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
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
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
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). Gunshot wounds are generally more serious than stab wounds, as 9S'>ii of gunshot wounds to the abdomen cau.se serious injury." The priority complications of gtinshot wounds are hemorrhage and sepsis.- While low-energy gunshot wounds to the abdomen that appear to be superficial are observed, it is necessary for most gunshot wounds to the abdomen to have an explorator\- laparotomy surgery. When penetrating trauma to the thoracoab- dominal area occurs with hemodynamic com promise, obvious peritoneal penetration, or peritoneal irritation upon examination, sur- Figure 2. Open packt-d abdomen after damage gicai intervention of laparotomy is indicated. control surgery. Reprinted with permission from Because the instrument is usually held in the the Trauma Imagebank.' assailant s right hand, the left upper quadrant 44 CRmcAL C^ARE NURSING QLIARTERLY/^ANUARY-MARCH 2(K)5
Vital signs unstable
Clinical indication for laparotomy' 1 Thoracoabdominal or flank wound
AbdominalCT and/or DPL (> IOOK RBOHPF)
Figure 3- Ptnt'trating abdominal Observation Liiparoltimy trauma. Reprinted wilh permission from Scalctta and Schaidcr,"' is the most commonly injured in stab level of the fifth intercostal space on the wounds.'^ It is estimated that only half of all left. Because of this, it is important to be stab wounds actually enter the abdominal suspicious of both thoracic and abdominal cavity. Stab wounds are more common!) injtiries." Tlie stage of tbe respiratory cy- observed.-^ Tlie timing of surgery for abdom- cle of the patient could affect the entrance inal stab wounds is debated in the literature of the penetrating object in the abdomi- and is a preferenee ofthe trauma surgeon.- nal cavity versus thoracic cavity. Innervated separately, the right and left liemidiaphragm phrenic nerves travel along the posterolat- Diaphragm eral mediastinum on the pericardial siLrface A.L. s diaphragm was lacerated by bullets and traverse the thoracic cavity." Injury ofthe in 3 plaees involving both hemispheres. The phrenic nerve could cause paralysi.s of por- diaphragm is a dome-shaped, thin, flat mus- tions or all of the diaphragm.^ The left hemidi- cle that is responsible for our breathing and aphragm is injured more frequent!)' than the serves as a division between the thoracic and right liemidiaphragm." The literalure explains ahdominal cavities.*^ During exhalation the this to be caused by the buffering and pro- diaphragm rises to the level of the fourth tective effect of the liver on the right hemidi- intercostal space on the right and to the aphragm." Penetrating and Blunt Abdominal Trauma 45
Figure 4. (;!ose nmge gunshot wOLind with flash suppressor burns about entrance in abdomen. Bul- let exited right posterior chest. Reprinted with per mission from the Trauma
The chest x-ray is the initial approach to diagnosis of a diaphragmatic injury.^ Positive findings may include an elevated diaphragm, fractured ribs, free air, or bowel in the tho- racic cavity.** Other studies valtiable in this situation include an abdominal ultrasound Figure 6. Same patient with vacuum pack tech- and Figure 5. Same patient sln)wing right posterior Figure 7. SholgLin wound to right laicral midtho- chest exit wound. Reprinted with permission from racic and abdominal cavities. Reprinted with per- the Trauma Imagebank.' mission from the Trauma Imagebank."' 46 CRITICAi. CARE NtlRSINt; QtlARTERLV/jANlIARY-MARCH 2005 parotomy with plans to remain ventilated for support. Of penetrating wounds, 15% of stab wounds and 46% of gunshot wounds had diaphragmatic injuries.^ The mortalit\' rate of penetrating diaphragmatic injury is approxi- mately 2%. Often with diaphragmatic injury, there are other organs injured as well7 Liver The word lit>er was derived from the old Hnglish word "life."'" Survival without the Figure 8. Close-up of the same sliotgiin wound. liver is impossible for more than a few hours Reprinted with permission fnini the Trauma except in very unusual circumstances; the Imagebank.' liver is certainly vital to human existence.'" Nearly ail of the blood that perfuses the gas- upon initial examination except for decreased trointestinal (Cil) tract drains into the liver via breath sounds, which were also due to the the portal vein.'" Twenty-five percent (jf the hemothonix. A.L.s diaphragmatic lacerations liver blood flow and almost 50% of its oxygen were repaired in the initial damage control la- are supplied by the hepatic artery. The portal vein supplies the remainder.'" Indication for surgery in patients with iso- lated splenic or hepatic injuries is the need for more than 2 U of blood to tiiaintain stable vital signs.'" With ;i nonoperative approach to blunt liver trauma, observation in-liospital of the patient for a minimum of several dnys is recommended.'" Observation includes se- rial hematocrits and repeated <^T scans until stable witb no further bleeding. The patient can then be discharged on limited activit>."' Physical activity should be slowl) increased over 6 to 8 weeks and contact sports should be avoided until a CH" scan shows healing of the liver injuries to prevent rehlecding.'" Dis- charge instructions should include advice to seek immediate medical attention for signs of symptoms ofa bleeding liver that include ab- dominal pain, shortness of breath, dizziness, and tachycardia.'' Since the liver is large and anteriorly lo cated in the right to left upper quadrants. It is provided only partial protection by ribs 8 to 12.'~ Ihe liver is the tnost common!) in- Figure 9. Same patients abdominal x-ray show- jured organ in penetrating abdominal trauma ing multiple intra-abdominal pellets from shotjiun due to its large size and location. Damage to blast. Reprinted with permission from the Trauma the liver is tbe most comtnon cause of death [mugebank.' after abdominal injury.'" Patients with hepatic Penetrating and Blunt Abdominal Trauma il injuries frequently present with hemody- ally require intervention of embolization or namic instabilit\.'