Abdominal injuries, which account for up to 4% of the total number of injuries received in peacetime, are classified as severe injuries, often associated with a real threat to the life of the injured person.
In the statistics of lethal outcomes from the received traumas, they occupy the third place( the leading positions in it belong to the cranial and thoracic - with damage to the chest - injuries).The level of mortality in case of abdominal trauma varies between 25-70%.
In peacetime, the structure of traumatic abdominal injuries is formed by cases of criminal injuries, falls from a height, natural disasters and road accidents.
Definition and Causes of
Abdominal trauma, in the language of the physician referred to as abdominal, is characterized by all kinds of abnormalities in the functional state or anatomical integrity of tissues and internal organs localized in the abdominal cavity, retroperitoneal space and pelvic area that result from external influences.
The perpetrators of open injuries usually become:
- all possible wounds: first of all, gunshot and knife;
- falls on sharp surfaces or objects.
Closed abdominal injuries are the result of:
- accidents in the workplace;
- car accident;
- falls from any height;
- falls on obtuse solid objects;
- accidental or intentional swallowing of objects with sharp angles and aggressive chemical substances( alkalis and acids);
- of iatrogenic factors( risks arising as a result of therapeutic effects on the patient's body).
In most cases, abdominal injuries are characterized by:
- multiplicity and severity of lesions;
- high level of mortality;
- with a large( up to 85%) number of postoperative complications.
The severity of the injuries received with open and closed abdominal injuries can be different;while injuries of a closed type are giving doctors more problems.
Because the wound and the external bleeding associated with it are absent in this case, and the injured person is often either in a state of traumatic shock or in extremely serious condition, the primary diagnosis is difficult.
A person suspected of having an abdominal injury is subject to urgent hospitalization.
After an immediate examination, a number of therapeutic measures are taken to prevent or stop internal bleeding and eliminate the risk of peritonitis( inflammation of the peritoneum).From the coherence and correctness of the actions of medical personnel at this stage depends the life of the victim. Further treatment of such patients is usually surgical.
Classification of
The variety of abdominal injuries is so great that none of the existing classifications can accommodate it. In the practice of domestic traumatologists, the classification proposed by VS Saveliev is most in demand.
Depending on the nature of the damaging agent, abdominal injuries are:
- mechanical;
- chemical;
- thermal;
- beam;
- combined( combining the effects of two or more types of damaging factors).
Symptoms and signs
The separation of mechanical abdominal injuries into open and closed belts emphasizes the fundamental difference of these injuries. Differences concern:
- receiving mechanism;
- methods of diagnosis and treatment;
- severity of the condition;
- of the final outcome.
This is why the symptoms of open and closed abdominal injuries are always treated separately.
Open abdominal trauma
- With bruises of the anterior abdominal wall , pain, local edema of the damaged area, abrasions appear;possibly development of hemorrhages. When emptying the intestine, during coughing, sneezing, sudden changes in the position of the body, painful sensations increase.
- With the rupture of the muscles and fascia of the abdominal wall , a similar symptom arises, but the pain is more intense. The organism of the victim can react to severe pain by developing intestinal obstruction caused by reflex paresis of the intestine( this is the condition characterized by a gradual decrease in the tone of the intestinal walls followed by the development of paralysis of the intestinal musculature).
- Abdominal trauma with rupture of the small intestine , characterized by the presence of aggravated pain, occurs as a result of a direct stroke in the abdomen. The victim feels the tension of the muscles of the anterior wall of the abdomen;his pulse is fast and vomiting may develop. With such damage, cases of traumatic shock are not uncommon.
- Blunt abdominal injuries with rupture of the large intestine have a similar mechanism of occurrence and almost similar symptoms( as in cases with small intestine ruptures), but - in connection with the often emerging intraabdominal bleeding - shock states are observed much more often.
- Closed abdominal injuries of are often accompanied by all kinds of liver damage( from subcapsular cracks to complete detachment of its individual fragments).In connection with the large number of blood vessels that permeate this organ, any injury to the liver is associated with the development of severe internal bleeding. The condition of the person who received such trauma is extremely severe and is often accompanied by loss of consciousness. The victims, who are conscious, complain of severe pain in the zone of the right hypochondrium, radiating to the area of the right collarbone. The breathing and pulse of the affected people become more frequent, the skin turns pale, and the arterial blood pressure decreases. Many of them have a marked symptom of traumatic shock.
