Abdominal and Pelvic Trauma
CHAPTER OUTLINE Objectives Introduction External Anatomy of the Abdomen Internal Anatomy of the Abdomen Peritoneal Cavity Retroperitoneal Space Pelvic Cavity Mechanism of Injury Blunt Trauma Penetrating Trauma Assessment History Physical Examination Adjuncts to Physical Examination Evaluation of Blunt Trauma Evaluation of Penetrating TraumaIndications for Laparotomy in Adults Specific Diagnoses Diaphragm Injuries Duodenal Injuries Pancreatic Injuries Genitourinary Injuries Small Bowel Injuries Solid Organ Injuries Pelvic Fractures and Associated Injuries Chapter Summary Bibliography
Upon completion of this topic, the student will identify common patterns of abdominal trauma based on mechanism of injury and establish management prioritiesaccordingly. Specifically, the doctor will be able to:
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Identify the key anatomic regions of the abdomen. Identify the patient at risk for abdominal and pelvic injuries based on the mechanism of injury. Apply the appropriate diagnostic procedures to identify ongoing hemorrhage and injuries that can cause delayed morbidity and mortality Describe the short-term management ofabdominal and pelvic injuries.
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Abdominal and Pelvic Trauma of the anterior abdomen, acts as a partial barrier to penetrating wounds, particularly stab wounds. The back is the area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crests. Similar to the abdominal-wall muscles in the flank, the thick back and paraspinalmuscles act as a partial barrier to penetrating wounds.
When should the abdomen be assessed in the treatment of multiply injured patients?
Evaluation of the abdomen is a challenging component of the initial assessment of injured patients. The assessment of circulation during the primary survey includes early evaluation of the possibility of occult hemorrhage in the abdomen and pelvisin any patient who has sustained blunt trauma. Penetrating torso wounds between the nipple and perineum also must be considered as potential causes of intraabdominal injury. The mechanism of injury, the force with which the injury was sustained, the location of injury, and the hemodynamic status of the patient determine the best method of abdominal assessment. Unrecognized abdominal injurycontinues to be a cause of preventable death after truncal trauma. Rupture of a hollow viscus and bleeding from a solid organ are not easily recognized, and patient assessment is often compromised by alcohol intoxication, use of illicit drugs, injury to the brain or spinal cord, and injury to adjacent structures such as the ribs, spine, or pelvis. Significant amounts of blood may be present in theabdominal cavity with no dramatic change in appearance or dimensions and with no obvious signs of peritoneal irritation. Any patient who has sustained significant blunt torso injury from a direct blow, deceleration, or a penetrating torso injury must be considered to have an abdominal visceral or vascular injury until proven otherwise.
Internal Anatomy of the Abdomen
The three distinct regions ofthe abdomen are the peritoneal cavity, the retroperitoneal space, and the pelvic cavity. The pelvic cavity, in fact, contains components of both the peritoneal cavity and retroperitoneal spaces (Figure 5-1).
It is convenient to divide the peritoneal cavity into two parts—upper and lower. The upper peritoneal cavity, which is covered by the lower aspect of the bony thorax,includes the diaphragm, liver, spleen, stomach, and transverse colon.
Diaphragm Liver Peritoneal cavity Pancreas
External Anatomy of the Abdomen
The abdomen is partially enclosed by the lower thorax; the anterior abdomen is defined as the area between the transnipple line superiorly, the inguinal ligaments and symphysis pubis inferiorly, and the anterior axillary lines laterally. The flank is...