- surger>; A.L. s liver was found to bave a grade 111 lac- Surgery t)r embolization is considered to eration activel)' bleeding that required surgi- control liver hemorrhage.- EmboH/ation is a cal interxention with a hepatorrhaphy, which procedure our trauma ser\ ice uses frequently is the placement of suturi's to close the liver to control iiepatic bleeding through a less laceration, (ielfoam is then packed over the invasive procedure tor lower grade liver liver to assist in hemostasis. injuries. The procedure is performed in the Although there are multiple references fbr angiogram suite by placing a catheter into grading organ injuries due to trauma, the ihe fetiioral arter) tbat is then ad\anced to organ-grading system that our tmuma team the site of injur)'. Fluoroscopy wilh injected utilizes has 6 levels t)f injury. dye allows the interventional radiologist lo visualize specificalh whicli vessels are damaged or leaking. Liver Injury When repairing (he vasculature of the liver. • Cirade I hematomas, which are subcap- kidney, spleen, or pelvic arteries, a method sular and nonexpanding, affect less than of "plugging up" the damaged vessels with 10% of surtace area. Grade 1 lacerations particulate matter, small metal coils, and gel are a capsular tear less than 1 cm deep foam is used. This plugging up" method is and nonbleeding. successful in these areas because of the col- • Clrade II hematomas include 10% to 50% lateral blood flow that continues adequate cir- of the subcapsular surface area with less culatioti to that organ. When repairing large than I-cm intraparenchymal hematoma. arteries with little collateral blood flow to Grade II lacenitions haw an actively that area (eg, the extremities), the method is bleeding capsular tear I to 3 cm deep |iatcliing' with a stent graft (similar to car- without trabeeular vessel involvement. diac stents). This is common fora penetrating • Grade III liver hematomas are expand- wound that lacerated a major vessel. Nursing ing greater than 50",. subcapsular or an considerations include replacing fluids and actively bleeding ruptured subcapsular blood products, monitoring, evaluating seria! hematoma. A grade III liver injury is also bemoglobin and hematoerit; and controlling an intraparenclnnial hematoma greater pain. than or equal to 2 cm or expanding. A grade III liver laceration is greater than Spleen 3 cm deep. The liver anil spleen are dense, solid in- • Grade IV hematomas have a ruptured par- trathoracic abdominal organs. Since the liver enchyma with active bleeding, (trade IV and spleen are high in the abtlominal cavily. lacerations involve 25% to 50"i, hepatic they are protected by the lower ribs." Lo- lobe parenchymal disruption. cated in the left upper quadrant, the spleen • Grade V lacerations involve greater than is protected by ribs 8 to 12." The spleen 50"u hepatic lobe parenchymal disrup- loses blood very rapidly because of its vast u- tion. Grade V vascular injury includes larity. Sixty percent of victims of splenic injury retrobepatic vena cava atid juxtabepatic will experience left shoulder \x\in. Kehr sign venous injuries. (Table I). The primary function of the spleen • Grade VI is a vascular hepatic avulsion.'^ is to clear blood-borne bacteria.** Because the (irades I and II injuries can often be mati- spleen is essential to our botl\ s immune sys- aged nonoperatlvel)' with serial hetnoglobin tem function, it is important to protect the and hemaiocrits and serial CH' abdomen and patient who bas a splenic injury, by admin- pelvis examinations to evaluate for further istering additional immunizations and consid- bleeding. Grades ill to VI Uver injuries usu- ering the needs of an immunt>-compromised 48 CRITICAL CARE NtiRsiN(i QtiARTERLV/jANtiARv-MARCii 2005 Table 1. These abdominal assessment signs are not conclusive but can be suggestive ofa spe- cific diagnosis'^' Assessment signs Grey Turner sign Associated with rctroptTitiineal bleeding ofthe pancreas, kidney, or fnim a pclvie fracture. Bluish discoloration of the lowtT alxloniinal tlanks and lower baek is usually seen 6 to 24 h after unset of rctroperitoncal bleeding.'' Kt-hr sign Characterized hy severe left-shoultlcr pain when in a supirif position caused hy diaphragmatic irritation, especially the phrenic ncrvr irritation pnnliict-il hy intniperitoneal hlooti and air. This sign is usually associaieil with splenic injur>' iuiil ectopic pregnancies, but ean he due to any intra-ahtlominal bleeding and Irtre air." Hallancc: sign (ihanieterized by J dull pertu,ssion in the Ifft upper qiuulrani ofthe alxlomen- RN should diK'ument in centinu-tcrs how far Iiclow the c<}stal margin the dull pcrcusMon extends for subsequent, serial examinations. This is a sign of splenic injury caused hy blood accumulating in the -.ulKapsular or cxtraeapsular spleen.'* (Atllcn sign Chanietcrized hy a hluish discol oral ion around the umbilicus that can indicate peritoneal hlcedinp, often pancreatic hemorrhage- " <;o()pcrnail sign c:haraeterized by ecchymosis of serotuni or labia indicative ofa pelvie fracture and pelvic or^n injur>'- 'Reprintfd with permission Irom Scmonin-Holtcran' and Wright." system.'" A.I-. ssplenic laeeration was a grade 3 cm deep without trabeeular vessel in- IV actively bleeding injury and his spleen was volvement but bleeditig acti\'ely. sttrgically removed in his initiai d;image con- • (irade III hematomas are greater than 50% trol laparotomy. expanding subcapsular. rupttired subcap- There are multiple references for organ- sular hematoma with active bleeding, and grading systems of trauma based on severity intrapenchymal hcmatonias greater than, a\ailable in the liteniture that have minimal or equal to, 2 cm or expanding, (irade variations. Hie organ-grading system utilized HI splenic injuries include lacerations by our trauma service for the spleen is a 5-level greater than 3 cm deep or involving tra- injury scale. Gnides I am! II splenic injuries beeular vessels. may be managed nonoperatively. but grades • (iratle IV splenic hematomas involve a in to V often require embolization or surgical ruptured parenchyma with active bleed- intervention. ing. Grade IV lacerations iticlude the hilar vessel with greater than 2S% devascular- Splenic Injttry iziition. • tirade I splenic injuries are hematomas • Cirade V lacerations invtjhe a completely involving less than \i)% of surtace area shattered spleen. Hilar vascular injur\- and are subcapsular and nonexpanding. with total devascularization ofthe spleen (Jrade I lacerations have a capsular tear is also considered a grade V splenic le,ss than I cm deep and are nonbleedijig. injury.'