- Blunt abdominal injuries with damage to the spleen account for about a third of the total number of abdominal injuries, accompanied by trauma to the internal organs. Spleen ruptures can be both primary( in this case, the symptomatology of the lesion manifests itself from the first minutes of the injury), and secondary( the appearance of anxiety signs is observed after a few days or weeks).The appearance of secondary spleen ruptures is characteristic of children. If the size of the ruptures is negligible, a spontaneous cessation of bleeding may occur. Significant damage to the spleen leads to the development of hemoperitoneum - a strong intra-abdominal hemorrhage, leading to a clump of blood between the sheets of the peritoneum. Clinical manifestations of hemoperitoneum coincide with the picture of hemorrhagic shock: the victim, who is half-asleep, pale, pours cold sweat and complains of a sharp pain in the abdomen( in the region of the left hypochondrium with irradiation to the left shoulder), severe dizziness and darkening in the eyes. He has tachycardia and hypotension. To reduce pain, the victim can lie on his left side, bending and pulling his legs to his stomach.
- With closed abdominal injury , an intraperitoneal or extraperitoneal rupture of the bladder can occur. This happens if, at the time of injury, the victim's bladder was full. If the bladder rupture was extraperitoneal, the patient experiences severe pain, crotch edema and false urge to urinate. Sometimes an insignificant amount of urine with an admixture of blood is released. With intraperitoneal rupture of the bladder, the victim feels pain in the lower abdomen and frequent false urge to urinate. Urine, trapped in the abdominal cavity, provokes the development of peritonitis. The abdomen of the patient remains soft;at palpation the victim feels moderate soreness;intestinal peristalsis is weakened.
- Pancreatic injuries occurs when very severe abdominal injuries occur, involving damage to several internal organs. The pancreas can get a concussion or bruise;sometimes trauma leads to its rupture. The victim, who is in serious condition, experiences a sharp pain in the epigastric region;his stomach is swollen, the muscles of the anterior abdominal wall are in a strained state, blood pressure is falling, and the pulse is increasing.
- Blunt abdominal injuries rarely result in damage to the kidneys located in the retroperitoneal space and protected by other tissues and organs on all sides. When receiving concussions and bruises of the kidneys, the victim begins to complain of pain in the lumbar region;in his urine appears blood, the body temperature rises. The most severe abdominal injuries can be accompanied by ruptures or crushing of the kidneys and trauma to other internal organs. In such cases, the victims, experiencing severe pain, often develop a shock state, there is a development of tachycardia and arterial hypotension.
Open injuries( wounds) can be inflicted by weapons( cold and gunshot) and by fragments of combat or secondary shells.
- For cutting wounds with a clear linear shape, considerable length and even edges, cold weapons( most often a knife or dagger) can be used. As a result of the incision of cut wounds, many blood vessels are dissected, severe external bleeding may occur in the affected person. When a large wound is received, sometimes there is an event - damage to the anterior abdominal wall, due to which there is a depressurization of the abdominal cavity, accompanied by loss of internal organs.
- A narrow stylet, an awl, a thin knife, a dining fork, bayonet or scissors can be used to apply the chipped wounds of , characterized by the presence of a narrow wound channel. The bleedingness of stab wounds can be insignificant, although due to the large depth of penetration, significant damage to the internal organs is possible. The main danger of such injuries is that the injured person at the sight of a minor and almost bleeding wound can not immediately seek medical help.
- Large chopped wounds , having uneven edges, accompanied by extensive dissection of soft tissues and heavy bleeding, occur when exposed to the ax.
- Ragged wounds , characterized by the presence of multiple injuries with tears and crushing of tissues, arise as a result of careless handling of machinery( in case of an accident at work) or due to the attack of aggressively tuned animals. A characteristic feature of lacerated wounds is very severe tissue contamination.
