourinary system controls reproductive functions and waste discharge organs of the genitourinary system are located in the abdomen and kidneys are the solid organs and the ureter's bladder and urethra are the hollow organs male and genit malgenitalia lie outside the pelvic cavity except for the prostate gland and seminal vesicles okay the female genitalia genitalia are located entirely within the pelvis except the vulva clitoris and labia the figure shows the organs of the male reproductive system and then this figure shows the organs of the female reproductive system injuries to the system so let's talk about the kidney injuries not commonly and rarely occur in isolation meaning a force blow or penetrating injury is often involved unless significant injuries can result from an indirect blow such as a football tackle we want to suspect kidney damage if the patient has a history or physical evidence of any of the following so an abrasion laceration or contusion in that flank area okay and so the flanks are the the sides of the lower back and a penetrating wound in the region of the lower rib cage and above the hip or flank or the upper abdomen fractures on either side of the lower rib cage or the lower thoracic or abdominal upper lumbar vertebrae a hematoma in the flank region is also evidence of perhaps kidney damage now let's talk about urinary bladder injuries and they may result in a rupture so urine would spill into the surrounding tissues blunt injuries to the lower abdomen or pelvis can cause a rupture to that urinary bladder particularly when the bladder is full and distended penetrating wounds of the lower mid abdomen or perineum can directly result in urinary urinary bladder injuries so in males sudden deceleration from a motor vehicle or motorcycle crash can shear the bladder from the urethra in later trimesters of pregnancy bladder injuries increase from displacement of the ureters the figure shows how a fracture of the pelvis can result in perforation of the bladder so when it comes to external genitalia injuries soft tissue wounds can be painful and of great concern to the patient but rarely life-threatening okay and they should not be given priority over more severe wounds unless there is significant bleeding pain may be referred to the lower abdomen with these injuries when it comes to female genitalia injuries internal female genitalia the uterus ovaries and fallopian tubes are rarely damaged they're small deep in the pelvis and well protected exceptions is when the female is pregnant okay so uterus enlarges substantially and rises out of the pelvis injuries can be serious because the uterus has a rich blood supply during pregnancy and also keep the fetus in mind external genitalia injuries so this can it includes vulva clitoris and the major and minor labia at the entrance of the vagina they have a rich nerve supply so injuries are painful and we want to consider sexual assault and pregnancy so ask the patient about the last known menstrual period and ask about sexual history assume all women of child bearing age are possibly pregnant in cases of external bleeding and trauma a sterile absorbent sanitary napkin or pad may be applied to the labia do not insert instruments glove finger or a tampon into the vagina all right so let's talk about the patient assessment in these injuries potential for patient embarrassment occurs so we have to maintain professional presence provide privacy and when possible we want to have an emt of the same gender perform the assessment scene size up so we have to assess foreseen hazards and threats to the crew apply standard precautions and look for indicators of the mechanism of injury patients may avoid the discussion to avoid undergoing the a physical exam and patients may also provide an mechanism of injury that seems less embarrassing than the actual mechanism so your primary assessment you're going to quickly scan the patient and also injuries can produce a significant amount of volume of blood so do not avoid this area in the rapid scan if bleeding is present you have to maintain privacy of course control severe bleeding first ensure the patient has a clear and paid patent airway provide assessment ventilations with the bag valve mask as needed and consider the need for spinal motion restriction when it comes to circulation we're going to do the pulse rate skin condition color temperature and cap refill clothes injuries do not do not have visible signs of bleeding so treat for signs of shock and note the patient's level of alertness transport decision we want to make sure we transport to a trauma center then we're going to do that history taking and we're going to investigate the chief complaint common associated complaints with genital urinary injuries are nausea and vomiting diarrhea blood in the urine vomiting blood and abnormal bowel or bladder habits the sample history so you use the opqrst and ask the patient about output especially blood in the urine ask about allergies to medications or environmental triggers repeat uh repeated or previous injuries or illnesses can help determine the extent of the current in injury or illness the last food intake in fluids are important because it can predict the genital urinary system's contents and then address the events leading up to the injury when it comes to the secondary assessment there are times when you will be unable to conduct this conduct this the need to provide ongoing life-saving treatment and transport time will keep you from doing that secondary assessment so when the patient has an isolated injury focus on that and the body region affected assess for decaf btls and obtain the patient's vital signs and reassess frequency then your reassessment repeat the primary assessment vital signs reassess the interventions and treatment you provided adjust interventions as necessary and of course communication and documentation and your concerns to the hospital staff and then describe all injuries and treatments given when it comes to care of specific injuries first we're going to talk about kidneys so damage may not be obvious upon inspections you may see signs of shock or blood in the urine so treat for shock transport promptly and monitor vital signs and route to the hospital all right so injury to the urinary bladder we have to suspect a urinary bladder injury if we see any blood in the urethra opening or signs of trauma to the lower abdomen pelvis or peritoneum if shock or associated injuries are present transport promptly and monitor the vital signs and route then if we have any external male genitalia injuries a few general rules for the treatment of injuries to the external genitalia apply injuries are painful they make the patient