Abdominal Trauma

DRG Category:	326
Mean LOS:	15.4 days
Description:	SURGICAL: Stomach, Esophageal, and Duodenal Procedure with Major CC
DRG Category:	394
Mean LOS:	4.4 days
Description:	MEDICAL: Other Digestive System Diagnoses with CC

Abdominal trauma accounts for approximately 15% of all trauma-related deaths. Intra-abdominal trauma is usually not a single organ system injury; as more organs are injured, the risks of organ dysfunction and death climb. The abdominal cavity contains solid, gas-filled, fluid-filled, and encapsulated organs. These organs are at greater risk for injury than other organs of the body because they have few bony structures to protect them. Although the last five ribs serve as some protection, if they are fractured, the sharp-edged bony fragments can cause further organ damage from lacerations or organ penetration (Table 1).

Injuries to the Abdomen

Table 1. Injuries to the Abdomen
ORGAN OR TISSUE	COMMON INJURIES	SYMPTOMS
Diaphragm	Partially protected by bony structures, the diaphragm is most commonly injured by penetrating trauma (particularly gunshot wounds to the lower chest) Automobile deceleration may lead to rapid rise in intra-abdominal pressure and a burst injury Diaphragmatic tear usually indicates multi-organ involvement	Decreased breath sounds Abdominal peristalsis heard in thorax Acute chest pain and shortness of breath may indicate diaphragmatic tear May be hard to diagnose because of multisystem trauma or the liver may “plug” the defect and mask it
Esophagus	Penetrating injury is more common than blunt injury May be caused by knives, bullets, foreign body obstruction May be caused by iatrogenic perforation May be associated with cervical spine injury	Pain at site of perforation Fever Difficulty swallowing Cervical tenderness Peritoneal irritation
Stomach	Penetrating injury is more common than blunt injury; in one-third of patients, both the anterior and the posterior walls are penetrated May occur as a complication from cardiopulmonary resuscitation or from gastric dilation	Epigastric pain Epigastric tenderness Signs of peritonitis Bloody gastric drainage
Liver	Most commonly injured organ (both blunt and penetrating injuries); blunt injuries (70% of total) usually occur from motor vehicle crashes and steering wheel trauma Highest mortality from blunt injury (more common in suburban areas) and gunshot wound (more common in urban areas) Hemorrhage is most common cause of death from liver injury; overall mortality 10%–15%	Persistent hypotension despite adequate fluid resuscitation Guarding over right upper or lower quadrant; rebound abdominal tenderness Dullness to percussion Abdominal distention and peritoneal irritation Persistent thoracic bleeding
Spleen	Most commonly injured organ with blunt abdominal trauma Injured in penetrating trauma of the left upper quadrant	Hypotension, tachycardia, shortness of breath Peritoneal irritation Abdominal wall tenderness Left upper quadrant pain Fixed dullness to percussion in left flank; dullness to percussion in right flank that disappears with change of position
Pancreas	Most often penetrating injury (gunshot wounds at close range) Blunt injury from deceleration; injury from steering wheel Often associated (40%) with other organ damage (liver, spleen, vessels)	Pain over pancreas Paralytic ileus Symptoms may occur late (after 24 hr); epigastric pain radiating to back; nausea, vomiting Tenderness to deep palpation
Small intestines	Duodenum, ileum, and jejunum; hollow viscous structure most often injured by penetrating trauma Gunshot wounds account for 70% of cases Incidence of injury is third only to liver and spleen injury When small bowel ruptures from blunt injury, rupture occurs most often at proximal jejunum and terminal ileum	Testicular pain Referred pain to shoulders, chest, back Mild abdominal pain Peritoneal irritation Fever, jaundice, intestinal obstruction
Large intestines	One of the more lethal injuries because of fecal contamination; occurs in 5% of abdominal injuries More than 90% of incidences are penetrating injuries Blunt injuries are often from safety restraints in motor vehicle crashes	Pain, muscle rigidity Guarding, rebound tenderness Blood on rectal examination Fever

Abdominal trauma can be blunt or penetrating. Blunt injuries occur when there is no break in the skin; they often occur as multiple injuries. In blunt injuries, the spleen and liver are the most commonly injured organs. Injury occurs from compression, concussive forces that cause tears and hematomas to the solid organs such as the liver, and deceleration forces. These forces can also cause hollow organs such as the small intestines to deform; if the intraluminal pressure of hollow organs increases as they deform, the organ may rupture. Deceleration forces, such as those that occur from a sudden stop in a car or truck, may also cause stretching and tears along ligaments that support or connect organs, resulting in bleeding and organ damage. Examples of deceleration injuries include hepatic tears along the ligamentum teres (round ligament that is the fibrous remnant of the left umbilical vein of the fetus, originates at the umbilicus, and may attach to the inferior margin of the liver), damage to the renal artery intima, and mesenteric tears of the bowel.

