CHAPTER 3 Trauma
Major trauma
Pathophysiology
Several factors must also be considered that can alter the patient’s response to blood loss and must be considered in the resuscitation of these patients. These include the patient’s age, location, type and severity of the injury, the amount of time that has elapsed since the injury, prehospital interventions to address blood loss, and medications taken for chronic conditions, especially anticoagulants and beta-blockers. Since the patient has many other injuries, the classic signs of shock may be altered.
In patients who sustain major trauma, a widespread inflammatory response known as systemic inflammatory response syndrome (SIRS) may be triggered by massive tissue injury and the presence of foreign bodies such as road dirt, missiles, and invasive medical devices. Inflammatory mediators activate the coagulation cascade, increased catecholamines stimulate the production and release of white blood cells, and endothelial dysfunction ensues. The hemodynamic response and clinical findings are similar to those with sepsis. (See Chapter 11 for information on SIRS.)
Psychological response
Victims of major trauma sustain life-threatening injuries. The patient often is aware of the situation and fears death. Even after the physical condition stabilizes, the patient may have a prolonged and severe psychological reaction triggered by the trauma called posttraumatic stress disorder (PTSD).
Major trauma assessment: primary
Breathing assessment
Major trauma assessment: secondary
Vital signs
• Pulse rate may be elevated if the patient has experienced blood loss or stimulation of the sympathetic nervous system (SNS) or be decreased in response to elevated intracranial pressure (ICP) from a severe head injury.
• Respiratory rate may also be increased due to SNS stimulation or hypoxia or may be decreased secondary to decreased level of consciousness.
• BP will be elevated with SNS stimulation or increased ICP or decreased due to hemorrhage.
• Temperature may be decreased from exposure to cold environment and development of hemorrhagic shock.
History
Head-to-toe assessment
• 
Observe each area for signs of trauma including bruising, abrasions, lacerations, and contusions.
• Palpate each area to feel for crepitus and swelling.
• Auscultate for lung sounds, heart sounds, bowel signs, and bruits.
Labwork
Blood studies can reveal indications of hypoxia and/or continued bleeding and developing shock as well as identify special circumstances such as pregnancy and intoxication.
• Blood typing and screening or cross-matching
• Complete blood counts: hemoglobin (Hgb), increased white blood cell (WBC) count
• Coagulation studies including platelets, prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR)
• Serial arterial blood gases (ABGs)
• Urine or serum beta human chorionic gonadotropin (hCG) for pregnancy
| Diagnostic Tests for Major Trauma | ||
|---|---|---|
| Test | Purpose | Abnormal Findings |
| Blood Studies | ||
| Type and screen/type and cross-match | To have type-specific and cross-matched blood available for resuscitation | Inability to cross-match if specimen is collected after multiple units of blood are transfused. |
| Arterial blood gas (ABG) | Assess for adequacy of oxygenation and ventilation and to determine the level of anaerobic metabolism. | pH <7.35 with increased PaCO2 (>45 mm Hg) indicates respiratory acidosis. Serum bicarbonate <22 mEq/L with a pH <7.35 can indicate metabolic acidosis. Decreased PaO2 indicates hypoxemia. Increased PaCO2 indicates inadequate ventilation. Base deficit <−2.0 mEq/L indicates increased oxygen debt. |
| Complete blood count (CBC) Hemoglobin (Hgb) Hematocrit (Hct) |
Assess for blood loss. | Decreased Hgb and Hct indicate blood loss. Often Hgb and Hct are within normal range initially, especially if the patient has not received a significant amount of fluid to replace the blood loss. The Hgb and Hct should be repeated after the patient has a fluid challenge if there is any indication of significant bleeding. |
| Electrolytes Potassium (K+) Glucose Creatinine |
Provide a baseline and assess for possible alterations. | Potassium may be elevated with crush injuries. Glucose is usually elevated after injury. Decreased glucose indicates hypoglycemia and may cause decreased level of consciousness. Elevated creatinine indicates decreased renal functioning, and care should be taken when administering contrast for radiologic studies. |
