Chapter 26. Abdominal and genitourinary trauma
A high index of suspicion is mandatory in potential abdominal trauma as signs and symptoms may be subtle or evolve slowly.
Mechanisms of injury
Three mechanisms of injury exist – blunt, penetrating and blast. In the majority of instances, injury results from blunt impact following a road traffic accident, sporting accident, fall or industrial accident. Blast injuries are fortunately rare.
Blunt injuries
Blunt impact results in definable injury patterns:
Bursting
Sudden, violent compression of the abdominal wall may dramatically raise intra-abdominal pressure leading to rupture of a bowel loop. An incorrectly fitted seatbelt is a common factor in these injuries.
Crush
Direct crush injuries occur when a viscus is injured by directly applied pressure. A common event is rupture of the retroperitoneal portion of the duodenum in bicycle accidents – the duodenum is compressed between a handlebar and the lumbar spine. The pancreas, liver and spleen are also readily injured in this way.
Shear
Shear force injuries occur when force is applied tangentially across vascular pedicles; structures at risk include the spleen, liver and small bowel mesentery. These injuries are commonly associated with sudden deceleration.
Collision
Collision injuries result typically from impact of a motor vehicle on a pedestrian. The pattern of injury will depend on the size of the victim – bumper (fender) impact on an adult usually involves the limbs and abdominal injury is relatively uncommon, but in a child the torso takes the brunt of the force and abdominal and chest injury should be assumed in the prehospital setting.
Ejection
Ejection from a vehicle can result in multiple injuries, including damage to the cervical spine, depending on how the casualty lands – the torso is a large target and the likelihood of abdominal injury under these circumstances is high.
Injury to the chest + injury to the pelvis = injury to the abdomen until proven otherwise
Penetrating injuries
Intra-abdominal penetration may be obvious however penetrating objects, bullets, fragments, knives or damaged vehicle parts can reach the abdomen from the lower chest, the back, flanks, buttocks and perineum. In the case of bullets and missile fragments, the entry site may be anywhere, as they may travel unpredictable distances and readily deflect from their original line of flight.
Recognition of injury
As many as 20% of patients with significant intraabdominal bleeding reveal little or nothing in the way of physical signs.
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