Chapter 15: Chest, Abdominal, and Pelvic Injuries

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Overview

Injuries to the chest, abdomen, and pelvis, include both soft tissue injuries (e.g., internal organ damage) and fractures (e.g., of the ribs or pelvic bones). While ribs are thin and more susceptible to fractures, a powerful force (e.g., from a fall or motor vehicle collision) is required to cause serious injury to the pelvic bones.

Because the chest, abdomen, and pelvis contain many of the body’s vital organs, injuries to these areas can be immediately life-threatening. A force that causes a severe injury in these areas may also cause injury to the spine. All injuries described in this chapter should cause serious concern: Any patient with a serious chest, abdomen, or pelvic injury should be placed in the rapid transport category.

General care for chest, abdomen, and pelvic injuries includes controlling any external bleeding, limiting movement of any injured areas as much as possible (especially if fractures are suspected), and taking steps to mitigate the effects of shock (which is common when internal organs are damaged).

Chest Injuries

Signs and Symptoms of Chest Injuries. Chest injuries can occur when either a blunt or penetrating force is applied to the chest. Chest wounds categorized as either open wounds (when an object penetrates the chest wall or a fractured rib breaks through the skin) or closed wounds (if the skin is not broken, generally caused by blunt force). The signs and symptoms of a serious chest injury include:

• Respiratory distress or arrest.
• Pain at the site of injury that increases with deep respirations or movement.
• Obvious deformity.
• Unequal or paradoxical movement of the chest wall.
• Flushed, pale, or bluish skin.
• Coughing up blood.

Rib Fractures. Rib fractures are usually caused by an external blunt-force impact to the chest (figures below). Although painful, a simple rib fracture is rarely life-threatening unless the fractured bone causes damage to the organs (e.g., the lungs) or major blood vessels.

An external blunt-force impact to the chest can cause a fracture of the ribs or sternum.

You should suspect a rib fracture in the following situations:

• The patient’s respiration presents as painful and shallow or laboured.
• The patient attempts to ease the pain by leaning towards the side of the fracture.
• The patient tries to stabilize the fracture by putting pressure on the injured area.

Chest injuries involving multiple rib fractures are more serious and can be life-threatening. Multiple rib fractures should be suspected if the MOI involves a severe blunt-force impact or crush injury to the chest. Multiple rib fractures often cause internal hemorrhaging and difficulty breathing (dyspnea), creating the risk of shock.

Care for Rib Fractures. If you suspect a rib fracture, perform the following steps:

1. Position the patient to facilitate respiration (a Semi-Fowler’s position is often most comfortable – see figure below).
2. Support and immobilize the injured area using a soft, bulky object, such as a pillow or rolled blanket.
3. Provide interventions for respiratory distress or arrest if indicated (e.g., supplemental oxygen, assisted ventilations).

Flail Chest. Multiple rib fractures can result in a section of the rib cage breaking free from the surrounding tissues, a condition referred to as ‘flail chest’ (see figure below). The loose section (commonly referred to as a flail segment) will not move normally during respiration. Usually, the loose section will move in the opposite direction from the rest of the chest; this is called ‘paradoxical movement’. If enough force is applied, a flail chest may also involve the sternum. A flail sternum occurs when the sternum is separated from the rest of the ribs.

Care for Flail Chest. If you suspect a flail chest, perform a focused exam of the ribs, gently palpating the area to locate the flail segment. Stabilize the flail segment by placing bulk dressings (at least 1.3 cm thick) over the entire injured area, ensuring that the dressing extends beyond the edges of the segment on all sides. This will allow sufficient pressure to be applied without causing unnecessary damage to the injured area. Secure the dressings in place with long strips of tape, taking care to avoid aggravating the injury or impairing the patient’s respiration.

Hemothorax. Hemothorax is bleeding into the pleural space around the lungs (see figure below). This can be caused by blunt or penetrating trauma to the chest that results in a lacerated lung or laceration of a blood vessel in the chest. Hemothorax can occur with closed or open chest wounds. The severity of the hemothorax depends on the amount of bleeding into the pleural space.

As the chest fills with blood, the lung on the affected side will become increasingly unable to expand and may collapse. The patient will present with dyspnea, and the onset of shock will occur if bleeding continues. Blood in the pleural space will also create pressure on the heart and lungs, resulting in further complications.