| Coagulation profile Prothrombin time (PT) with international normalized ratio (INR) Partial thromboplastin time (PTT) Fibrinogen D-dimer |
Assess for causes of bleeding, clotting and disseminated intravascular coagulation (DIC) indicative of abnormal clotting present in shock or ensuing shock. | Decreased PT with low INR promotes clotting; elevation promotes bleeding; elevated fibrinogen and D-dimer reflect abnormal clotting is present. |
| Blood alcohol | To determine the level of alcohol in the patient’s blood | >10 mg/dl indicates the presence of alcohol in the patient’s blood. The higher the level, the more chance the patient has of showing signs of intoxication, but an absolute value will depend on the patient’s tolerance. This may interfere with neurologic assessment. |
| Carbohydrate deficient transferring (CDT) | To identify patients who have had excessive drinking for the past few weeks and may be at risk for alcohol withdrawal | >20 units/L for males and >26 units/L for females indicate excessive drinking. |
| Drug screen | To identify the presence of drugs in the patient”s system | Positive value indicates recent use of the substance. |
| Radiology | ||
| Chest radiograph (CXR) | Assess thoracic cage (for fractures), lungs (pneumothorax, hemothorax); size of mediastinum, size of heart. | Displaced lung margins will be present with pneumothoraces and hemothoraces. Cardiac enlargement may reflect cardiac tamponade. |
| Pelvic radiograph | Assess the integrity of the pelvic ring to indentify fractures and determine stability of the pelvis. | Fracture lines through any of the bones in the pelvis, widening of the symphysis pubis, and widening of the sacroiliac joint(s) |
| Computerized tomography head, neck, chest, abdomen, and/or pelvis | Assess for internal injuries. | Any findings of skeletal fractures, misalignment, organ damage, or abnormal collections of blood indicates injury to the organ/tissue involved. |
| Ultrasound: FAST Focused Assessment with Sonography for Trauma |
Assess for fluid around the heart, liver, spleen and bladder. | Abnormal collection of fluid |
| Invasive Studies | ||
| Diagnostic peritoneal lavage (DPL) | Assess for blood or in the peritoneal cavity or abnormal substrates in the peritoneal lavage fluid. | The presence of red or white blood cells, bile, food fibers, amylase, or feces in the lavage fluid suggests injury to the abdominal organs. Lavage fluid coming from the Foley catheter indicates bladder rupture. Lavage fluid coming from the chest tube, if present, indicates diaphragm rupture. |
Collaborative management
Care priorities
3. Manage hemorrhage and hypovolemia:
Stopping blood loss and restoring adequate circulating blood volume are imperative. Lack of resuscitation will lead to increasing oxygen debt and eventually to MODS and death. The goal of resuscitation in any trauma patient should be to restore adequate tissue perfusion. Two or more large-bore (XXgw:math1XX^ZZgw:math1ZZ16-gauge) short catheters should be placed to maximize delivery of fluids and blood. Use of intravenous (IV) tubing with an exceptionally large internal diameter (trauma tubing), absence of stopcocks, and use of external pressure are techniques used to promote rapid fluid volume therapy when indicated. In some cases the patient may require large central venous access, such as an 8.5 Fr introducer. When rapid infusion of large amounts of fluid is required, all fluid should be warmed to body temperature to prevent hypothermia. Rapid warmer/infuser devices are available to facilitate rapid administration of blood products. Fluid resuscitation should be used more judiciously in pediatric and older patients, as well as patients with significant craniocerebral trauma, who have precise fluid requirements (see Traumatic Brain Injury, p. 341).
• Crystalloids: Initial fluid used for resuscitation should be an isotonic electrolyte solution such as 0.9% normal saline (NS), or lactated Ringer’s (LR). Other balanced electrolyte solutions, such as Normosol-R pH 7.4 (Hospira) or Plasmalyte-A 7.4 (Baxter) may be used after initial fluid resuscitation has been completed.
