ABDOMINAL TRAUMA Bernie is a 28 y/o man who was driving while intoxicate, fell asleep at the wheel and

was involved in a one-car accident. He was not wearing a seat belt and was thrown forward, forcing the steering wheel into his chest and abdomen. Upon arrival in the emergency room, he was awake and oriented but slightly combative. There was a 2 cm scalp laceration over his left frontal area. His pupils were equal and reactive at 5 mm. He had abrasions over his left lower rib cage and abdomen, his breath sounds were diminished on the left side and Bernie stated that it hurt to breathe. Subcutaneous emphysema was present from the L nipple line to the L upper abdominal quadrant. His abdomen was round and firm, with no audible bowel sounds. He was uncooperative during the abdominal examination, thrashing around on the stretcher. He complained of L shoulder pain while lying flat. Relevant Lab data included: pH- 7.30, PaCO250, PaO2- 76, SaO2- 92%, HCO3-24, Hct- 39, Hgb- 14, WBC 13,000,RBC- 4.4,Plat- 350,000, Na- 138,K- 4, Cl-100, CO2-24, Creat- 0.7, Urinalysis- WNL FF Treatments were performed: 1. A L chest tube was placed. Upon insertion, a large gush of air was heard. Breath sounds following insertion were audible bilaterally with equal chest excursion 2. 40% O2 was administered via face mask 3. A 16- gauge IV cath was inserted in the R antecubital area, and an infusion of 1000 ml LR was begun. 4. An orogastric tube was inserted. The contents tested for blood. An orogastric tube is the route of choice when a basal skull fracture or cribiform plate fracture may be present. This route decreases the chance of an intracranial intubation and the development of sinusitis 5. A foley cath was inserted. Urine was negative for blood 6. A peritoneal lavage was performed, and the ff results were obtained from the peritoneal fluid: RBC- 114,000 cells/mm3, WBC- 524 cells/mm3, Amylase- 30 U/liter,bacteria- absent, bile- absent, feces- absent A chest x-ray revealed fractures of ribs 5-10 on the L and a well inflated L lung with the chest tube in place. He remained hypotensive after rapid infusion of 2 liters of LR, so he was taken to the OR where he was found to have a ruptured spleen. A splenectomy was performed, and he was brought to the surgical ICU. Upon admission to the unit, his VS and ventilator settings were: Bp90/60, HR- 128, RR- 14, T- 36.2, Mode- assist control, Rate- 14, FiO2 0.40, TV- 900 He had a pulmonary artery catheter in place with the ff hemodynamic parameters: CVP-1, PAP- 18, PAWP-3, CO-3.4, SVR-1576 After 2 units of whole blood and 1000 ml of LR were administered, these paramenters stabilized into their normal ranges. QUESTIONS 1.What are the two mechanisms of injury involved in abdominal trauma? a. BLUNT usually results from motor vehicle collisions, assaults, recreational accidents or falls b. PENETRATING stab wounds and gunshots, some resulting in obvious peritoneal irritation and requiring immediate exploration 2. Which organs sustain injury most during blunt abdominal trauma?(5) a. Liver b. Spleen

c. Small Bowel d. Pancreas e. Colon 3. Which organs are most often injured with penetrating trauma? (2) a. Small Intestines b. Liver 4. What diagnostic procedure is commonly used to determine intraperitoneal trauma? Diagnostic peritoneal lavage (DPL) 5. How is peritoneal lavage performed? After application of local anesthesia, a vertical skin incision is made one third of the distance from the umbilicus to the pubic symphysis. The linea alba is divided and the peritoneum entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material attempted using a syringe. If no blood is aspirated, 1 litre of warm 0.9% saline is infused and after a few (usually 5) minutes this is drained and sent for analysis. 6. What constitutes a positive peritoneal lavage? 10ml of blood or enteric contents (stool, food, etc.) constitutes a positive DPL. >100,000 RBCs/mm3, >500 WBCs/mm3, Amylase >175 IU/dl, Succus, food fibers, bile. 7. What signs and symptoms eliminate the need for a peritoneal lavage with the patient being transported directly to the OR? ( 3) a. When exploratory laparoscopy is clearly indicated b. When with Coagulopathy c. Multiple prior abdominal surgeries 8. What other diagnostic tests may be used when intraabdominal trauma is suspected? (10) a. CT Scan c. Focused Abdominal Sonography for Trauma (FAST) e. Laparoscopy & Laparotomy g. i. b. Ultrasound (UTZ) d. Local Wound Exploration (LWE) f. CBC h. j.

9. What are the signs and symptoms of peritoneal irritation? (10) a. Abdominal tenderness, suggesting inflammation of an underlying organ b. Rebound abdominal tenderness elicited by percussion c. Involuntary contraction of the abdominal wall d. Shallow rapid respirations e. Nausea and Vomiting f. Fever g. h. i. j.

10.What are Kehrs and Balances sign? Kehrs Sign (Splenic injury / ruptured ectopic): Severe left shoulder (tip) pain following injury to the spleen. The pain is due to irritation of the left diaphragm and phrenic nerve by intraperitoneal blood, or air when the patient is in the supine position. Balances Sign (Splenic Injury): Dullness on percussion of the left upper quadrant of the abdomen due to collection of blood in the subcapsular or extracapsular layers of a ruptured spleen 11. What is the medical management for injury to the spleen? SPLENECTOMY 12.What are the possible complications of abdominal trauma? (7) a. Severe Blood Loss b. Peritonitis c. Abdominal Abscess d.

e. f. g. 13. Following splenectomy, what is the most life- threatening complication that may develop? Immune thrombocytopenic purpura (ITP) is a clinical syndrome in which a decreased number of circulating platelets (thrombocytopenia) manifests as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae). In persons with immune thrombocytopenic purpura (ITP), platelets are coated with autoantibodies to platelet membrane antigens, resulting in splenic sequestration and phagocytosis by mononuclear macrophages. The resulting shortened life span of platelets in the circulation, together with incomplete compensation by increased platelet production by bone marrow megakaryocytes, results in a decreased platelet count.

14. List the appropriate nursing Diagnoses with related factors (3) and nursing interventions (5except monitoring V/S))that would pertain to the pts case?