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Penetrating and Blunt Abdominal Trauma Kristine L

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Penetrating and Blunt Abdominal Trauma Kristine L Cril Cure Xurs Q ViiL 28. No, l,pp, U-Sy © 2iWi Uppineou Williams & Wilkins. Ine. Penetrating and Blunt Abdominal Trauma Kristine L. Eckert, BSN, RN, CEN Tliis articlf is an overview of abUonitnal trauma relating to both penftraling and blunt mecha- nisms ot injun. Tlic incidence of abclomin;il injuries is discussed. Illusiraled through case studies are inter\enti<Jns and treatment a[>pliCLible to nursing practice. Cit-neral principles of ahdominal assessment are included. Anatomy and ptiysiology ot the diffcrent orj-an systems, as well as com- plications, is briefly ovcrviewed. Differences between solid and hollow organs are reviewed. Pearl.s and pitfalls that impact nursing practice are presented tor specific injuries. Key words: iihilamen. ahdoniinul, blinit, penetrating, trauma HE abdomen is divided into 3 differ- will he illustrated througli a series of case Tent anatomic areas, the peritonea! space studies. and the retroperitoneal space, the region be- hind the peritoneum, and pelvis.' The peri- toneal cavity includes the diaphragm, liver, CASE STUDY 1 spleen, stomach, and transverse colon, and a portion of the cavity is covered by the At 0032. medics arrived on the scene of bony thorax.' The retroperitoneal organs and a possible gang-related incident in which vessels include aorta, vena cava, pancreas, A.L., a 36-year-oId male, had stistainetl 5 gtin- kidtieys, ureters, and portions of the duode- shot wounds to his chest, back, and leg. num and colon.' The pelvic organs and ves- Paramedics reported no palpable peripheral sels include rectum, bladder, uterus, and iliac pulses and no palpable blood pressure, and vessels.' no oxygen sattiration reading was available, which was contributed to by A.L. scombative The abdomen contains both solid and hol- behavior Lting sounds were decreased on the low organs. The liver, spleen, patiereas, and left side. At 0033, the base hospital physician kidneys (atid ureters) comprise the solid or- ordered a needle thoracostomy that was per- gans whereas the intestines, stomach, gall- formed by the panimedics with an 18-gauge bladder, and urinar>- bladder comprise the catheter in the left chest wall, midciavicular hollow organs. Complications of abdominal line. Tlie needle thoracostomy was successful trauma include hemorrhage, shock, peritotii- with clear and equal breath sounds with min- tis, and sepsis." imai bloody drainage. Medics established a in this article, the differences between l6-gauge rv catheter in the right antectibital penetnithig and blunt abdominal trauma area as well as a 14-gauge IV catheter in the left antecubital area with fluids rutming wide open. A.L. was awake, conversing, but /'n</« Iht' Trauma .Services Department. Scripps Mercy Hospital, i^etei I Trauma Center. .San i^ief{n, combative and uncooperative. Heart rate per Catif medics was 126 beats per minute (bptii) with Spedat tbanks to Sijeihy Mecleititi-IUmtje. RN, trauma respirations of 24/min, skins ashen, moist, and mirse leam leader. Scripps Mercy Hnspitai. for ber as- clammy, (ilascow Coma Scale (GCS) was 14. sistance uith researcb and topic tlcfeio/nnenl. thanks atso /o (-race ticker! fnr ediluriai assistance. Medics arrived at 0051 at the trauma resus- citation room with A.L., who was talking and Correspiimiing author Kristine L i-ckerl. BSN. RN. CAIN. 5750 hiars Rd f20i, Sun Diego. CA <J2liO (email: thrashitig on the backboard. After the tntuma kHstitie-ecfeert^shcgioiyai.twtJ. team obtained a brief history that indicated no 41 42 CRITICAL CARE NUR-SING QUARTERLY/JANUARY-MARCH 2(X)5 ongoing medical problems or allcrgifs, AL. was immediately intiibatcd at 0054 after rapid sequence induction with 20 mg of etomidate und succinykholine (140 mg IV pusli). The trauma nurse then gave vecuronium (10 mg IV push) to maintain paralysis for further diag- nostic and trcatmenl procedures. Initial vital signs inelude a blood pressure of 1S3/7O mm Hg, a lieart rate of 124 bpm. respirations of 30/niin. and 92% oxygen saturation on a non- rebreatber mask. An 8.0-Freneh large bore left femoral cordis (eentral venous litie) was placed by the attend- ing trauma surgeon at 0056 as well as an arte- rial line in the left groin, from which blood samples were sent to the laboratory includ- ing a blood tube for type and eross. The Foley catheter was placed after the trauma surgeon contlrmed rectal, prostate, and nieatus exam- Figure 1, Arrows depict the location of A.L.s gun- inations are normal. An important point to re- shot wounds. member witli placement of a urethral catheter is never to blow up ihe balloon until you see tation A.L. s systolic blood pressure dropped elear urine return, as damage to the urethra dramatically into the 80s. He then received can occtir. This is especially true in cases of 2 11 of O-negative packed red blood eells as trauma where there may already be genitouri- well as approximately 4000 cc of warmed nor- nary (GIT) damage and injury. A.I,, s urine was mal saline, 0.9% while being rushed to the op- bloody. A nasogastric tube, as well as a right erating room (OR) at 0120 for a damage con- chest tube, is placed by the trauma surgeon trol laparotomy. at 0102, which revealed a hemothorax. The The principles of damage eontrol surgery emergency department physician performed are to control hemorrhage, prevent contam- a FAST abdominal ultrasound at the bedside in inatioti from the bowel, avoid further injury, the trauma bay to rule out free fluid in the ab- and simultaneous vigorous resuscitation with dominal cavity. There was no free fluid noted blood and clotting factors.