• Rapid bolus: From 1 to 2 L of rapid IV fluid infusion for adults and 20 ml/kg for pediatric patients should be initiated in the prehospital setting. If the patient continues to show signs of shock after the bolus is complete, blood transfusions should be considered.
• Packed red blood cells (PRBCs): Typed and cross-matched blood is ideal, but in the immediate resuscitation period, if cross-matched blood is not available, type O blood may be used. Once the patient has been typed, type-specific blood can be used. Those patients requiring continuous blood transfusions need reassessment to identify the source of bleeding and definitive treatment to stop ongoing blood loss. A massive transfusion protocol may also need to be initiated.
• Massive transfusion is defined as replacement of one half of the patient’s blood volume at one time or complete replacement of the patient’s blood volume over 24 hours. A massive transfusion protocol ensures the patient receives plasma, platelets, and cryoprecipitate in addition to the packed red blood cells to prevent the complications related to coagulopathy. Another concern with massive transfusion is hypocalcemia caused by calcium binding with citrate in stored PRBCs, resulting in depressed myocardial contractility, particularly in hypothermic patients or in those with impaired liver function. One ampule of 10% calcium chloride should be considered for administration after every 4 units of PRBCs.
Only O-negative packed cells should be transfused into prepubescent females and women in childbearing status to prevent sensitization and future complications during pregnancy.• Autotransfusion: Shed blood from the patient can be collected, filtered, and reinfused. Shed blood is captured from chest tube drainage or the operative field and reinfused immediately. Various techniques are used to capture and reinfuse the blood. Advantages of autotransfusion include reduced risk of disease transmission, absence of incompatibility problems, and availability. Disadvantages include risk of blood contamination and presence of naturally occurring factors that promote anticoagulation.
• Colloids: Resuscitation with colloids has not been shown to reduce mortality and is not used in the initial resuscitation of trauma patients.
• Recombinant factor VIIa (rFVIIa): The standard use of rFVIIa in the resuscitation of trauma patients is still controversial. Some studies have shown a decrease in the number of units of PRBCs required for patients in hemorrhagic shock but have not shown a decrease in mortality. More studies are needed to determine the appropriate indications, contraindications, dosage, and timing of rFVIIa administration in trauma patients experiencing hemorrhagic shock.
Warmed blankets, forced warm air blankets, and warmers for IV fluids and blood should be used to prevent hypothermia. If the patient is already hypothermic, more aggressive measures to rewarm the patient may be necessary. Warming lights are useful for pediatric patients. Core rewarming measures can include irrigation of the peritoneal and/or thoracic cavities with warmed saline, use of heated humidified oxygen, and extracorporeal blood rewarming.An indwelling catheter is inserted to obtain a specimen for urinalysis and to monitor hourly urine output. See Renal and Lower Urinary Tract Trauma, p. 317, for precautions.
8. Control pain and anxiety with analgesics and anxiolytics:
Relief of pain and anxiety are accomplished using IV opiates and anxiolytics. All IV agents should be carefully titrated to desired effect, while avoiding respiratory depression, masking injury, or disguising changes in physiologic parameters. Use of the World Health Organization (WHO) ladder for pain management and a pain-rating scale are essential for the trauma population.
9. Provide tetanus prophylaxis:
Tetanus immunoglobulin and tetanus-toxoid are considered on the basis of Centers for Disease Control and Prevention (CDC) recommendations (Table 3-1).
10. Initiate nutritional support therapy:
Infection and sepsis contribute to the negative nitrogen state and increased metabolic needs. Prompt initiation of nutrition therapy is essential for rapid healing and prevention of complications. Parenteral nutrition or postpyloric (jejunal) feedings may be used if postoperative ileus or injury to the gastrointestinal (GI) tract is present. For more information, see Nutritional Support, p. 117.
11. Facilitate evaluation for surgery:
CARE PLANS: MAJOR TRAUMA
Ineffective tissue perfusion, cardiopulmonary
related to significant blood loss/volume
Blood Loss Severity1. Monitor for sudden blood loss or persistent bleeding.