Penetrating injuries are those associated with foreign bodies set into motion. The foreign object penetrates the organ and dissipates energy into the organ and surrounding areas. The abdominal organs most commonly involved with penetrating trauma include the intestines, liver, and spleen. Complications following abdominal trauma include profuse bleeding from aortic dissection or other vascular structures, hemorrhagic shock, peritonitis, abscess formation, septic shock, paralytic ileus, ischemic bowel syndrome, acute renal failure, liver failure, adult respiratory distress syndrome, disseminated intravascular coagulation, and death.

Causes

At least half of the cases of blunt abdominal trauma are caused by motor vehicle crashes (MVCs). These injuries are often associated with head and chest injuries as well. Other causes of blunt injury include falls, aggravated assaults, and contact sports. Penetrating injuries can occur from gunshot wounds, stab wounds, or impalements.

Genetic considerations

No clear genetic contributions to susceptibility have been defined.

Gender, ethnic/racial, and life span considerations

Traumatic injuries, which are usually preventable, are the leading cause of death in the first four decades of life. Most blunt abdominal trauma is associated with MVCs, which are two to three times more common in males than in females in the 15- to 24-year-old age group. In teens and young adults, whites have a death rate from MVCs that is 40% higher than that of blacks/African Americans. Penetrating injuries from gunshot wounds and stab wounds, which are on the increase in U.S. preteens and young adults, are more common in blacks/African Americans than in whites.

Global health considerations

Specifically with respect to abdominal trauma, MVCs are the leading cause of abdominal injury and they occur most commonly in males 14 to 30 years of age. According to the World Health Organization, falls from heights of less than 5 meters are the leading cause of injury globally, but estimates are that only 6% of those are related to abdominal trauma.

Assessment

History

For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. AMPLE is a useful mnemonic in trauma assessment: Allergies, Medications, Past medical history, Last meal, and 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.

Physical examination

The patient’s appearance may range from anxious but healthy to critically injured with 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. 606). 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 include reevaluation. Serial assessments are critical because large amounts of blood can accumulate in the peritoneal or pelvic cavities without early changes in the physical examination.

The most common signs and symptoms are pain, abdominal tenderness, and gastrointestinal hemorrhage in the alert patient. When you inspect the patient’s abdomen, note any disruption from the normal appearance such as distention, lacerations, ecchymoses, and penetrating wounds. Inspect for any signs of obvious bleeding, such as ecchymoses around the umbilicus (Cullen’s 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 hyperresonance can indicate free air; abnormal dullness may indicate bleeding. When you palpate the abdomen and flanks, note any increase in tenderness, which 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	Normal Result	Abnormality With Condition	Explanation
Contrast-enhanced computed tomography scan	Normal and intact abdominal structures	Injured or ruptured organs; accumulation of blood or air in the peritoneum, in the retroperitoneum, or above the diaphragm	Provides detailed pictures of the intra-abdominal and retroperitoneal structures, the presence of bleeding, hematoma formation, and the grade of injury
Focused abdominal sonogram for trauma (FAST); four acoustic windows (pericardiac, perihepatic, perisplenic, pelvic)	No fluid seen in four acoustic windows	Accumulation of blood in the peritoneum	Provides rapid evaluation of hemoperitoneum; experts consider FAST’s accuracy equal to that of diagnostic peritoneal lavage (DPL) (see below)
Diagnostic peritoneal lavage (DPL); indicated in spinal cord injury, multiple injuries with unexplained shock, intoxicated or unresponsive patients with possible abdominal injury	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 crossmatch; drug and alcohol screens; serum chemistries; serum glucose; serum amylase; abdominal, chest, and cervical spine radiographs; urinalysis and excretory urograms; arteriography; magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of bile duct injuries.

Primary nursing diagnosis

Diagnosis

Ineffective breathing pattern related to pain and abdominal distension

Outcomes

Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

Interventions

Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Planning and implementation

Collaborative

The initial care of the patient with abdominal trauma follows the ABCs (airway, breathing, circulation) of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion include the establishment of an effective airway and a supplemental oxygen source, support of breathing, control of the source of blood loss, and replacement of intravascular volume. Titrate intravenous fluids to maintain a systolic blood pressure of 100 mm Hg; overaggressive fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

surgical.

Surgical intervention is needed for specific injuries to organs. Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years. Esophageal injury is often managed with gastric decompression with a nasogastric tube, antibiotic therapy, and surgical repair of the esophageal tear. Gastric injury is managed similarly to esophageal injury, although a partial gastrectomy may be needed if extensive injury has occurred. Liver injury may be managed nonoperatively or operatively, depending on the degree of injury and the amount of bleeding. Patients with liver injury are apt to experience problems with albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation, resistance to infection, and nutritional balance. Management of injuries to the spleen depends on the patient’s age, stability, associated injuries, and type of splenic injury. Because removal of the spleen places the patient at risk for immune compromise, splenectomy is the treatment of choice only when the spleen is totally separated from the blood supply, when the patient is markedly hemodynamically unstable, or when the spleen is totally macerated. Treatment of pancreatic injury depends on the degree of pancreatic damage, but drainage of the area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage from pancreatic enzymes. Small and large bowel perforation or lacerations are managed by surgical exploration and repair. Preoperative and postoperative antibiotics are administered to prevent sepsis.

nutritional.

Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to eliminate gastrointestinal feedings for extended periods of time depending on the injury and the surgical intervention required. Total parenteral nutrition may be used to provide nutritional requirements.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Histamine-2 blockers	Varies with drug	Ranitidine (Zantac); cimetidine (Tagamet); famotidine (Pepcid); nizatidine (Axid)	Block gastric secretion and maintain pH of gastric contents above 4, thereby decreasing inflammation

Other Therapies: Narcotic analgesia to manage pain and limit atelectasis and pneumonia and antibiotic therapy as indicated

Independent

The most important priority is the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. Be prepared to assist with endotracheal intubation and mechanical ventilation by maintaining an intubation tray within immediate reach at all times. Maintain a working endotracheal suction at the bedside as well. If the patient is hemodynamically stable, position the patient for full lung expansion, usually in the semi-Fowler position with the arms elevated on pillows. If the cervical spine is at risk after an injury, maintain the body alignment and prevent flexion and extension by using a cervical collar or other strategy as dictated by trauma service protocol.

The nurse is the key to providing adequate pain control. Encourage the patient to describe and rate the pain on a scale of 1 through 10 to help you evaluate whether the pain is being controlled successfully. Consider using nonpharmacologic strategies, such as diversionary activities or massage, to manage pain as an adjunct to analgesia.

Emotional support of the patient and family is also a key nursing intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the ABCs, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives and keep them updated as to the patient’s response to therapy. Notify the physician if the family needs to speak to her or him about the patient’s progress. If blood component therapy is essential to manage bleeding, answer the patient’s and family’s questions about the risks of hepatitis and HIV transmission.

Evidence-Based Practice and Health Policy

Harvey, R., Herriman, E., & O’Brien, D. (2013). Guarding the gut: Early mobility after abdominal surgery. Critical Care Nursing Quarterly, 36(1), 63–72.

Perpetual inflammation resulting from immobility significantly impacts surgical patients’ outcomes.
Structured mobility programs that encourage patients to ambulate as early as the first day postabdominal surgery has the potential to reduce inflammation, promote a faster return of gastrointestinal function, and increase muscle force at discharge, reducing lengths of inpatient stay.
The use of nonrigid abdominal binders demonstrate improved patients’ self-reported comfort and ability to participate in physical activity, such as early ambulation. Despite some clinicians’ hesitancy to use abdominal binders, evidence shows no significant differences in forced vital capacity, expiratory volume, or expiratory flow rate.

Documentation guidelines

Abdominal assessment: Description of wounds or surgical incisions, wound healing, presence of bowel sounds, location of bowel sounds, number and quality of bowel movements, patency of drainage tubes, color of urine, presence of bloody urine or clots, amount of urine, appearance of catheter insertion site, fluid balance (intake and output, patency of intravenous catheters, speed of fluid resuscitation)
Comfort: Location, duration, precipitating factors of pain; response to medications; degree of pain control
Presence of complications: Pulmonary infection, peritonitis, hemorrhage, wound infection, alcohol withdrawal
Assessment of level of anxiety, degree of understanding, adjustment, family’s or partner’s response, coping skills
Understanding of and interest in patient teaching

Discharge and home healthcare guidelines

Provide a complete explanation of all emergency treatments and answer the patient’s and family’s questions. Explain the possibility of complications to recovery, such as poor wound healing, infection, and bleeding. Explain the risks of blood transfusions and answer any questions about exposure to blood-borne infections. If needed, provide information about any follow-up laboratory procedures that might be required after discharge. Provide the dates and times that the patient is to receive follow-up care with the primary healthcare provider or the trauma clinic. Give the patient a phone number to call with questions or concerns. Work with the trauma team to assess the need for home health assistance following discharge. Provide demonstration and information on how to manage any drainage systems, colostomy, intravenous therapies, or surgical wounds.