Abdominal and Pelvic Trauma Flashcards

A patient involved in a high-speed motor vehicle collision is found to have an unstable pelvis on assessment. The patient is tachycardic and hypotensive. Which intervention is the highest priority for managing life-threatening hemorrhage from this injury?

Answer: Application of a pelvic binder or circumferential sheet.

An unstable pelvic fracture can disrupt the pelvic ring, dramatically increasing its volume and leading to massive, life-threatening hemorrhage from venous plexuses and arteries. The most critical immediate intervention is to apply a pelvic binder or sheet circumferentially at the level of the greater trochanters to 'close the book,' which reduces the pelvic volume, stabilizes fracture ends, and promotes tamponade of the bleeding. [26, 28, 30]

A patient with blunt abdominal trauma complains of acute pain in the tip of their left shoulder. This finding, known as Kehr's sign, is most commonly associated with irritation of which structure?

Answer: The diaphragm

Kehr's sign is referred pain to the left shoulder caused by irritation of the diaphragm from blood in the peritoneal cavity. [5, 7, 8] This is a classic sign of a splenic rupture, as the spleen lies just inferior to the diaphragm in the left upper quadrant. [6, 12] The phrenic nerve, which innervates the diaphragm, shares the same nerve roots (C3-C5) as the nerves that provide sensation to the shoulder. [8]

You are treating a patient with a stab wound to the abdomen resulting in an evisceration of the small intestine. What is the most appropriate prehospital management for the exposed organ?

Answer: Cover the intestine with a moist, sterile dressing, then an occlusive dressing.

The proper management for an abdominal evisceration is to cover the exposed organs with a saline-moistened sterile dressing to prevent the tissue from drying out. [17, 18, 22] This should then be covered with an occlusive dressing to minimize heat and fluid loss. Organs should never be pushed back into the abdomen in the field, and dry dressings can adhere to the tissue and cause damage. [22, 24]

Which of the following physical exam findings is the strongest contraindication to inserting a urinary catheter in a male trauma patient with a suspected pelvic fracture?

Answer: Blood at the urethral meatus.

Blood at the urethral meatus is a cardinal sign of urethral injury. [1, 4, 10] Attempting to insert a catheter in this situation can convert a partial urethral tear into a complete transection, causing significant further damage. Other signs include a scrotal hematoma or a high-riding prostate. [4, 9]

A 17-year-old bicyclist struck a fixed post, impacting his left upper abdomen and flank on the handlebar. He is pale and tachycardic with a BP of 88/58 mmHg. Based on the mechanism and location of injury, which organ is most likely the source of his hypovolemia?

Answer: Spleen

The spleen is a highly vascular, solid organ located in the left upper quadrant (LUQ) of the abdomen. [15, 16] It is the most commonly injured organ in blunt abdominal trauma. [19] A direct blow to the LUQ, such as from a handlebar, is a classic mechanism for splenic injury, which can lead to rapid and severe internal hemorrhage. [16, 21]

When performing a secondary survey on a conscious patient with a painful, deformed femur fracture following a fall, what is the most significant limitation of the abdominal physical exam?

Answer: The presence of a painful distracting injury can make abdominal findings unreliable.

A severe, painful injury, such as a femur fracture, is considered a 'distracting injury.' It can mask the pain and tenderness associated with a concurrent abdominal injury because the patient's perception of pain is focused on the more obvious injury. [11] This can lead to a falsely reassuring abdominal exam. Therefore, a high index of suspicion based on the mechanism of injury is crucial, even with a seemingly benign abdominal exam.