2. Prevent blood volume loss (e.g., apply pressure to site of bleeding).
3. Monitor for fall in systolic BP to less than 90 mm Hg or a fall of 30 mm Hg in hypertensive patients.
4. Monitor for signs/symptoms of hypovolemic shock (e.g., increased thirst, increased HR, increased systemic vascular resistance (SVR), decreased urinary output [urine output], decreased bowel sounds, decreased peripheral perfusion, altered mental status, or altered respirations).
5. Position the patient for optimal perfusion.
6. Insert and maintain large-bore IV access.
7. Administer warmed IV fluids, such as isotonic crystalloids, as indicated.
8. Administer blood products (e.g., PRBCs, platelets, plasma, and cryoprecipitate) as appropriate.
9. Administer oxygen and/or mechanical ventilation, as appropriate.
10. Draw arterial blood gases and monitor tissue oxygenation.
11. Monitor Hgb/hematocrit (Hct) level.
12. Monitor coagulation studies, including INR, PT, PTT, fibrinogen, fibrin degradation/split products, and platelets.
13. Monitor lab studies (e.g., serum lactate, acid-base balance, metabolic profiles, and electrolytes).
14. Monitor fluid status, including intake and output, as appropriate.
15. Monitor for clinical signs and symptoms of overhydration/fluid excess.
1. Monitor BP, pulse, temperature, and respiratory status, as appropriate.
2. Note trends and wide fluctuations in BP.
3. Auscultate BPs in both arms and compare, as appropriate.
4. Initiate and maintain a continuous temperature monitoring device, as appropriate.
5. Monitor for and report signs and symptoms of hypothermia and hyperthermia.
1. Examine the pH level in conjunction with the PaCO2 and HCO3 levels to determine whether the acidosis/alkalosis is compensated or uncompensated.
2. Monitor for an increase in the anion gap (greater than 14 mEq/L), signaling an increased production or decreased excretion of acid products.
3. Monitor base excess/base deficit levels.
4. Monitor arterial lactate levels.
5. Monitor for elevated chloride levels with large volumes of NS.
related to airway obstruction, inadequate oxygenation
Respiratory Status: Gas Exchange; Respiratory Status: Ventilation
1. Assess for patent airway; if snoring, crowing, or strained respirations are present, indicative of partial or full airway obstruction, open airway using chin-lift or jaw-thrust and maintain cervical spine alignment.
2. Insert oral or nasopharyngeal airway if patient cannot maintain patent airway; if severely distressed, patient may require endotracheal intubation.
3. When spine is cleared, position patient to alleviate dyspnea and ensure maximal ventilation, generally in a sitting inclined position unless severe hypotension is present.
4. Clear secretions from airway by having patient cough vigorously, or provide nasotracheal, oropharyngeal, or endotracheal tube suctioning as needed.
5. Have patient breathe slowly or manually ventilate with bag-valve-mask device slowly and deeply between coughing or suctioning attempts.
6. Assist with use of incentive spirometer as appropriate.
7. Turn patient every 2 hours if immobile. Encourage patient to turn self, or get out of bed as much as tolerated if patient is able.
8. Provide chest physical therapy as appropriate, if other methods of secretion removal are ineffective.
1. Provide humidity in oxygen.
2. Administer supplemental oxygen using liter flow and device as ordered.
3. Restrict patient and visitors from smoking while oxygen is in use.
4. Document pulse oximetry with oxygen liter flow in place at time of reading as ordered. Oxygen is a drug; the dose of the drug must be associated with the oxygen saturation reading or the reading is meaningless.
5. Obtain arterial blood gases if patient experiences behavioral changes or respiratory distress to check for hypoxemia or hypercapnia.
6. Monitor for changes in chest radiograph and breath sounds indicative of oxygen toxicity and absorption atelectasis in patients receiving higher concentrations of oxygen (FIO2 greater than 45%) for longer than 24 hours. The higher the oxygen concentration, the greater is the chance of toxicity.
7. Monitor for skin breakdown where oxygen devices are in contact with skin, such as nares and around edges of mask devices.
