all right welcome back to the 286 podcast Um picking up in the trauma PowerPoint Um moving on to abdominal injuries So first I just want to review the anatomy of the four abdominal quadrants When you're assessing a trauma patient and thinking about the complications and problems that they're going to have you have to remember the four quadrants So if you are told the patient has a trauma to the left upper quadrant what should you be thinking about Your most common injury for penetrating and blunt injury trauma is the spleen Your most common injury for blast injuries is the stomach If you're told the patient has trauma to the right upper quadrant what would you be thinking about Uh liver lacerations gallbladder perforation deadinum rupturing with a blast injury perforation of the dadum Now for left lower penetrating injuries could be the colon or any of the arteries Um blunt could be really anything Um could tear any of the organs displace or disconnect any arteries Uh blast any injuries any hollow organ So most likely the colon could be affected And then for right lower for penetrating and blunt injuries think arteries intestines and appendix For blast injuries same thing Any hollow organ So the intestines for either of the lowers also think injury to the bladder and the pelvis like a pelvic fracture Hemorrhage is really common after intraabdominal injury So you must assess for this For penetrating injuries usually a gunshot wound or a stab wound Um the penetrating object such as a knife is still there We do not remove it Excuse me We wrap gauze around it to stabilize it and then you wait for your trauma surgeon to remove it in the O There could be hollow organ injury such as small bowel solid organ injuries such as the liver Uh this is most frequently injured due to um how big it is and how close it is to the anterior of the patient For blunt injuries this usually occurs with a motor vehicle accident falls um explosions blows to the abdomen Usually you're going to see this with extra abdominal injuries to the head chest or extremities These are more difficult to detect because they will most likely be internal There is massive blood loss with these because of the peritineal cavity and how large it is and how much fluid it can contain For your assessment this should include a full abdominal assessment as well as a hemodynamic assessment So make sure you're getting all of your vital signs Your most common injury is going to be to your liver and spleen Signs of peritineal irritation are going to include the absence of bowel sounds abdominal distension involuntary guarding or hesitation tenderness and pain and rigidity And then remember your signs and symptoms of shock and bleeding hypotension tacocardia hypo um hypotension hypoxmia and impending doom That feeling patient's going to die For labs we want to get a CBC for hemoglobin hematocrit and white blood cell count which is going to be elevated during trauma Get a lactate for acidosis We want AGS and we want our clotting times especially our INR For pain make sure that you're assessing the location of the pain because the location of the pain can indicate certain types of injuries There are nerve pathways in the abdomen that when those are irritated they can cause referred pain to like a shoulder which is called KURS sign Left shoulder pain indicates hemorrhage from a ruptured spleen whereas right shoulder pain is hemorrhaging from a liver laceration So yes we want to assess the front of the body but we also have to turn our patients over and assess the back and the flanks We're also going to do a CT scan as well as your bedside fast exam Assessing for your hemorrhage internal and external So like I said your um imaging fast exam CT X-ray look at the front of the body the back and the flanks For vitals look for hypotension tacicardia low oxygen saturation signs of shock and internal bleeding So a lot of these are the same hypotension tacic cardia hypoxmia and impending doom For paritineal hemorrhage you could see colon sign which is bruising around the belly button and then gray turner sign which is more um hip and flank bruising signs of your internal hemorrhaging You could also have tenderness or rebound tenderness regarding rigidity and spasms increasing uh distension pain and referred pain these bluish bluish discolorations asymmetry contusions and abrasions So how we treat this We do our ABCs assessing for that internal and external hemorrhaging stopping that triad of death or your lethal um lethal diamond We can do um blood transfusions Always prepare for emergency surgery And then your blunt versus penetrating injuries For blunt you want spine immobilization until the spine injury can be ruled out for penetrating uh protruding abdominal viscera So if you have intestines protruding we cover with a moist saline dress um sterile saline dressing So just dump a bunch of sterile saline on a large piece of gauze and coat it We don't want the bowels to dry out We're going to give tetanus boosters prophylactic antibiotics as well as not removing the object for your pelvic and genital urinary trauma Uh pelvic we think pelvic instability shortened limb with external rotation So you see that on the top left Uh crepitus you're going to feel the movement of bones Genito ura um sorry genital urinary you could have hematia scrotal echimosis paranium echimosis inability to urinate For our interventions we can do a pelvic binder which is what you see in the top right This is if the patient is hemodynamically unstable It's going to kind of hold everything together uh Foley is going to be contraindicated until there's imaging done because if they have scrotal echimosis paraneium echimosis or blood at the urinary miatus we don't want to stick a catheter in there and cause more damage or the catheter ends up in the wrong location So prepare that patient for surgery assess the pulses and then we also want to get an occult stool test