^ • Grade II hematomas involve 10% to 50% of subcapsular surface area or have less Diagnostics than I-cm intraparenchymal hematoma. A <.;T scan is the most sensitive diagnostic Grade II laceration is a capsular tear 1 to tool for most abdominal trauma injuries. The I^netrating and Blunt Abdominal Trauma 49 (T of the chest, abdomen, and pelvis with although this is considered an unreliable ini- contrast most commonh diagnose spleen and tial marker of injtir).^ Hollow viscus injury liver injtiries in conjunelion with clinical find- is indicated b> bacteria, bile, or vegetable ings and patient symptoms.'' The CH" .scan al- matter'' lows grading of splenie and liver injuries and also assists in the identifieation of other as- GH system sociated intra-abdomitial atul retroperitoneal In (il' trauma, the most ct)mnionly involved injtiries. organ is the kidney." Itijury to the urinary A TAST scan is a rapid, noninvasive ultra- system is indicated when gro.ss or micro- sountl at the bedside to quickly evaluate intra- hematuria is present, although I0"o to 25% abdotninal hemorrhage and is inexpensive. of significant renal injuries present without However, it is le.ss sensitive and cannot visu- hematuria." In the urban setting, approxi- alize all organs nor note a small amoutit of tnately 20%of penetrating injuries resttit in re- fluid. 'Hie emergency department pliysician nal injuries. Penetrating injuries in this set- ustially perfoniis the FAS f scan in our trauma ting are generally from gunshot wounds and resuscitations.'' stab wounds. A diagnostic peritoneal lavage (DPL) is a Lirgent radiographic assessment of the uro- procedtire that has beeome less utilized be- logic system after penetrating trauma is indi- cau.se ottlie availability of FAST scans and CTs, cated with ;ni\ degree ol lieniaturia. but only It is still used in situations when the patient if hemodynamicaily stable.** Excessive and is too hemodynamicaily tinstable to travel to [lersisteni retroperitoneal bleeding, ptilsatile the (Tscan. A positive DIM. is nonspecific but retroperitoncal hetiiatotna, tirinary extravasa- would also question rupture t)f solid organs." tion, significant amounts of nonviablc tissue, A DPL is performed imder sterile condi- and vascular injury associated with renal in- tions where a nasogastric/orogastric tube and jury are indications for surgical exploration. urinar>' catheter must be in position.'"' A ver- Postoperatively, after gn>ss hematuria clears, tical skin incision is matle one third of the ambulation is allowed." distance from the umbilicus tt) the symphysis A.L.s left kidney hilar vessels were found pubis after injecting lidoeaine.'"^ To prevent to be shattered with severe, signitlcant hem- bowel perforation, the linea alba is divided orrhage. This is a grade V kidney injtiry The before the peritoneum is entered.''' Next the trauma surgeon had to remove his left kidney trauma surgeon itiserts a peritoneal dialysis in the initial damage control laparotomy. Tlie catheter toward the pelvis and aspiration of cr readings also noted a right kidney grade I material is attempted.'"* Infusion of I L of stnall perinephric hematoma. warm 0.9% saline is then initiated.''' After 'ITie kidney injury grading scale utilized by waiting S minutes to dwell, the Htiids are al- our trauma .serv ice is a S-Ievel scale w ith grade lowed to flow back by gravit\' lo the bag 1 being the most minor injury atid grade V the placed on the floor.'^ Some of this fluid is most severe injury. collected and sent to the laboratory for eval- uation. The presence of bile, enteric con- Kidney injury tents, greater than 5 mL of blood aspirated • Cirade 1 kidney injurie.s involve contu- before fluid is infused, or the inability to sions diagnosed w ith normal urologic stu- read standard newsprint through the returned dies but microscopic or gross hematuria fluid in the bag are indications for immediate is noted. Subcapsular, nonexpanding laparotomy.'*^ Laboratory results of KM),OOO bematomas without parenebymal lacera- retl blood cells per tnm^ signify a positive Di'L tions are also considered grade I injtiries. indicating intra-abdominal hemorrhage and is • Cirade II injuries involve a nonexpand- 90'>ii accurate.'' If there are more than SOO ing periretial beniatt)ma confined to the white bl(K>d cells per mm^ in the DPL re- retrt>peritoneum. A grade II kidney lac- turns, the procedure is considered positive. eration is le^ than 1 cm deep without 50 CRITICAI. CAM NtiRsiNC. QIJARTERLY/JANLIARY-MARCH 2005 collecting system rupture or urinary threatenitig hemorrhage, this pos.sibility extravasation. would not change the management of the • A grade III laceration is greater than I cm resuscitation for this patient." This is due to deep without collecting system rupture the general principles of trauma protocols or urinary extravasation. that mandate hemodynamicaily unstable • Grade IV kidney injuries involve lac- patients go directly to the ()R. When an erations extetiding through the cortex, immediate exploratory laparott)tiiy is per- medulla, und collecting system. A grade formed, the surgeon focuses his or her IV itijury also includes main arterial or ve- attention first to control hemorrhage and to nous injury with contained hemorrhage. continue resuscitation. Once this has been • A grade V itijury is a completely shattered accomplished, contamination from the 01 kidney and avulsion of renal liilum with a tract can be controlled and then attention is devascularized kidney.' ^ turned to the repair of injuries. On day 7 of A.L. s hospitalization, his cre- Gunshot wounds to the anterior abdomen atinine level rose to 2.1 mg/dL from a stable in which the peritoneal cavity is penetrated l.H mg/dL. By day 9, his ereatinine level rose