8. Provide oxygen therapy during transportation and when patient gets out of bed.
1. Monitor rate, rhythm, and depth of respirations.
2. Note chest movement for symmetry of chest expansion and signs of increased work of breathing such as use of accessory muscles or retraction of intercostal or supraclavicular muscles.
3. Ensure airway is not obstructed by tongue (snoring or choking-type respirations) and monitor breathing patterns. New patterns that impair ventilation should be managed as appropriate for setting.
4. Note that trachea remains midline, as deviation may indicate patient has a tension pneumothorax.
5. Auscultate breath sounds following administration of respiratory medications to assess for improvement.
6. Note changes in oxygen saturation (SaO2), pulse oximetry (SpO2), end-tidal CO2 (ETCO2), and ABGs as appropriate.
7. Monitor for dyspnea and note causative activities/events.
8. If increased restlessness or unusual somnolence occurs, evaluate patient for hypoxemia and hypercapnia as appropriate.
9. Monitor chest x-ray reports as new films become available.
Comfort Status: Physical, Pain Level
1. Assess and document the location and intensity of the pain. Devise a pain scale with patient, rating discomfort from 0 (no pain) to 10 or any system that assists in objectively reporting pain level. If intubated, use a physiologic scale such as adult nonverbal pain scale or the FLACC scale.
2. Determine the needed frequency of making an assessment of patient comfort and implement monitoring plan.
3. Provide the patient with optimal pain relief with prescribed analgesics.
4. Ensure pretreatment analgesia and/or nonpharmacologic strategies prior to painful procedures.
5. Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience.
related to altered temperature regulation
Patient will maintain a normal body temperature above 36°C (96.8°F).
Thermoregulation1. Cover with warmed blankets, as appropriate.
2. Administer warmed (37° to 40°C) IV fluids, as appropriate.
3. Administer heated oxygen, as appropriate.
4. Infuse all whole blood and PRBCs through a warmer.
5. Institute active core rewarming techniques (e.g., colonic lavage, hemodialysis, peritoneal dialysis, and extracorporeal blood rewarming), as appropriate.
related to inadequate coping ability due to major physical and emotional stress
Anxiety Level; Coping1. Explain all procedures, including sensations likely to be experienced during the procedure.
2. Provide factual information concerning diagnosis, treatment, and prognosis.
3. Encourage family to stay with patient, as appropriate.
4. Create an atmosphere to facilitate trust.
5. Control stimuli as appropriate, for the patient needs.
6. Determine the patient’s decision-making ability.
7. Administer medications to reduce anxiety, as appropriate.
1. Provide an atmosphere of acceptance.
2. Provide the patient with realistic choices about certain aspects of care.
3. Acknowledge the patient’s spiritual/cultural background.
4. Encourage the use of spiritual resources, if desired.
5. Encourage verbalization of feelings, perceptions, and fears.
6. Assist the patient to identify available social supports.
Additional nursing diagnoses
Also see nursing diagnoses and interventions as appropriate in Nutritional Support (p. 117), Mechanical Ventilation (p. 99), Hemodynamic Monitoring (p. 75), Prolonged Immobility (p. 149), and Emotional and Spiritual Support of the Patient and Significant Others (p. 200).
Abdominal trauma
Pathophysiology
Blunt trauma
There are three mechanisms of action with blunt trauma.
1. Rapid deceleration: On impact, the different organs that reside inside abdominal cavity move at different speeds depending on their density. This creates what is known as shear force, that is, two different directions applied to the organ, usually at the point of attachment, causing injury to other organs such as the aorta.
2. Crush of contents between the walls: Solid viscera are exceptionally affected when the compression occurs from the anterior abdominal wall and the spine or posterior cage.
3. External compression force: The force of external traumatic impact may increase the organ and abdominal pressures to such a degree that the hollow organs rupture.
Mechanisms of action with penetrating injury
• Diaphragm: Commonly injured at the left posterior portion after blunt trauma, the tear is best visualized by chest radiograph, which reveals an elevation of the left hemidiaphragm and air under the diaphragm.