Care for Hemothorax. Provide care for respiratory distress or arrest (e.g., if the patient is hypoxic, provide high-concentration supplemental oxygen). Assisted ventilations are usually indicated for a patient with shallow or inadequate respirations. If the hemothorax is a result of a penetrating chest injury, the patient may require interventions for an open pneumothorax as well. A patient with a hemothorax will require emergency surgery and should be placed in the rapid transport category.

Pneumothorax. Pneumothorax is a condition caused by air entering the pleural space around the lung (see figure below). It may occur as a result of blunt or penetrating trauma, or it may be spontaneous (spontaneous pneumothorax). A one-time escape of air into the pleural space is referred to as a ‘simple pneumothorax’. The patient’s presentation will vary depending on how much air has entered the pleural space: The lung may be partially or totally collapsed, and this will be reflected in the patient’s signs and symptoms. The signs and symptoms of pneumothorax may include:

• Pleuritic chest pain (pain increased by coughing or inhaling deeply).
• Dyspnea and/or tachypnea.
• Decreased or absent breath sounds on the affected side.
• Subcutaneous emphysema

• Spontaneous Pneumothorax.: Pneumothorax can occur in otherwise perfectly healthy people without any associated trauma. This is referred to as spontaneous pneumothorax and is most frequently seen in young, thin, tall males. Typically, the patient complains of a sudden, sharp chest pain and sudden shortness of breath following strenuous exertion, coughing, or air travel.
• Tension Pneumothorax: In some cases, a pneumothorax can progress to a tension pneumothorax. While pneumothorax is caused by a single entry of air into the pleural space, tension pneumothorax occurs when lung tissue is torn, causing a continual flow of air into the pleural space and a steady increase in pressure (see figure below). The mounting pressure of the air in the pleural space causes the lung to eventually collapse, diminishing the volume or air that can be inhaled and exhaled with each respiration. As the air continues to mount in the pleural space, pressure is placed on the unaffected lung, heart, and major blood vessels as well. Accompanying signs may include tachycardia, hypotension, tracheal deviation, and jugular venous distension (JVD). As the condition worsens, signs of hypoxia and severe respiratory emergency will be evident. Provide any necessary interventions, such as supplemental oxygen or assisted ventilations, based on the patient’s presentation. A patient with a suspected tension pneumothorax should be placed in the rapid transport category.

Subcutaneous Emphysema (SCE). SCE is a rare condition that occurs when air becomes trapped in tissues beneath the skin. Damage to the respiratory system (especially penetrating trauma to the lungs and bronchial tube) can allow air to escape into the body. Affected areas often appear swollen. ASE produces an unusual crackling sensation when the affected area is touched.

While not a serious condition in itself, SCE can be an indicator of serious internal trauma such as tension pneumothorax.

Penetrating Chest Injuries. A penetrating object can injure any structure within the chest, including the lungs, heart, and major arteries or veins, causing complications that range in severity from minor to life-threatening. A hole in the chest wall disrupts the intrathoracic pressure, which can prevent the lungs from functioning properly and cause respiratory distress. Puncture wounds may also allow air or blood to enter the chest cavity, causing pneumothorax or hemothorax.

Care for Penetrating Chest Injuries. When providing treatment for a penetrating chest injury, your goal is to control any external hemorrhaging without increasing the pressure in the chest from occlusion (meaning that the wound no longer allows air to enter or exit). Occlusion significantly increases the risk of a tension pneumothorax, so it must be prevented. If bleeding is minor, leave the wound exposed to the air or use a non-occlusive dressing. If an external hemorrhage is present, it must be quickly controlled: Apply direct pressure to the chest wound with your gloved hand and/or a non-occlusive dressing (figure a). If the dressing becomes saturated with blood, it will become occluded: monitor the dressing closely and replace saturated dressings immediately (figure b).

Figure a-b: a) Control an external hemorrhage by applying direct pressure to the wound with a gloved hand and non-occlusive dressing; b) Change saturated dressings immediately.

If the patient is hypoxic, administer oxygen and take steps to minimize the onset of shock. Assisted ventilations may also be necessary. Place the patient in a position of comfort that allows for ease of breathing. If you roll the patient into the recovery position, make sure the injured side is towards the ground.

Abdominal Injuries

Unlike the chest, the abdomen is not surrounded by a cage of bones, so it is more susceptible to injury. Because it contains many vital organs (and these organs tend to bleed profusely), injuries to the abdomen are often life-threatening.

The liver is located in the upper right quadrant of the abdomen, partially protected by the lower ribs. The liver is rich in blood and can be damaged by blunt trauma or penetrated by a fractured rib. The resulting bleeding may be severe and can become fatal. When injured, the liver can also leak bile into the abdomen, which can cause severe infection.

The spleen is located in the upper left quadrant of the abdomen, behind the stomach, and is protected somewhat by the lower left ribs. The spleen is easily damaged, as it may rupture when the abdomen is truck forcefully by a blunt object. Since the spleen stores blood, an injury can quickly lead to a severe loss of blood and become life-threatening.

The stomach changes shape depending on its contents, the stage of digestion, and the size and strength of the stomach muscles. Because the stomach is lined with many blood vessels and nerves, it can hemorrhage internally when injured, and food contents may empty into the abdomen, causing infection.

Damage to the GI tract can cause internal hemorrhaging as well. If the contents of the intestines are spilled into the abdominal cavity, the risk of infection is very high.

Signs and Symptoms of Abdominal Injuries. An injury to the abdomen may be either open or closed. Even with a closed wound, the rupture of an organ can cause internal hemorrhaging. This can be extremely painful and may result in shock. Serious complications can occur if organs leak blood or other contents into the abdomen. The signs and symptoms of serious abdominal injuries include:

• Severe pain.
• Bruising.
• External bleeding.
• Nausea and vomiting (sometimes vomit containing blood).
• Pale, moist skin.
• Thirst.
• Pain, tenderness, or a tight feeling in the abdomen.
• Distension in the abdomen.
• Organs possibly protruding from the abdomen.
• Signs and symptoms of shock.

Blunt trauma to the abdomen may not cause external signs of injury and may even be painless, even when serious injuries have occured. You should suspect serious abdominal injuries if the MOI suggests that they are likely, even if the patient’s presentation does not suggest serious injuries. Penetrating wounds to the abdomen may cause internal hemorrhaging. The patient may also develop peritonitis (an infection of the abdominal lining) in the hours or days following the event.

A patient who has experienced serious trauma to the abdomen should be in the rapid transport category, even if the signs and symptoms of serious injury are absent.

Care for Abdominal Injuries. Place the patient in the supine position. Bend the patient’s knees slightly, allowing the muscles of the abdomen to relax. Place rolled-up blankets or pillows under the patient’s knees. If moving the patient’s legs causes pain, leave them straight.

If external bleeding is present, attempt to control it by applying trauma dressings and gentle pressure: avoid applying firm pressure to the abdomen, as this can exacerbate internal injuries. If gentle pressure is not sufficient to control the bleeding, place the patient in the rapid transport category immediately.

Evisceration. When a major open wounds occurs to the abdomen, abdominal organs may begin to protrude through the wound (figure a). Internal organs are then very susceptible to environmental conditions. Interventions you perform should focus on protecting the organs from extremes of heat and cold, dust, and shock. Avoid touching the exposed organs, and do not attempt to force protruding organs back into place.

Remove clothing from around the wound (figure b) and cover the area lightly with moist, sterile dressings placed loosely over the wound (figure c). Saline or warm tap water can be used to moisten the dressings. Cover the dressings loosely with plastic wrap, if available. Place a folded towel or blanket over the area to maintain warmth (figure d). If necessary, gently secure the towel or blanket in place with large bandages, but avoid putting pressure on the injured area.

Abdominal Aortic Aneurysm (AAA). An AAA occurs when the wall of the abdominal aorta weakens and bulges, creating a localized enlarged area (see figure below).

Signs and Symptoms of AAA. Initially, an AAA may present few or no signs or symptoms. As the AAA expands, it may become very painful in the chest, abdomen, or scrotum, accompanied by a pulsating sensation in the abdomen. This is due to the vessel walls become thinner with the risk of the aneurysm rupturing increasing.

A patient may also have absent or decreased femoral or pedal pulses on both sides of the body.

If you suspect AAA, do not put pressure on the abdomen. Many older adults mistake AAA for renal colic, as the pain pattern is quite similar.

A patient with a ruptured AAA will present with signs and symptoms of internal bleeding, and will likely be in shock. Any patient with a suspected AAA should be in the rapid transport category.

Pelvic Injuries

The pelvis is a ring-shaped bony structure consisting of the sacrum, the coccyx, and the three innominate bones: the ilium, the ischium, and the pubis. The pelvis is the lower part of the trunk and contains the bladder, the the female reproductive organs, and the lower portion of the large intestine (including the rectum). An array of arteries and nerves passes through the pelvis.

The organs within the pelvis are well protected at the sides and rear, but not in the front. Forceful blows from blunt or penetrating objects are the most common cause of pelvic injuries. Fractured bones in the pelvis can puncture or lacerate internal organs and major blood vessels, causing severe internal hemorrhage. Injury to the nerves that travel through the pelvis can result in bowel, bladder, and sexual dysfunctions. When assessing or treating a suspected pelvic injury, minimize movement of the pelvis, as any motion increases the risk of damage to internal structures.

Signs and Symptoms of Pelvic Injuries. Pain, pelvic instability, and crepitus are key indicators of a pelvic fracture. Certain pelvic injuries may also cause loss of sensation in the legs, decreased range of motion, or paralysis. This may indicate an injury to the lower spine or to the nerves of the pelvis.

If there are internal injuries to pelvic organs, there may be visible bleeding (rectal, urethral, or vaginal). Depending on the MOI, there may also be soft tissue injuries to the genitals, including pain and hematoma.

Care for Pelvic Injuries. Your priorities are to minimize additional damage, control external bleeding, and mitigate the effects of shock until the patient can be rapidly transported for advanced emergency interventions.

If you suspect a fracture of one of the pelvic bones, perform a three-plane assessment to assess its stability. Apply gentle pressure to the pelvis, first inwards, then upwards, and finally downwards. This allows you to assess the pelvic girdle as a whole, followed by the pubis, and finally the sacral coccygeal spine. If the pressure causes the patient any pain, stop the assessment and initiate pelvic binding (described below).

Keep the patient supine and as still as possible. If necessary, immobilize the patient on a backboard. Avoid any unnecessary movement of the patient, and avoid putting pressure on the pelvis. If any organs are visibly protruding, provide care for evisceration.

Pelvic Binding. Pelvic binding is a technique that creates even pressure on a fractured pelvis from all sides, supporting the bones and reducing the risk of additional damage to internal structures. It may be used when fractures of the pelvic bones make the pelvis unstable.

Pelvic binding provides the following benefits:

• Assists in controlling internal hemorrhaging by stabilizing the pelvic ring to encourage clot formation.
• Maintains circumferential immobilization and stability.
• Reduces the volume within the pelvic cavity.
• Allows for easy access to the abdomen, femoral vessels, and perineum.

Pelvic binding is not recommended for patients who have sustained fractures from low-energy or lateral impacts.

There are various commercial pelvic binding devices available, however if one is unavailable, you may use a modified method, securing a flannel blanket or bed sheet in place with clamps. To do so, perform the following steps:

1. Remove outer clothing and bring the legs together.
2. Insert a narrow, folded sheet (20-30 cm wide) under the knees, and slide it up and under the pelvis. Ensure that the top of the sheet is level with the iliac crest.
3. Cross the ends of the sheet on the anterior side of the pelvis and apply gentle tension with the beginning of a granny’s knot. Synchronize the movements of each side of the sheet to ensure even pressure is applied. Avoid any movement of the patient.
4. Secure the binding with a granny’s knots to prevent loss of tension.
5. Carefully tuck any loose ends of the sheet away so they will not interfere with the transporting of the patient.
6. Reassess sensation and distal circulation in the lower extremities to ensure that they have not been affected.
7. Reassess the binding periodically to ensure the tension is maintained.

During pelvic binding, patient safety is paramount. Pelvic binding needs to be performed early in the course of the treatment. Once the binding is applied, it should not be removed until the patient reaches the hospital. Gentle application is recommended because manipulation and movement of an injured pelvis can cause severe damage. A scoop or clamshell stretcher is ideal. A logroll should not be used if there is a suspected pelvic injury.

Genital Injuries

Genital injuries are soft tissue injuries and may be either closed wounds or open wounds. Due to the large number vascular structures, genital wounds often hemorrhage. Care for injuries to the genitals is the same as care for any other soft tissue injuries.

Injuries to the genital area can be embarrassing for the patient. Act in a confident and professional manner, and briefly explain the interventions you intend to provide to the patient before proceeding. Attempt to maintain the patient’s privacy as much as possible while providing care.