- Gunshot wounds of the abdomen are ranked as extremely serious injuries because when they occur, not only the wound channel is formed, but serious( with a radius of damage three times the size of the pellet or bullet), soft tissue contusion. As a result of concussion, compression, stretching, delamination or rupture of affected organs and tissues occurs. In some cases( with the location of the inlet holes in the lumbar region or in the side), gunshot abdominal injuries can be of an implicit nature.
- The perpetrators of the rupture-bruised wounds can become the secondary shells( in their role may be fragments of metal parts or glass fragments).This type of abdominal injuries can be the result of automobile accidents, man-made disasters or accidents at manufacturing plants.
Blunt abdominal injuries
In the international classification of diseases of the latest version( ICD-10) blunt abdominal injuries are classified in the XIX class, combining injuries, poisoning and a number of other consequences caused by external causes.
Under the appropriate codes in it you can find the injuries:
- of the abdominal organs( S36);
- of the spleen( S36.0);
- of the liver or gallbladder( S36.1);
- of the pancreas( S36.2);
- of the stomach( S36.3);
- of the small intestine( S36.4);
- of the colon( S36.5);
- of the rectum( S36.6);
- several intra-abdominal organs( S36.7);
- of other intra-abdominal organs( S36.8).
Since closed abdominal injuries are often accompanied by damage to the internal organs, consider the characteristic signs of damage to each of them.
Diagnosis
If there is a suspicion of an abdominal injury, the victim should be rushed to a medical facility immediately for diagnostic procedures and treatment.
- The victims, admitted to the hospital in the order of emergency hospitalization, must take for analysis( general and biochemical) blood and urine( general), establish a blood group and Rh factor.
- Electrocardiogram is mandatory.
- With the procedure of radiography of the abdominal cavity organs it is possible to establish the presence of ruptures of hollow organs, the location of pellets and bullets( in the case of a gunshot wound), and to confirm or disprove the assumption of concomitant injuries of the chest and pelvic bones.
- More reliable information can be given by the procedure of ultrasound, which allows to detect any intra-abdominal bleeding and internal injuries, soon fraught with the occurrence of such bleeding.
- For a detailed study of the condition and structure of internal organs, a computer tomography procedure is used to track the presence of even minor injuries and bleeding.
- If there is a suspicion of a bladder rupture, a catheterization technique is used, consisting of the insertion of a soft or hard catheter into the bladder. Isolation through the catheter of small portions of urine with an admixture of blood is a confirmation of the preliminary diagnosis. If there is doubt, an X-ray procedure of ascending cystography is performed, consisting in the introduction of the radiopaque drug into the bladder cavity( through the urethra).If this organ is ruptured, the radiopaque substance will be found in the tissues of the peri-bubble tissue.
- The most effective diagnostic technique, which leaves no doubt about the correctness of the diagnosis, is the procedure of laparoscopy. Having made a small incision, the specialist enters a special device into the abdominal cavity of the patient - an endoscope equipped with a video camera and connected to a monitor. The endoscope allows us to examine internal organs and, assessing the extent of their damage, to outline the scope of the forthcoming surgical intervention. With the help of laparoscopy, you can not only clarify the diagnosis, but also carry out a series of therapeutic measures aimed at stopping bleeding and removing blood accumulated in the abdominal cavity.
First aid
When receiving a serious abdominal injury, correct and urgent emergency care can not only preserve the health of the victim, but also save his life.
When providing first aid, it is necessary:
- To give the patient the most comfortable position.
- Put something cold on his stomach.
- If you have breathing problems, wear the oxygen mask on the affected person.
- Before performing analgesic injection, it is necessary to clarify the symptomatology of the injury( this point does not apply when there are signs of a penetrating injury).For anesthesia, you can use a 50% solution of metamizole or ketorolac( intravenously).When open abdominal injuries, accompanied by a ventilation of the entrails, the use of narcotic painkillers( for example, trimeridine) is allowed.
- Immediately deliver the patient to the nearest hospital.
- In no case should the internal organs fall out of the abdominal cavity. When copious contamination is allowed, careful washing of the internal organs with a warm solution of antiseptic and fixation with a bandage impregnated and constantly moistened with the same solution.