• Spleen: The organ most frequently injured after blunt trauma, massive hemorrhage from splenic injury is common. Damage to the spleen may occur with the most trivial of injuries, so index of suspicion should be high. Splenic injury is often associated with hepatic or pancreatic injury due to close proximity of these organs. Splenectomy is the treatment of choice for major spleen injuries. Minor splenic injuries may be managed with direct suture techniques
• Liver: Most frequently involved in penetrating trauma (80%) because of its large size and location, the liver is less often affected by blunt injury (20%). Control of bleeding and bile drainage is the priority with hepatic injury. Mortality from liver injuries is about 10%. In most patients, bleeding from a liver injury can be controlled, such as with perihepatic packing. About 5% of injuries require packing for bleeds. Major arterial bleeding from the liver parenchyma will require further attention. Biliary tree injuries may require surgical repair and should be suspected with liver injury. The patient may be asymptomatic or have mild to moderate abdominal discomfort with biliary tree injury.
• Retroperitoneal vessels: Tears in retroperitoneal vessels associated with pelvic fractures or damage to retroperitoneal organs (pancreas, duodenum, and kidney) can cause bleeding into the retroperitoneum.
• Although the retroperitoneal space can accommodate up to 4 L of blood, detection of retroperitoneal hematomas is difficult and sophisticated diagnostic techniques may be required.
• Colon: Injury is most frequently caused by penetrating forces, although lap belts, direct blows, and other blunt forces cause a small percentage of colonic injuries. Because of the high bacterial content, infection is even more a concern than it is with small bowel injury. Most patients with significant colon injuries require a temporary colostomy.
• Undetected mesenteric damage: May cause compromised blood flow, with eventual bowel infarction. Perforations or contusions result in release of bacteria and intestinal contents into the abdominal cavity, causing serious infection.
Assessment: abdominal trauma
In an unstable patient, immediate identification of free intra-abdominal fluid by Focused Assessment with Sonography for Trauma (FAST) examination or a diagnostic peritoneal lavage (DPL) is imperative and supports decisions to move straight to the operating room.History and risk factors
First and foremost, it is essential to establish issues involved with the injury event (Box 3-1). These details regarding circumstances of the accident and mechanism of injury are invaluable in detecting the presence of specific injuries. Second, allergies, medications, and last meal eaten will play an important role in the maintenance of good resuscitation. Other information, previous abdominal surgeries, and use of safety restraints (if appropriate) should be noted. Hollow viscous injury is often missed but should always be suspected with a visible contusion on the abdomen. Medical information including current medications and last tetanus-toxoid immunization should be obtained. The history is sometimes difficult to obtain because of alcohol or drug intoxication, head injury, breathing difficulties, or impaired cerebral perfusion. Family members and emergency personnel may be valuable sources of information.
Vital signs
• 
Hypotension: Presence of hypotension is a sign of impending doom, but the absence of hypotension does not always accurately reflect an absence of hemorrhage. After an injury, a profound neuroendocrine response ensues to activate the beta receptors (sinus node and ventricular contractile tissue), the alpha receptors (smooth muscle in the arteries), and the renal tubules (promoting preservation of fluid), resulting in significant tachycardia, profound vasoconstriction, and progressive oliguria. These responses may mask the severity of hemorrhage. Patients on alpha or beta antagonists or those with acute spinal cord injuries (above C5) will not manifest these responses and therefore will have few compensatory mechanisms.
• Pulse pressure: This measure may be effectively used to determine the amount of volume in the arteries (systolic minus diastolic BP, normal greater than 40 mm Hg). Pulse pressure generally correlates with the volume ejected by the left ventricle and therefore is a valuable tool for indication of volume in the vascular bed. Presence of pulsus paradoxus (Box 3-2) may be visualized with either the invasive arterial pressure trace or the plethysmograph of the pulse oximeter and is an invaluable tool in evaluating arterial volume.
Box 3-2 MEASURING PARADOXICAL PULSE
• After placing BP cuff on patient, inflate it above the known systolic BP. Instruct patient to breathe normally.
• While slowly deflating the cuff, auscultate BP.
• Listen for the first Korotkoff sound, which will occur during expiration with cardiac tamponade.
• Note the manometer reading when the first sound occurs, and continue to deflate the cuff slowly until Korotkoff sounds are audible throughout inspiration and expiration.
• Record the difference in millimeters of mercury between the first and second sounds. This is the pulsus paradoxus.
Observation and subjective/objective symptoms
• Inspection of all surfaces of trunk, head, neck, and extremities, including anterior lateral and posterior exposure, with notation of all penetrating wounds, contusions, tenderness, ecchymosis, or other marks and indicators. Multiple wounds may represent entrance or exit wounds but do not eliminate the possibility of objects that may remain internally.
• Kehr sign (left shoulder pain caused by splenic bleeding) also may be noted, especially when the patient is recumbent.
• Nausea and vomiting may occur, and the conscious patient who has sustained blood loss often complains of thirst—an early sign of hemorrhagic shock.
• Preoperative pain is anticipated and is a vital diagnostic aid. The nature of postoperative pain also can be important. Incisional and some visceral pain can be anticipated, but intense or prolonged pain, especially when accompanied by other peritoneal signs, can signal bleeding, bowel infarction, infection, or other complications.
It is important to note that damage to retroperitoneal organs such as the pancreas and duodenum may not cause significant signs and symptoms for 6 to 12 hours or longer. Relatively slow bleeding from abdominal viscera may not be clinically apparent for 12 hours or longer after the initial injury. In addition, the nurse should be aware that complications such as bowel obstruction caused by adhesions or narrowing of the bowel wall from localized ischemia, inflammation, or hematoma may develop days or weeks after the traumatic event. The need for vigilant observation in the care of these patients cannot be overemphasized.Inspection
• Abrasions and ecchymoses may indicate underlying injury. The absence of ecchymosis does not exclude major abdominal trauma and massive internal bleeding. In the event of gunshot wounds, entrance and exit (if present) wounds should be identified.
• Ecchymosis over the left upper quadrant (LUQ) suggests splenic rupture, and erythema and ecchymosis across the lower portion of the abdomen suggest intestinal injury caused by lap belts.
• Grey-Turner sign, a bluish discoloration of the flank, may indicate retroperitoneal bleeding from the pancreas, duodenum, vena cava, aorta, or kidneys.
• Cullen sign, a bluish discoloration around the umbilicus, may be present with intraperitoneal bleeding from the liver or spleen. Ecchymosis may take hours to days to develop, depending on the rate of blood loss.
Auscultation
• Bowel sounds: These are likely to be decreased or absent with abdominal organ injury or intraperitoneal bleeding. The presence of bowel sounds, however, does not exclude significant abdominal injury. Immediately after injury, bowel sounds may be present, even with major organ injury. Bowel sounds should be auscultated in each quadrant every 1 to 2 hours in patients with suspected abdominal injury. Absence of bowel sounds is expected immediately after surgery. Failure to auscultate bowel sounds within 24 to 48 hours after surgery suggests ileus, possibly caused by continued bleeding, peritonitis, or bowel infarction.
Palpation
• Tenderness to light palpation suggests pain from superficial or abdominal wall lesions, such as that occurring with seatbelt contusions.
• Deep palpation may reveal a mass, which may indicate a hematoma. Internal injury with bleeding or release of GI contents into the peritoneum results in peritoneal irritation and certain assessment findings. Box 3-3 describes signs and symptoms that suggest peritoneal irritation.
• Subcutaneous emphysema of the abdominal wall is usually caused by thoracic injury but also may be produced by bowel rupture.
• Measurements of abdominal girth may be helpful in identifying increases in girth attributable to gas, blood, or fluid. Visual evaluation of abdominal distention is a late and unreliable sign of bleeding.
• Peritoneal signs (pain, guarding, rebound tenderness) or abdominal distention in an unconscious patient requires immediate evaluation in either case.