result in GI tract injury approximately 90% of to 4.6 mg/dL. During this time he had been the time, whereas about 50% of the time stab nonoliguric, discharging 2 I, of urine a day. (^n wounds result in G) tract injury. Early and day 10, a right femoral Vas-Cath was placed to accurate diagnosis of small bowel and colon begin daily dialysis. A.L. was dialysis depen- injuries, as well as restoring the GI tract con- dent for 3 weeks. A.L. s comorbids of initial tintiity, decreases tbe risk of ahdominal septic kidney injury, hypovt)lemia, hypotension, as complications. An unrecognized hollow vis- well as nephrotoxic drugs, put hini at very cus injury will almost surely lead to pro- high risk for acute renal failure. found .sepsis and possible mortality, whereas a The stages of renal failure are as fol- missed minor solid-organ itijury may have few lows: prerenal failure that is characterized long term consequences.' Because of these by decreased circulation atid ischemia to the tiiorbid risks with hollow viscous injury, a kidneys."' Victitiis of trautna are at a higher high level of suspicion should be maintained risk for prerenal failure due to hypovolemia, tor a potential bowel injury." In past his- hypotension, and cardiac failure. Intrarenal tory a mandatory trauma laparotomy was in- failure is characterized by kidne>' tissue, strue- dicated for both bitint and penetrating trauma ture, and function being directly affected by to the abdotiien; currently a nonoperative physiologic events such as antiliiotics and approach with minimally invasive diagnostic contrast media (IVP dye), both nephrotoxic tools is available. Modalities commonly used agents. Rhabdomyolysis can also cause in- are the FAST scan ultrasound, CT scans of trarenal failure. "^' Po.strenal failure is character- the abdomen and pelvis with rv eontrast. and ized by an obstruction in venous blood flow DFL." from the kidney or urine flow from the col- The most common complication Irom (il lection ducts to the external urethnti orifice, tract injury is sepsis." Other complicatiotis in- which resulls in decreased urinary output.''' clude the formation ofan intra-abdominal ab- scess caused by contamination at the time of Gastrointestinal system injtiry and sutttre line leakage or breakdown.^ Before considering a bowel injtir), the Signs and symptoms of intra-abdominal sep- patient's respiratory, hemodynamic, atid neu- sis are often seen 5 to 7 days after surgery, rologic status should be evaluated becaii.se which Include fever, leukocytosis, prolonged of a much greater immediate threat to life ileus, or subfascial woutid drainage. Antibi- from these systems rather than a delay in otics are routinely given preoperatively as diagnosis of a bowel injury." Although injury well as a course for a minimum of 24 hours to the bowel tnesentery can result in life- postoperatively. Penetrating and Blunt Abdominal Trauma 51 During A.L. s damage control laparotomy, 2 trauma." While blunt es<}phageal injury with small bowel injuries were (bund within ap- a perforation along the length of the esopha- proximately 6 in of each other and. there- gus is uncommon, it is otie ofthe ni()st lethal fore, resection of that loop of small bowel injuries of any site in the GI tract." Blunt in- to incorporate both injuries was carried juries usually result from a direct blow to the oul. A stable and lunctional end-to-end anas- e.sophagus when the neck is h\perextended, tomosis was perfortncd with stapling de- and are most eommon in the cervical area. ** vices and oversewing with Ix^mbert silk Distal esopbageal rupture can be caused by sutures. acute compression ofthe stomach. Penetrating irautiia causes \irtually all tho- Esophagus racic esophageal injuries. A high index of Because of the close proximit\ of the di- suspicion for esophagea! injury should be aphragmatic injuries, the trauma surgeon was considered wheti the patient present.s with suspicious of an esophageal injury. 'IXvelve posterior chest wounds, transmedia.stinal in- hours after A.L. s arrival to the trauma bay. an juries, penetnttion of the neck, and tracheo- esophagoscopy (l-CiD) was done at the bed- bronchial trauma." Bl(M)d in the nasogastric/ side in the intensive care unit (KUt). A tear orogastric tube is a nonspecific finding be- was noted to the distal end of the esopha- cause it can be swallowed blood or cotild have gus. A.L. returned to the OR for a second time resulted frotn traumaiic insertion. Sytiiptoms within 13 hours of arrival for repair of his associated with cervical esophageal injury- esophageal tear Although this diagnosis was include subcutaneous emphysema, anterior delayed, it was timeh in this case because of tracheal deviation, atid spitting of blood with other life-threatenitig injuries that took prece- hoarseness without oral injur). TItoracic dence. Tlie surgical procedure performed was esopbageal injttries are usually tnore subtle a segmental esophagectoni\ wilh stapling at initially, with minimal subctitaneous emphy- the proximal and distal esophagus, a left pos- sema and dyspnea noted." terolatenil thoracotom\. and a left lting wedge A.L. retttrncd to the OR for his third surgery' resection of the lower lobe with the abdomen on day 2 afier his arrival for placemetit of ga.v packed open. tro.stomy (G-tube) and jejunostomy 0-tube) The literature does note that the clini- ttibes, abdominal lavage anti closure, and cal findings of esophageal injtir\ are usually cholecystectom\. Subsequentl\, tube-feedings subtle and can he overlooked until sepsis wea- started in the J-tube. On hospital day is noted. Because of delayed diagnosis of n. A.L. had surger\ (o place a traclieostomx esophageal itijur>. the mortality rate is nearly anil drain the inaxil!ar\ sinuses with an eth- 90%." The esophagus location keeps it pro- tuoidectomy and frontal sinusolomy for acute tected reasonably well from external trauma." sintisitis. Despite this protection, a high level ol suspi- On hospital day 4.