^ Minimizing the in the intra-abdominal cavity and no pericar- amount of time spent prehospital and in the dial fluid n<Jte(.I by the FAST ultrasound exam- tniuma room or emergency departmenl is life ination (Fig 1). saving and should be the collaborative goal for Physical examination revealed a gunshot this patient ssurvival.'' All unnecessary proce- wound to the left lateral chest, mid to pos- dures and studies should be deferred at the terior axillary line, approximately niidchest: titiie of the initial phases of resuscitation if a gun.shot wound to just left of midline in it does not affect the itnniediate management the upper lumbar region of the back; a gun- ofthe patient.^ Aggressive fluid resuseitation shot wound noted to the right anterolateral prior to surgery is futile and will worsen coag- flank, which appeared to go into the abdom- ulopathy and hypothermia.^ Aiso. in the lab- inal cavity, with some active venous bleed- oratory results, clot quality can be interfered ing; a gunshot wound to the lateral right with by colloid .solutions.-^ knee and tlic posterior right thigh; and a When hemodynamically unstable patients macerated gunshot wound in the left antecu- arrive in the trauma room, rapid transfer to bital region, which appeared to be superficial. the OR is essential where stirgical control of Distal neurovuscular status was intact in ail hemorrhage and simultaneous vigorous resus- extremities. During this period of the resusci- citation can be implemented.^ Small caliber Penetrating and Blunt Abdominal Trauma 43 venous access is of limited use in this ag- or cavities, but the trajeetory (path) of the gressive resuscitation with blood, fresh frozen bullet depends on many variables, such as plasma, cryopreeipitate, and platelet trans- the angle and distance from which the gun fusions, while a large bore central venous was fired as well as the caliber of the bullet.- femoral access is valuable.^ An arterial line is The bullet path can also be ehanged and re- also useful tbr patient monitoring.^ fracted off bony surfaces/' For example, ab- A.L. s injuries di.scovered in the OR in- dominal trauma shotild be considered with cluded laceration of spleen, bilateral kidneys, the presentation of a chest or buttock gun.shot diaphragm, liver, and small bowel. ProcetUires wound.'' The assessment should also include perfortned were a left nephrectomy, splenec- distinguishing entrance and exit wounds and tomy, hepatorrhaphy, small bowel resection their locations to assist in determining the tra- with primar) anastomosis, repair of diaph- jectory of the bullet and what organs may be ragm lacerations x3, and a pericardial win- involved (Figs 4-6).- dow. The pericardial window showed no car- If the patient is stable, care should be taken diae damage. The abdomen was left packed to establish the path of the pe net nit ing ob- open with (Jelfoam over the liver and exter- ject b\' thoroughly examining the entire body nal kerlix. A towel suction vacuum closure to look for possible sites of entry or exit." A with Ioban dressing was used to clo.se the ab- thorough examination includes examination domen open. This method of closure is rapid of skin folds, the back, the perineum, the axil- and temporary.^ Patients requiring a damage lae, and the buttocks,* After determining the eontrol laparotomy will frequently return for location ofthe wounds, plain x-niy films can multiple surgeries. Also, because t)f the high be laken in hemodynamically stable patients.^ risk of abdominal compartment syndrome, it The ECG electrode patches are a commonly is suggested in the literature that the abdomen used radiopaque object to mark penetrating sh(5tikl be left open as a laparotom\ with a silo- wound sites for diagnostics sucii as plain films bag or vacuum-paek technique (Fig 2).^ and computed tomography (CT).^ These plain films are helpful in tlctermining the tnick or Penetrating trajectory of the penetrating object and the location of any bullets." Computed tomogra- It is important to note that the extemal ai> phy is more helpftil in defining injury. Next, pearance of the wound does not determine a comparison of the number of holes and bul- the extent of internal injury (Fig .3).- Because Ifts and the ntimber found on physical ex- ofthe external location of a gunshot woLind, amination shouki occur to rule out a missed it may appear not to involve certain organs wound or a nonvisualized bullet (Figs 7-9).
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