- When an open wound is formed, a sterile dressing is necessary.
- Despite strong thirst, which occurs in the victim due to massive blood loss, you can not drink it.
- If vomiting occurs, put the patient in such a way that the vomit does not interfere with his breathing.
- Do not give medication to the victim.
- It is not allowed to remove wounded objects( sharpening, knife or awl) from the wound. For their additional fixation, you can use an adhesive plaster, and also hold with your hand.
Treatment in adults and children
When choosing the tactics of treatment, the determining factor is the mechanism of injury, since the therapy of open and closed abdominal injuries has a number of cardinal differences.
- In the presence of open wounds , urgent surgical intervention is necessary.
- Surface non-penetrating injuries require primary surgical treatment and thorough rinsing of the wound cavity. After this, the contaminated and non-viable structures are excised and overlap.
- When receiving penetrating wounds, the tactic of surgical treatment depends on whether any internal organs are affected.
- Treatment of bruises and ruptures of fascia and muscle is carried out by conservative methods. For the implementation of drug therapy, antibacterial drugs, analgesics, tranquilizers( anxiolytics) are used. Patients should comply with strict bed rest. In some cases, he showed the use of infusion therapy and physiotherapy.
- In the presence of large hematomas ( cavities containing liquid or coagulated blood) resort to their opening, performed under local anesthesia. Having made a small incision in the center of the hematoma, the surgeon releases the cavity from the liquid blood and its clots. After rinsing the cavity with a solution of furacilin, apply a couple of seams and install a drain using a rubber graduate or tube. The final stage is the imposition of a sterile pressure bandage.
- In abdominal injuries with damage to hollow and parenchymal organs accompanied by intra-abdominal bleeding, immediate surgical operations requiring general anesthesia are performed. During the mid-laparotomy, the surgeon carefully examines the condition of the abdominal organs. All detected damage is eliminated. In some cases, blood transfusion is performed during the operation.
- During the postoperative period, further treatment of patients is performed with the use of analgesics and antibiotics.
- Therapeutic activities of the initial phase ( first aid, diagnosis) in the treatment of children are no different from the treatment of adults. Some differences relate only to the size of the tubes used for intubation( the so-called insertion of a special tube in the trachea that provides airway patency) of the trachea of small patients: they are already considerably equipped with a special cuff.
- Given the high immunological significance of the spleen for the child's body, the priority in the treatment of this organ is given to conservative therapies. If there is a suspicion of spleen damage, laparotomy is performed only if the bleeding has not been stopped or if there are reliable data on the presence of lesions of hollow organs. In the course of surgery, the surgeon takes measures to eliminate spleen injuries.
- The complex of therapeutic measures for the treatment of all other abdominal injuries received by children is almost identical to that of adults.
- If the parenchymal organs are damaged in children, the doctors resort to a wait-and-see tactic.
Complications of
Abdominal injuries, accompanied by damage to internal organs, are fraught with development:
- Peritonitis - inflammation of the peritoneum( serous membrane lining the surface of internal organs and internal walls of the abdominal cavity).The abdominal cavity of a healthy person is sterile. When receiving an abdominal injury accompanied by rupture of the intestine or stomach, the contents of these organs( represented by the microorganisms contained in them, feces, gastric juice, food remnants and digestive enzymes) enter this sterile environment, provoking the development of the inflammatory process.
- Internal bleeding that occurs when any organ is injured. Minor bleeding can stop on their own. The appearance of serious bleeding is fraught with a sharp deterioration in the condition of the injured person: it becomes covered with a cold sticky sweat, its blood pressure drops rapidly, and the skin covers turn pale. In this condition, the victims often lose consciousness and die from massive blood loss.
- Abdominal sepsis( the so-called systemic inflammatory reaction of the body that arises in response to the appearance of a pathological process in the abdominal cavity) and septic shock( a severe condition characterized by the simultaneous presence of both infection and systemic inflammatory response of the body).
- Enteral insufficiency - a violation of the small intestine, characterized by an insufficient degree of absorption of the products of decomposition of nutrients through the walls of the intestine.
Video on how to provide emergency care for a knife wound in the abdomen: