24 ABDOMINAL
Abdominal Trauma
TRAUMA
CORE CONCEPTS
• Identify the anatomy and physiology of abdominal organs.
• Assess a casualty with a suspected abdominal injury in a combat environment.
• Treat a casualty with a suspected abdominal injury in a combat environment.
INTRODUCTION racic vertebrae (T4). Figure 24-1 shows the abdominal
quadrants and their associated organs.
Abdominal injuries are difficult to evaluate in the
military treatment facility (MTF) and even more so in Physiology
the field. Immediate surgical intervention is needed for
all penetrating abdominal injuries. Blunt injuries may The liver stores about 10% of a person’s total blood
be more subtle in their presentation but may be just as volume. It metabolizes carbohydrates (sugars), fat, and
deadly. Regardless of their cause, abdominal injuries protein and stores vitamins and iron. The liver forms
present two life-threatening dangers: infection and various blood-clotting factors, as well as bile, which
hemorrhage. Stay alert to the danger of early shock in breaks down fat for digestion and serves as a means
casualties with abdominal injuries. Infection can be for excreting certain waste products from the blood.
fatal, but with prompt recognition of abdominal injury The liver is also responsible for detoxifying, excreting,
and rapid evacuation of the casualty, field interven- and metabolizing many different drugs.
tion will not be required. This lesson will provide an The gallbladder stores bile formed by the liver. It
understanding of the anatomy of the abdomen and empties bile into the duodenum (first part of the small
the types of injuries that may be encountered. You will intestine). If stones form in the gallbladder, they may
learn the principles of abdominal injury assessment obstruct the drainage system (bile duct) to the small
and casualty stabilization. intestine.
The pancreas produces and secretes digestive
ANATOMY AND PHYSIOLOGY enzymes into the first part of the small intestine via
the pancreatic duct. It also produces and secretes hor-
Boundaries mones (insulin and glucagon) that regulate the blood-
sugar (glucose) level into the blood. Insulin promotes
The abdominal cavity is inferior to (below) the tho- glucose entry into most cells of the body, decreasing
racic cavity and superior to (above) the pelvic cavity. blood glucose levels. Glucagon increases the release of
Its boundaries are pelvic bones, the spinal column, and glucose from the liver into the circulating body fluids,
muscles of the abdomen and flanks. When identifying increasing blood glucose levels.
the source of pain in the abdomen, use the quadrant Carbohydrates, proteins, and fats are absorbed in
arrangement. the small intestine, as are ions (sodium, chloride, bi-
The four quadrants of the abdomen include the right carbonate, calcium, iron, and potassium) and the water
upper quadrant (RUQ), left upper quadrant (LUQ), that accompanies the ions. However, most water is
right lower quadrant (RLQ), and left lower quadrant absorbed in the colon (large intestine). Water and elec-
(LLQ). The diaphragm is the upper abdominal cavity trolytes (up to 7 L/day) are absorbed in the colon. The
boundary and, when relaxed, is level with the 4th tho- colon also stores fecal matter until it can be expelled.
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68W Combat Medic Textbook
Diaphragm
Stomach
Spleen
Tail of the
Pancreas
Colon
Left
Kidney
Descending
Colon
RLQ LLQ
Small
Inferior -l------ll---_:
Vena Cava
1,,.--_H---,--Hf++:Ft::.. Intestine
Abdominal
Large ------+--t Aorta
lntestine
Ureters
Bladder -1.----1----------r-
Figure 24-1. Abdominal quadrants and their associated organs.
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Abdominal Trauma
The stomach stores food until it can be converted vertebrae (T4), may involve abdominal structures
into chyme (the semifluid, creamy material produced (Figure 24-2).
by digestion of food) and then emptied into the duo-
denum. It secretes digestive enzymes and is poor at
absorption except for highly lipid-soluble substances
like alcohol and medications (eg, aspirin).
The spleen is an organ of the lymphatic system.
It contains the largest amount of lymphatic tissue in
the body. It stores red blood cells and platelets and
removes ones that are worn out or defective. The
spleen carries out immune functions and contains
cells involved in fighting infections. It is a highly
vascular organ that, if injured, may result in massive
hemorrhaging.
Note: The spleen may become inflamed and enlarged
in patients with infectious mononucleosis (“mono”).
These patients should be advised to avoid contact
sports for up to 6 weeks after diagnosis due to a
remote possibility of splenic rupture.
Most of the end products of bodily metabolism are
excreted by the kidneys via blood filtration and urine
formation. The kidneys regulate the water, electrolyte,
and acid-base content of the blood.
Solid and Vascular Organs
The liver, spleen, aorta, and vena cava bleed into
the abdominal cavity when injured. Blood loss into
the peritoneal cavity, regardless of the source, will
contribute to hypovolemic shock. A casualty’s entire
circulating volume can be lost into the abdominal
cavity.
Figure 24-2. Penetrating thoracic injuries below the T4 level
(nipple line) have a high probability of involving abdominal
Hollow Organs
structures. Reproduced from Nissen SC, Lounsbury DE,
Hetz SP, eds. War Surgery in Afghanistan and Iraq 2003–2007.
The intestine, gallbladder, and urinary bladder Washington, DC: Department of the Army, Office of the
may spill their contents into the peritoneal cavity and Surgeon General, Borden Institute; 2008: Chap IV.4, Fig 4.
retroperitoneal space upon injury. Release of digestive
acids, enzymes, bacteria, and chyme into the peritoneal
cavity causes peritonitis (inflammation of the perito- ASSESSING ABDOMINAL TRAUMA
neum or lining of the abdominal cavity) and sepsis (a
massive systemic infection that includes hypotension, Penetrating Trauma
decreased urine output, and altered mental status).
Bleeding from an intestinal injury is typically minor Mentally visualize the path of all penetrating trau-
unless larger vessels of the mesentery are damaged. ma of the abdomen and thorax; never probe penetrat-
Due to the proximity of the thoracic and abdomi- ing or abdominal wounds with fingers or instruments.
nal regions, a wound that started out in the abdomen Trauma to the thorax or abdomen may continue into a
may end up in the chest, or the other way around. different cavity depending on the position of the dia-
Any penetrating thoracic injury below the nipple phragm on impact. Penetrating wounds to the flanks or
line, which is also level with the fourth thoracic buttocks may involve organs of the abdominal cavity.
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68W Combat Medic Textbook
Penetrating trauma in the gluteal area is associated
with significant intra-abdominal trauma in up to 50%
of cases. In penetrating trauma, the casualty may not
initially appear to be in shock unless the object or pro-
jectile penetrates a major vessel or organ (Figure 24-3).
Figure 24-4. How blunt trauma occurs to crewmembers after
their armored vehicle is struck by an improvised explosive
device.
be caused by restraining devices such as seat belts,
gunner’s harnesses, and litter straps.
Kinematics
The mechanism of injury and a high index of sus-
picion play important roles in identifying possible
life-threatening abdominal injuries. For example, ap-
proximately 15% of stab wounds (low energy) require
surgical intervention, whereas approximately 85% of
Figure 24-3. M16 entry and exit wounds to the abdomen. gunshot wounds (medium and high energy) require
Reproduced from Nissen SC, Lounsbury DE, Hetz SP, eds. surgical intervention. Fragmentation wounds are the
War Surgery in Afghanistan and Iraq 2003–2007. Washington, most common cause of penetrating injuries in combat.
DC: Department of the Army, Office of the Surgeon General, The following are key indicators of abdominal
Borden Institute; 2008: Chap V.1, Fig 1. injuries:
Blunt Trauma • obvious signs of trauma,
• signs of hypovolemic shock without obvious
Blunt trauma poses a greater threat to life than pen- cause,
etrating trauma. It is difficult to diagnose, and objective • degree of shock greater than would be ex-
evidence of blunt trauma may not appear on the casu- pected by other injuries,
alty for hours. The mechanism of injury, such as that • presence of peritoneal signs, and
depicted in Figure 24-4, and the casualty’s complaints • mechanism of injury.
of pain may be the only signs of an underlying injury.
Compression injuries are a type of blunt trauma The primary factor in assessing abdominal trauma
in which organs are crushed between solid objects. is not the accurate diagnosis of the injury but rather the
Shearing injuries occur when tearing forces are exerted determination that an abdominal injury exists. This and
against the supporting ligaments of solid organs and the resulting delay of treatment are the major causes of
vessels. Deceleration injuries are common and may morbidity and mortality in abdominal trauma.
38
Abdominal Trauma
History 2. What is the most reliable indicator of intra-
abdominal bleeding?
When obtaining a casualty’s history, there are 3. Why are soft-tissue injuries a poor indication
several key factors to consider. If the individual has of intra-abdominal bleeding?
been involved in an automobile accident, determine
the position of the vehicle, extent of vehicle damage, MANAGING ABDOMINAL TRAUMA
and position of the casualty within the vehicle. Find
out if there was an explosion that threw the victim Casualty Management
against immobile objects or transmitted blast pres-
sure to organs inside the abdomen. Keep in mind that Once an abdominal injury is identified, the casualty
overpressure can rupture hollow organs and leave no should be evacuated to an MTF as soon as possible.
sign of external injury; ruptured eardrums may sig- Evacuating a casualty to an MTF that does not have
nify hollow organ rupture from overpressure. If the surgical capabilities defeats the purpose of rapid
injury was caused by a weapon, determine the type evacuation. Categorize these casualties as urgent sur-
of weapon used and the casualty’s distance from the gical for evacuation precedence.
weapon. Consider fragmentation wounds. In each case,
determine whether safety equipment, such as vehicle
seat belts, helmets, or body armor, was used.
Physical Examination
The most reliable indicator of intra-abdominal
bleeding is the presence of hypovolemic shock.
Look for signs and symptoms of compensated, and
later decompensated, shock (see Chapter 8, Shock).
Do not waste time auscultating the abdomen in a
combat environment; your findings will not alter
casualty treatment before reaching the MTF. Inspect
for soft-tissue injuries and distention. Soft-tissue
injuries due to blunt trauma may not be apparent
for hours after the injury; the adult peritoneal cav-
ity can hold up to 1.5 L of fluid before evidence of
distention is apparent.
For combat-related abdominal injuries, lightly pal-
pate each quadrant to assess for tenderness and rigid-
ity. Pain or rigidity in any quadrant requires surgical Figure 24-5. Simulated casualty presenting with penetrating
exploration. Avoid deep or aggressive palpation be- trauma to the abdomen. The casualty’s knees are flexed to
cause it may dislodge blood clots, exacerbate existing relieve pain.
hemorrhage, and increase spillage of gastrointestinal
tract contents. Note any voluntary guarding (ie, the Position the casualty for transport with knees bent
casualty seems to tense up) and involuntary guarding when possible (Figure 24-5). Manage conditions associ-
(ie, spasms of the abdominal wall muscles that remain ated with hemorrhage, airway, breathing, and circula-
even when the casualty is distracted). Palpate the pelvis tion (HABCs). Establish vascular access with a saline
for instability in three steps: (1) press posteriorly on lock. Follow fluid resuscitation protocols (see Chapter
the iliac crest, (2) press inward on the iliac crest, and 8, Shock) for combat casualties in hemorrhagic shock.
(3) press posteriorly on the symphysis pubis. You must achieve the delicate balance of maintain-
ing perfusion to the vital organs without restoring a
Check on Learning normal blood pressure that will increase internal bleed-
ing. Provide oral or intravenous antibiotics, depending
1. What type of physical examination should on availability and the casualty’s condition.
be completed on a combat casualty with an
abdominal injury?
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68W Combat Medic Textbook
Special Considerations
Treatment of abdominal trauma can be complicated
by many factors. Some significant considerations are
addressed below.
Impaled Objects
Do not move or remove impaled objects; leave that
task to the surgeon. Instead, stabilize the object either
manually or mechanically with built-up bulky dress-
ing. Apply direct pressure with the flat of the hand
to control bleeding around the edges of the wound if
necessary. Do not palpate the abdomen (Figure 24-6).
Figure 24-7. Wound showing evisceration of the small in-
testine. Reproduced from Nissen SC, Lounsbury DE, Hetz
SP, eds. War Surgery in Afghanistan and Iraq 2003–2007. Wash-
ington, DC: Department of the Army, Office of the Surgeon
General, Borden Institute; 2008: Chap V.5, Fig 1.
Pregnancy
Until about the 12th week of gestation, the uterus re-
mains protected by the pelvis. Injury to the uterus can
include rupture, penetration, abruptio placentae, and
premature rupture of the membranes. The placenta
and uterus are highly vascular and can hemorrhage
profusely. Additionally, hemorrhage can be concealed
Figure 24-6. A 22-year-old male impaled by a 5-ft iron bar for a period of time within the uterus. A casualty with
due to a traffic accident. The patient fully recovered after the vaginal bleeding secondary to trauma should be evacu-
bar was removed. Photograph by Dr Biplab Mishra. ated urgently.
Reproduced with permission from [Link]
By the third trimester, the mother’s heartbeat in-
[Link]/main/image/754/. License at [Link]
[Link]/licenses/by-nc-sa/2.5/legalcode creases by 15 to 20 beats per minute. By the 36th week
of pregnancy, the mother’s blood volume has increased
by about 50%. Because of increases in cardiac output
Evisceration and blood volume, a pregnant casualty may lose 30%
to 35% of total blood volume before showing signs of
Focus your efforts on protecting the protruding hypovolemia. Systolic and diastolic blood pressure
segment of intestine or other organs from further drop 5 to 15 mmHg during the second trimester but
damage. Most abdominal contents require a moist will return to normal by term. Ask the casualty about
environment. Apply a clean or sterile dressing that issues with pregnancy that may complicate your as-
has been moistened with saline (normal saline intra- sessment and management.
venous fluid can be used). Do not attempt to replace The best way to ensure the survival of the mother
the protruding segment in the abdominal cavity. Any and fetus is to provide the mother with aggressive
action that increases intra-abdominal pressure, such resuscitation and transport. Treatment and transport
as crying, screaming, coughing, or bearing down, can of a pregnant casualty are similar to that of any other
force more of the organs outward (Figure 24-7). casualty. First, manage conditions associated with
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Abdominal Trauma
Genitourinary Injuries
Damage to the kidneys, ureters, and bladder often
presents with hematuria, which will not be noted un-
less the casualty has a urinary catheter (unlikely in a
combat environment). Injuries to external genitalia
result in soft-tissue hemorrhage, significant pain, and
psychological concern. Given the supplies available on
the battlefield, control hemorrhage with direct pres-
sure or pressure dressings and manage amputated
genital body parts as you would any other amputated
body part on the battlefield (Figure 24-8).
Check on Learning
4. What are your options when treating an ab-
dominal evisceration?
5. How should an obviously pregnant female
be transported?
6. What is the proper way to manage an impale-
Figure 24-8. Injury to the kidney. Reproduced from: Nissen ment?
SC, Lounsbury DE, Hetz SP, eds. War Surgery in Afghanistan
and Iraq 2003–2007. Washington, DC: Department of the SUMMARY
Army, Office of the Surgeon General, Borden Institute; 2008:
Chap V.4, Fig 2. Uncontrolled hemorrhage and time are the enemies
of the abdominal trauma casualty, and both have
immediate consequences to life. You must promptly
HABCs. Then transport the casualty on her left side, recognize abdominal injury and the early onset of
tilt the right side of the spine board, and elevate the shock in these casualties. The keys to survival for those
casualty’s right leg or manually displace the uterus to suffering from abdominal injuries are early recogni-
the left to relieve supine hypotension. tion, stabilization, and rapid evacuation.
KEY TERMS
Abruptio placentae. Premature detachment of the placenta.
Bile duct. Any of the intercellular passages that convey bile from the liver to the hepatic duct, which joins the
duct from the gallbladder (cystic duct) to form the common bile duct (ductus choledochus) and which enters
the duodenum about 3 inches below the pylorus.
Colon. The large intestine from the end of the ileum to the anal canal.
Duodenum. The first part of the small intestine, between the pylorus and the jejunum; it is 8 to 11 inches long.
The duodenum receives hepatic and pancreatic secretions through the common bile duct.
Gallbladder. A pear-shaped, gray-blue sac that stores bile from the liver and aids in digestion.
Mesentery. The peritoneal fold that encircles the small intestine and connects it to the posterior abdominal wall.
Pancreas. A compound acinotubular gland that performs multiple functions and is considered both an exocrine
and endocrine organ. The exocrine secretions of the pancreas consist of enzymes that digest food in the small
intestine. The endocrine cells produce hormones such as glucagon, which raises blood glucose, and insulin,
which assists cells of the body to uptake glucose.
Pancreatic duct. The duct that conveys pancreatic juice to the common bile duct and duodenum.
Peritonitis. Inflammation of the serous membrane that lines the abdominal cavity and its viscera.
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68W Combat Medic Textbook
Sepsis. A systemic inflammatory response to infection, in which there is fever or hypothermia, tachycardia,
tachypnea, and evidence of inadequate blood flow to internal organs.
Spleen. A dark red, oval lymphoid organ, located in the left upper abdominal quadrant, that aids in the removal
of cell debris; microorganisms; and cells that are old, damaged, abnormal, or coated with antibodies. The spleen
also produces white blood cells.
CHECK ON LEARNING ANSWERS
1. What type of physical examination should be completed on a combat casualty with an abdominal
injury?
For combat-related abdominal injuries, lightly palpate each quadrant to assess for tenderness and rigidity.
Pain or rigidity in any quadrant of a combat casualty requires surgical exploration. Avoid deep or aggres-
sive palpation because it may dislodge blood clots, promote existing hemorrhage, and increase spillage of
contents of the gastrointestinal tract.
2. What is the most reliable indicator of intra-abdominal bleeding?
The presence of hypovolemic shock from an unexplained source.
3. Why are soft-tissue injuries a poor indication of intra-abdominal bleeding?
They may not be apparent for hours after the injury.
4. What are your options when treating an abdominal evisceration?
Focus on protecting the protruding segment of intestine or other organs from further damage. Because
most abdominal contents require a moist environment, apply a clean or sterile drssing that has been
moistened with saline (eg, normal saline IV fluid). Do not try to replace the protruding segment back
into the abdominal cavity.
5. How should an obviously pregnant female be transported?
Transport the casualty on her left side, tilt the right side of the spine board, and elevate the casualty’s
right leg or manually displace the uterus to the left to relieve supine hypotension.
6. What is the proper way to manage an impalement?
Do not move or remove the impaled object. Stabilize it either manually or mechanically with a bulky
dressing and apply direct pressure with the flat of your hand to control bleeding around the edges of the
wound if necessary.
SOURCES
National Association of Emergency Medical Technicians. PHTLS: Prehospital Trauma Life Support, Military Edition.
8th ed. Jones & Bartlett Learning; 2016.
Taber’s Cyclopedic Medical Dictionary, 22nd ed. F.A. Davis Co; 2013.
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