^. A.L. was taken back to cion should be titilized especially with mul- the OR tor a neck exploration because of 2 tiple injuries, such as with A.L. s case. Stutl- (.lays of bleetling of unknown etiology from ies to diagnose these kinds of injuries incltide the mouth, nose, and cervical pliar\ngotom\ CT of the chest, abdomen, and pelvis with site, where a carotid bulb fistula was noted. contrast: ati esophagoscopy: flexible en- This was likeK secontlary U) |ihar\ngeal tube doscopy: and swallow studies. Treatment of crosioti. Ibe va.scular surgeon repaired the esophageal injuries is surgical repair. carotid bulb with sternocieidomastoid muscle Althotigh iiijiir\ lo the esophagus is rela- interposition between the carotid bulb and fis- tively rare, it tloes pose challenges because tula tract. of the complexity of presentation, work- Complications dtiring A.L. s hospitalization up, and treattnent options." The majority of included disseminated intravascular coagula- csophageai itijuries are due to penetrating tion, acute renal failure requiring dialysis, 52 CRITICAI. CARE NURSING QiiAKTERtY/jAiNfUARY-MARCH 2005 acute posthemorrhagic anemia, pansiniisitis at 2315. 38 minutes after his arrival to the secondary to disseminated intravascular co- trauma bay. agulation, a carotid bulb fistula, a left subdi- Once involved in the exploratory laparo- aphragmaiic abscess for which 2 pigtail drains tomy, the trauma surgeon found bladder lac- were placed, sepsis, acute re.spiratory distress erations and perforation as well as a retroperi- syndrome, pneumonia, sputum cultures posi- toneal bematoma in tbe right pelvic area. tive for Enterococcus, Aspergillus, Rhizopus, Wbile in the OR, the trauma surgeon repaired Streptococcus beta group C:, and MRSA: blood tbf through and through bladder injury and cultures positive tor Streptococcus and Fep- placed a suprapubic (SP) cystostomy tube in tostreptococcus; a decubitus ulcer, and acute an open fashion. He also removed a large gastritis. After 2 months in the ICU. A.L. was clot from JJ.'s bladder and reported approx- transferred to the floor. He had been weaned imate!) half a liter of blood in tbe abdomen. off the ventilator to a tracheostomy collar I - Tlie orthopedic surgeon also treated the left months after admit. A week after his trans- femur fracture with an open reduction inter- fer to the floor, he was discharged to an nal fixation witb nails and a rod. acute care rehabilitation center with a J-tubc JJ. s urethra! catheter was removed 2 days tbr tube-feedings and a (i-tube drain. A.L has postoperation. On postoperative day 2, J.J. further surgeries planned for esophagcal re was noted to have significant swelling of the pair and resection. left thigb with leaking of serosanguineous fluid onto his dressing. An angiogram of tbe CASE STUDY 2 left lower extremity was performed, which noted a small area of contrast leakage from A victim of violence, J.J., a 39-year-(>kl man, a vcsscl-off of the profunda femoris; this was was standing with a group of friends when then embolized by interventional radiology. he was shot at twice by someone in a vehicle \.}. then returned to the surgical intensive care that was driving hy. Paramedics reported en- imit and was subsequently transferred to the trance gunshot wounds to his right buttock OR for an urgent left-tbigh fasciotomy because and left lateral thigh. jJ. arrived in the trauma of arterial compression and reduced blood bay. J.J.'s initial set of vitals at 2237 were supply to the lower extremity.'' The ortlio blood pressure of 120/S6 mm Hg. pulse rate of pedic surgeon released tbe femur compart- 90/min, respirations of 18/min, and 99% oxy- ment by leaving open tbe wound. After the gen saturation on a nonrebreather mask with fasciotomy, J.J.'s peripheral neurovascular sta- a CCS of 15. tus was not further comprised and he was able Upon examination, the trauma surgeon pal- to return to the OR 4 days later for delayed pri- pated a bullet in the left middle quadrant re- mary closure of the woimd. gion, near the umbilicus, with bruising that J.J. was discharged to home after a lO-day was collaborated by the abdominal flat plate liospitaliz;ition with instructions to follow up x-ray. No peritonitis was noted. The left fe- with urology at tbe clinic 2 days after dis- mur film showed a left proximal fcmiir frac- cbarge for removal of the SP catheter and ture and tbe pelvis x-ray showed a left pelvis 3 days after discharge with the trauma clinic fracture that gave the patient significant pain. for abdominal woimd evaluation as well as sta- This made it difficult for the staff members to ple removal of the abtlomen. After tbe cys- thoroughly complete their examination with- togram confirmed tbat there was no bladder out moving the patient: therefore. J.J. was in- leak, the SP catheter was removed on postop- tubated in the trauma room in preparation for erative day 13. surgery. Because ofthe transabdominal nature of the gunshot wound, the patient was a can- GU system didate for immediate surgery and no CTs were riie rctroperitoneal cavity contains the kid- completed prior to the OR. J.J. left t()r the OR neys and ureters, whereas the pelvic cavity Penetrating and Blunt Abdominal Trauma S3 contains the bladder.' lhe kidneys and not to place a catheter, because it may convert ureters are considered solid organs whereas a partial tear into a complex tear. A urology the bladder is a hollow organ. consult is advised." Witb gunshot woimds to the abdomen, it is Postrenal failure can be caused by a riijv more obvious to suspect GU trauma; bowever. tured bladder, urethra! tear, or pressure from pelvic fractures, lower rib fractures, and frac- hematomas. Nontraumatic causes may in- tures of tbe transverse process of the lumbar clude urinary retention from a urinary tract spine due to blunt trauma can also be associ- infection or a neurogenic bladder.'^' ated with CiII trauma."' Pain referred to the testicle is indicative of retroperitoneal injury Assessment and commonly seen witb urogenital and duo- Observation denal injury."' • I^atient's appearance: skin color, respira- The most common mechanism of injury tory pattern, and position • Guarding and rebound tenderness are • Signs and symptoms of peritonitis in- signs of peritoneal irritation that indicate clude abdominal pain tbat increases with tbe possible presence of blood, bile, or fe- movement, abdominal rigidity, rebound ces in the peritoneal cavity^ tenderness and voluntar)' guarding, ab- dominal distention with diminished or ab- Perineum, rectal, vaginal examinations sent bowel sounds, fever, chills, nau.sea, • Wben performing rectal examinations, vomiting, anorexia, shallow, rapid respira- check for blood indicating bowel perfo- tions due to pain, and tachycardia."' ration and assess sphincter tone to de- termine spinai injury.' Also note anterior Blunt tenderness that indicates peritoneal irrita- tion and palpate the prostate assessing if Because of hemorrhage, shock, and sep- it is bigb-riding tbat is suggestive of ure- sis, undetected abdominal trauma can rapidly thral injury.'*' lead to death (Fig 10)." Motor vehicle crashes accotint for 70% of blunt trauma.' Many in- • Look for perineal lacerations espeeially if juries are due to failure to use seat belts." a known pelvic fracture exists.' Only 11% of tbe American population regu- • Wben performing vaginal examinations. larly wears a seat belt.- There is a higher in- it is important to look for penetrating cidence of death due to blunt trauma than wounds or bony fragments from a pelvic due to penetrating trauma.^ Tliis is true be- fracture that would indicate an open cause injuries from blunt abdominal trauma fracture.' can be hidden and cause delays in diagnosis." Evahtatiftn Furthermore, more obvious, but less fatal, in- juries can mask abdominal injuries.- • If abdomen is rigid and distended (peri- (Common injuries tlue to blunt abdomi- tonitis) and/or hemodynamically unsta- nal trauma include tears to tbe liver, rup- ble, go straigbt to the OR.*' tured spleen, pancreatic tear, duotlenum rup- • Often findings are subtle. 20% of patients ture, tear of the me.sentery vessels, bladder with significant hemoperitoneum have a rupture, and kidne\' injuries.^ Fractures of benign abdominal examination upon ini- solid organ capsules and parenchyma can be tial assessment.'' caused by the compression and deceleration • Altered level of consciousness and sen- of blunt trauma."' In blunt trauma, the hol- sation due to alcohol, substance abuse, low organs can collapse and take in more head injury, spinal cord injury, and sbock force.'*' Generally, solid organs bleed in re- contributes to tbe iliftkulty of an accu- sponse to trauma, whereas hollow organs rate, reliable clinical assessment, and may rupture and release tbeir contents into the mask abdominal injur)'.'^*' peritoneal cavit>, which causes infection and • Serial abdominal examinations are recom- inflammation.'^' The small bowel and colon mended for patients with a mechanism in- injuries are most frequent because of a sudden jury to tbe abdomen at least hourly for the increase in intralimiinal pressure or sbearing first 8 bours or more frequently as nee- forces due to rapid deceleration, whicb is seen essary to recognize cbanges indicative of in motor vehicle crashes witb seat belts.'^' abdominal trauma.' • Absent bowel sounds ean indicate an ileus.' CASE STUDY 3 • Recommended laboratory studies are CBC (Hct. Hgb). serum amylase, lipase. Medics bad requested a major trauma acti- urinalysis, drug toxicity screen, serum vation tbr J.P. a 73-year-old female, who was alcohol level, and serum human chori- involved in a motor vehicle crash with sig- onic gonadotropin (pregnancy test) as nificant damage to both vehicles. Sbe was a appropriate.'' restrained driver, with no airbag deployment Penetrating and Blunt Abdominal Trauma 55 Vital signs unstable i) Pronounce Asystole dead Immediate Pulseless ,+. llioracotomv Abdominal CT Candidate for non ope rat ive management'!'^"^^ Figure 10. Blunt abdominal lr.ium;L Reprinted with permission from Scalctta and Schaidcr,"' that had been T-boned on the driver's side at domen, despite the fact tbat sbe denied pain. 35 to 40 mph. Al scene, medics reported tbat We proceeded to include the cervical spine she presented witb a unilateral weakness and and abdomen/pelvis to the bead, cbest, tbo was leaning toward one side with a complaint racic, and lumbar spine CAT scans. J.P.'s am- of ebest pain. She was amnesic and repetitive nesia and repetitive questioning continued. en route. Tbe report indicated that a medical Once down in tbe CT scanner, J.P.'s emergency might have caused J.P.'s motor ve- blood pressure dropped significantly from hicle crasb. 135/61 mm Hg to 90/48 mtn Hg and ber J.R arrived at Scripps Merey Hospital's heart rate increased from 94 to 120 bpm. The trauma resuseitation room at 1444. The trauma surgeon ordered a lluid bolus for J.R paramedic called out report ofthe accident, Her blood pressure was not significantly im- which included a significant history of severe proving witb tbis Intervention when tbe ac- ebronic obstructive pulmonary disease, hy- tively bleeding liver laceration on tbe CT mon- pertension, and dementia. J.R was confused itor was noted, wbile the CT scan was in with a GCS of 14 upon initial assessment progress. Additionally. J.P s CT scan results in tbe trauma bay. Her cbief complaint was were significant for multiple right rib frac- about right-side chest pain. The primary and tures, 6 to 12. and a grade I pancreatic con- secondary surveys revealed decreased breatb tusion. Her head CT was normal despite ber sounds bilaterally, right-chest wall tenderness, altered mental status. right tlank eccbymosis, and eqtial strength in We tben ordered packed red blood cells all extremities. Tbe patient's confusion and and fresh frozen plasma from tbe blood bank distraeting pain in ber cbe.st was enough for and prepared for emboHzatiijn of tbe liver in the team to determine tbat the patient s ex- the angiography suite. Tbe trauma surgeon amination was unreliable. Because of this, we explained that embolization is the treatment were unable to clear her cer\ ical spine and ab- of choice tbr tbis patient due to ber age. 56 NI1RSIN(; H 2005 comorbids, and severit)' of the liver lacera- pancreas is located in close proximity to tion. He stated that she was a poor candi- the aorta, portal vein, inferior vena cava, re- date for surger)' due to her age and medical nal veins, left kidney, liver, duodenum, and history. spleen. Because of its anatotitic position, By this time, J.P's respirations were more wben the pancreas is injured, one can be labored at 28 to 32/min and she required a confident that other organs are also affected. nonrebreather mask to maintain ber oxygen Tbus. a victim of multiple organ injury is a red saturations. Tlie trauma surgeon decided to flag suggesting the possibility of a pancreatic preventatively intubate her. recognizing that injur\,'" Death related exclusively to the pan- a patient with tbe.se .significant injuries and creas is rare.' - Mtjst deaths from trauma to tbe history would rapidly progress into respira- pancreas are often secondary to bemorrhage tory failure. The team also discussed that in- from the surrounding large vessels and occur tubation woiLld be necessary for the patient s witbin 48 b(jurs after itijury.'- comfort hecause of tbe abilit)- to give more Signs and symptoms of pancreatic injury in- sedati\ es atid pain medications during tbe em- clude acute abdotiien, increased serum amy- bolization procedure. This would also prepare lase levels, epigastric pain nidiating to the ber for etnergent surgery if tbe etiibolization back, as well as nausea and vomiting."' was unsticcessful and she developed hypo- Common complications of pancreatic injury volemic shock. are upper abdominal abscesses, p.seudocysts, Alter a successful intubation, we quickly common duct obstructions, and peritonitis."^ transported her to tbe angiography suite to Other complications include multiple exac- correct the cause of her hypovolemia, tbe ac- erbations of acute pancreatitis tbat can lead tively bleeditig liver laceration. To maintain to chronic pancreatitis."' c;iinical evidence of ber fluid status and blood pressure, we had paticreatic trauma is often minor in tbe first 2 been continuing boluses of crystalloid and hours after blunt injury, but usually progresses packed red blood cells since the first drop to significant evidence within 6 bours."' in her blood pressure. J.R received adequate Diagnosis of a pancreatic injury can be diffi- m<»rpbine and Versed tbroughout the proce cult. Computed tomography and FAST exami- durc. while her blood pressure and fluid sta- nations are unlikely to diagnose itijury A for- tus were closely monitored. Tbe embolization mal ultrasound is the examination of choice bad been successful. J.P. was stabilized atid following an endoscopic retrograde cbolan- would not require liigh-risk itivasive surgery giopaticreatograpby. which can best demon- at this time. J.P was then transported to the strate injury when other examinations have ICU. failed.'^ Duritig J. R s 18-da\- stay, we diagnosed The pancreatic or^an-grading scale utilized further injuries including a right calcaneus by our trauma service is a 5-level scale. fracture and a rigbt proximal ulna process fracture. Complications that developed were Pancreatic Injury Sc bilateral pleural effusions requiring chest • Grade I pancreatic hematomas involve tuhe placement, pneumonia, (^lostrlditim dif- a minor contusioti without duct injury, ficile colitis, and due to a prolonged inabil- whereas lacerations are superficial with- ity to wean from tbe vent, sbe required a out duct injury. tracbeostotiiy. After her hospitalization, J.P. • Ciradc II hematomas are considered major was transferred to a skilled nursing facility. contusions and lacerations without duct injury or tissue loss. Pancreas • Clrade III pancreatic injuries are char- The incidence of pancreatic injury in pa- acterized by a distal transecting lacer- tients witb a penetrating traitma is mucb ation or parenchyma! injury with duct higher than in blunt trauma victims.'- llie Penetrating and Blunt Ahdominal Trauma 57 • Grade IV injuries include proximal tran- was picking up a friend from Softball practice secting lacerations or parencbymal injury when the accident occurred. involving the papilla. Initial vital signs at 1718 were a blood pre.s- • A grade V laceration is a massive disrup- sure of 122/75 mm Hg. pulse rate of 101/tiiin, tion of tbe pancreatic beaid.' ^ respirations of l6/min. oxygen saturation of 99% on room air, oral temperature of 97.7 K GaUbladder and a GCS of 15. Secondary sur\'ey revealed A gallbladder injury is rare. It is protected an abrasion across tbe lower abdometi from by its sheltered location and its small size,'- iliac crest to iliac crest with mild tenderness t^ management is related to the extent of iti- to palpation as well as a rigbt sbin contusioti. l^ry. A eliolecystectomy is usually performed Tbe FAST scan pertbrmed by tbe emergency only tbr injuries that disrupt the structure or department pbysician was within normal litn- associated anatomy and vaseulature.'" its. MJ. denied past medical history atid the possibility of pregnancy. We ordered a preg- nancy test as well as a complete blood cell Liver count ((^BC), alcohol level test, and drtig tox- Beeause the liver is a highly vascular organ, icity screen, M J. s abdomen was sbielded for it hemorrhages very quickly," The large size the cbest x-ray. Her pregnancy test came back of tbe liver, friable parenchyma, thin capsule, negative with a normal (^IK; SO we were able and essentially fixed position allow the liver to proceed to CT for an abdomen atid pelvis to be particiiIarK prone to blunt injury. As at 1739, whicb was normal. Her hlood alcohol Wits exetnpliiled by JR. s case study, profound level was 120 mg/dL so we had to consider shock aft:er a blunt injury to the abdomen is her examination unreliable becaitse of tbe ;il- often a liver injury' cobol on board. Similar to J.P, suspect blunt liver in- We admitted MJ, to tbe floor for serial jury when fractures are diagnosed on the abdominal exatiiinations and serial CBCCs. At lower rigbt side of ribs. Liver injury should 2t)()0. MJ. s wbite blood cell count had risen be suspected wben ct)ntusions and pain to 12,000 from 6000 upon arrival, her al> are noted to the right upper quadrant of dominal examination contitiued to have otily tbe abdomen that frequently radiates to tiiild tenderness. At 2300, upon recheck tbe the right shoulder- (Complications of liver trauma surgeon noted signs and symptoms of trauma include bile peritonitis and hepatic peritonitis tbat included an exquisitely ten- dysfunction.'- All patients with hepatic in- der abdomen. M.J. was taken to the OR for juries require admission.'- surgery at 2335 wbere the trauma surgeon found a colon laceration of the stnall bowel CASE STUDY 4 in tbe jejunum and ileum, a laceration of the large bowel in the greater omentum. and a mi- MJ., a 15-year-oId female, arrived at Scripps nor spleen laceration of the lower pole. Af- Mercy Hospital at 1718 after a motor vehicle ter surgery M.J, developed a paralytic ileus collisioti. Medics reported tbat she was tbe that resolved without surgical ititervention rigbt rear passenger with a lap belt only that and she was discharged to home after a 7-day had a bead-on collision into a brick wall on her hospitalization. high school s campus at approximately 40 to 60 mpb. Ibe patient reported bitting a ditch Spleen and the ear flew in the air and then bit tbe Motor vehicle crashes, sports, and falls are brick wall, ITiere was no loss of con.scious- often causes of splenic trauma due to direct ness and tbe patient complained primarily of blows to tbe left cbest or upper abdometi,^ abdominal pain. M.J, admitted to having sev- If left lower rib fractures with bntising or eral beers and sbots after scbool today atid abrasions have been diagnosed, splenic injury' 58 CRITICAL CARE NtiRSiNc; QUARTERLY/JANUARY-MARCH 2005 and left kidtiey injury associated with tbe splenic injur\' could be indicated.' Tbe spleen is tbe most frequently injured organ after blunt trauma, while it ranks second to tbe liver as a source of life-threatening hemorrhage.- C^omplications of spleen injuries are typi- cally due to delayed treatment or missed in- jitries. The rupture of an expanding subcap sular bemorrbage or pseudoatieurysm may present days or weeks after an itiitial normal examination.'-' Gastrointestinal system For lap-belt use in motor vehicle crashes, Figure 11. Seat-belt mark from shoulder restraint. a classic "seat-belt sign" consists of lower ab- Reprinted with permission from ihc Trauma dominal ecchymosis and contusions. More [magebank.' tban half of tbe patients who present with seat-belt signs bave intra-abdominal injuries.' - Tbe literature notes complications of in- Tbere is a higher incidence of small bowel testinal injur>' to be wound deliisccnce, injuries cau.sed by blunt force thati that of wound itifection, intra-abdominal abscess, eolonic injuries.'- The most frequently seen sbort bowel syndrome, Intestinal obstruction, hollow viscus injuries due to lap-belt use and fasciitis.'^ are intestinal perforations and mesenteric As many as 35% of patients with colonie avulsions, of which the small bowel perfora- perforations bave serious abdominal septic tions are the most common.'- Undiagnosed eomplieations, including intra-abdominal ab- mesenteric tears can lead to intestinal ob- .scesses and peritonitis.'- The development struction. Perfbrations and devascularizations of a tension pneumoperitoneum, which can of tbe intestines as a result of blunt trauma occur with pneumothontx, is an unusual are seeti more frequently in adults,'- Patients complication of bowel pertbrations. Tension with Cbanee fractures ofthe thoracic and lum- pneumoperitoneum is an accitniulation of bar spine are at an increased risk for intesti- nal injuries. If surgery is performed witbin 10 to 24 hours, the mortality rate from intestinal injuries is usually low. Because of tbe close associatioti of tbe severity of related injuries, the mortality rate from blunt intestinal injur>' ranges from 2% to 30% (Figs 11 and 12).'- As in M.J. s case, the itiitial exatiiination may be negative or benign, but delayed di- agnosis of intestinal perforatioti is common even itp to 1 week after a traumatic evetit.'- Symptoms of a hollow viseus injury inclitde abdominal pain, distension, nausea, vomiting, decreased bowel sounds possibly due to an ileus resulting from associated injuries, such as a retroperitotieal hematotna or a lumbar L spine fracture. Other signs and symptoms are Figure 12. Seat-belt mark trom shoulder and lap fever, a rising wbite blood cell count, and restraints. Reprinted with permission from the peritonitis.'^ Trauma Imagebank.' Penetrating and Blunt Abdominal Trauma 59 air beneath the diaphragm that is under inciudes nonoperative management with a na- pressure.'^ sogastric tube, serial examinations, and hyper- Since the stomach is well proteeted beeause alimentation (TPN). If tbere is extensive dam- of its location, perforations from blunt trauma age to tbe duodenum, a perforation, or an are a rare injury.'^ Only 1% of patients with unresolved bowel obstruction after 2 weeks, blunt abdominal trauma suffer from stomach tben surgical repair is required. '- perforation."' Altbougb there is ati increased A useful diagnostic study to evaluate hoUow risk for stomach injurj' immediately after eat- viscus injury is the CT of the abdomen and ing, the risk for peritonitis is decreased be- pelvis. The CT sean can distinguish perfora- cause of the small amotints of bacteria iti the tions from hematomas.'- Suggestive findings stomach.'- Stomach injuries represent 20% of include unexplained peritoneal fluid collec- intra-abdominal penetrating trauma"' tions, bowel wall thickening, and focal bowel Duodenal hematomas and duodenal per- bematomas. Extravasated IV contrast outside forations are mostly sports-related due to a tbe lumen of the bowel suggests a tom mesen- sbcaring-type mechanism, sitcb as a handle teric vessel.'- bar injury. Duodenal hematomas are rarely Overall, as a practitioner caring for trauma life-tbreatening while perforations are infre- patients, a high level of suspicion for abdom- quent.'- Presentation of duodenal injury can inal injury sbould be maintained after a trau- be benign, but may include upper abdotiiitial matic event. It is important to be vigilant in pain, vomiting, and hematemesis. Symptoms performing serial abdominal examinations as may not appear for several days.^" Treatment well as in evaluating serial CBCs. REFERENCES I. Wachtcl 1. Critical cart- conttpts in llic 7. Lewis 1. Trimkey I). Current Tberupyofirdiinni. till ment of abdominal iraiima. CWf Care Nurs Q. ed. St Um\s. Minn: Moshy; 1999. 8 Feiiciano I). Matlox K. M