uncomfortable so use sterile moist compresses to cover the areas stripped of skin apply direct pressure with dry sterile gauze to control bleeding and never move or manipulate foreign objects in their urethra identify and take evolved parts to the hospital with the patient if the patient has an evulsion of the skin on the penis wrap the penis in a soft sterile dressing moistened with sterile saline transport promptly and use direct pressure to control any bleeding try to save the and preserve that skin if you have an amputation of the penile shaft managing blood loss is the top priority use local pressure with a sterile dressing on the remaining stump never apply a constricting device and surgical reconstruction as possible if you can locate the amputated part wrap that part in moist sterile dressing place it in the bag and transport it in a cool container without it directly touching ice if the connective tissue surrounding that tissue is severely damaged the shaft can be fractured or severely angulated sometimes injuries can require surgical repair so associated with intense pain bleeding into tissues is the fear accidental laceration of the head of the penis is associated with heavy bleeding local pressure with sterile dressing usually stops the hemorrhage and then skin or shaft or foreskin can get caught in the zipper if a small segment of the zipper is involved you could cut the pants if a larger segment is involved use heavy scissors to cut the zipper out of the pants then urethra injuries in the male are not very common so lacerations of the urethra can result though with straddle injuries pelvic fractures or penetrating rooms of the peritoneum it is important to know if the patient can urinate or if there's blood in the urine so save any urination for later examination at the hospital any foreign bodies protruding from the urethra wall will have to be surgically removed a bulging of skin of the scrotum may damage the contents so preserve the evolved skin in a moist sterile dressing for possible use for reconstruction wrap the scrotal contents in um or in the perineal wall area with a moist compress and use local pressure dressings to control bleeding direct blows to the scrotum may result in a rupture of the testicle and significant accumulation of blood around the testes so apply ice pack to the scrotal area during transport then there's female genitalia injuries so treat lacerations abrasions or avulsions with moist sterile compresses use local pressure to control bleeding or hold dressings in place with a diaper type bandage do not place any dressings into the vagina leave any foreign objects in place after stabilizing it with bandages injuries are painful but generally not life-threatening in hospital evaluations is required so transport urgency in determined by associated injuries and the amount of hemorrhage and the presence of shock when it comes to rectal bleeding that's a common complaint possible causes include sexual assault foreign bodies hemorrhoids or ulcers in the digestive tract significant rectal bleeding can occur after hemorrhoid surgery and then next we're going to talk about sexual assault so assault um and rapes are all too common victims are generally women and sometimes men and children are victims often there is little you can do beyond providing compassion and transport the patient may have sustained multi-system trauma and need treatment for shock do not examine unless obvious bleeding requires application of a dressing follow appropriate protocols and procedures shield the patient from curious onlookers and document the patient's history assessment treatment and response to the treatment for possible court appearances follow any crime scene policy of your ems system you want to advise the patient not to wash bathe shower douche urinate or defecate until after physical exam if oral penetration occurred advise the patient not to eat drink brush the teeth or use mouthwash until after the exam handle the patient's clothes as little as possible and place the articles of clothing or other evidence in paper bags do not use plastic bags because mold can grow and destroy the evidence make sure the emt caring for the patient is of the same gender as a patient whenever possible treat medical injuries and provide privacy support and reassurance okay so that concludes chapter 31 of the genital urinary injuries now we're going to go through the review questions to see what we've learned all right so peritonitis would most likely result from which of the following injuries it's going to be d remember it's the hollow organs that spill their contents that are going to cause the peritonitis the stomach is the hollow organ which of the following organs would be most likely to bleed profusely if severely injured well we know that the liver which is the largest organ in the stomach or in the at that abdominal area and it's a solid right so approximately 40 percent of the total blood volume at any given time is in the liver which of the following statements regarding intra abdominal bleeding is false so see intra-abdominal bleeding is commonly common following the blood trauma to the abdomen the absence of pain and tenderness rules out intra-abdominal bleeding when seat belts are worn properly and airbags deploy injury may occur to the and we know that's the iliadic crest because that's where the seatbelt is worn when inspecting the interior of the wrecked automobile you should be most suspicious that the driver experienced an abdominal injury if you find and we know that's the deformed steering wheel other than applying moist sterile dressing covered with a dry dressing to treat abdominal evisceration an alternative form of management may include and it's going to be d and that is applying occlusive dressing secured by trauma dressings you're transporting a patient with possible peritonitis following trauma to the abdomen which position would most likely prefer to assumed and we know that this is probably with the legs drawn up of course if there's no trauma suspected legs drawn up a 16 year old boy was playing football and was struck in the left flank during a tackle his vital signs are stable however he has a lot of pain you should be most concerned with his injury too and we know that's the kidney the flanks the term hematuria is defined as and we know that this is blood in the urine hema blood and then urine urea okay when caring for a female with trauma to the external genitalia the mt should and we know that there is a just local um some type of local pressure can usually control the bleeding okay thank you for um going over chapter 31 with us today if you've liked this lecture go ahead and subscribe to the channel thank you