High-concentration oxygen by nonrebreather mask, consideration of needle decompression for tension pneumothorax, preparation for endotracheal intubation if breathing becomes inadequate.

When arriving at the scene of a shooting or stabbing, your first priority is:

Your safety.

The appearance of the entrance wound caused by a bullet:

May indicate signs of subcutaneous emphysema if the shot was fired at very close range.

When caring for a patient with a penetrating injury to the abdomen, keep in mind that:

The bowel is very tolerant of compression and stretching.

Ballistics

The study of the characteristics of projectiles in motion and their effects on objects they strike

Profile

Size and shape of a projectile as it contacts a target; it is the energy exchange surface of the contact

Factors in energy dissipation

Drag, cavitation, profile, stability, expansion, shape

Due to cavitation; depends on amount of energy transferred: space created behind the high-energy bullet as tissue move rapidly away from the bullets path

Temporary cavity

Are that extends beyond the area of permanent injury; slow to heal, disrupted blood flow and infection

Zone of injury

In penetrating neck wounds, air can enter into the external jugular vein resulting in what

Pulmonary emboli

For scene assessment

Ensure police secured the scene before entering, look to make there is no weapons within reach of the PT, preserve crime scenes as much as possible

Medium-energy/ medium velocity weapons

Handguns, shotguns, low powered rifles (bullets, slugs, pellets) Handgun bullets - smaller and much slower (250 - 400 mps)

What is the most commonly injured organ in cases of blunt trauma?

Spleen

When spleen is damaged it will

Bleed profusely so frequently results in shock and life threat, blood accumulates under diaphragm so pain can be referred to left shoulder pain

When pancreas is injured where is pain often located?

Upper abdo that radiates to back

When kidney is injured where is pain often located?

Radiates from flank to groin and hematuria(blood in urine)

When liver is injured where is pain often located?

Right shoulder

What are the hollow organs in body?

Stomach, gall bladder, large/small intestines, ureters/urinary bladder

What is important to consider when hollow organs rupture?

Content spillage which causes inflammation of peritoneum

When stomach is injured what happens?

Immediate peritonitis, pain, tenderness, guarding, rigidity

When colon is injured what is to be considered?

Spillage of bacteria, may take 6 hrs to develop peritonitis

When small bowel is injured what is to be considered?

Fewer bacteria, may take 24-48 hrs to develop peritonitis, a gradual onset of diffuse pain when bacterial

What are the % for penetrating trauma ?

Liver 40%, small bowel 25% large bowel 10%

What organs are most often affected by blunt trauma?

#1 spleen, and liver

Injury to abdominal wall may lead to

Evisceration (spilling of abdominal contents)

What is the major concern when hollow organs rupture

Spillage of contents into - retroperitoneal space - peritoneal space- pelvic space

If there is a leakage from large intestines

There is a large amount of bacteria with can result in sepsis

Manifestations of blood loss

Hematochezia, hematemesis, hematuria

Blood in stool

Blood in emesis

Blood in urine

Spleen, pancreas, kidney, liver

Solid organs are prone to?

Contusion, profuse bleeding which will cause abdo distention, fracture, unrestricted hemorrhage if organ is ruptured

Injury to vascular structures

Blood accumulates beneath diaphragm causing : irritation of muscular structures, pain referred to shoulder region, greater volume of blood can be lost, presence of blood in abdo may stimulate vagus nerve resulting in slowing of HR

When this is a disruption to blood vessels supplying bowel:

It can lead to ischemia, necrosis, or rupture

When the peritoneum is injured where is pain often located and what happens?

Slight tenderness @ location of injury, rebound tenderness (associated w/peritonitis ), guarding, rigid, board like feel

If your PT has eviscerated intestines what steps should you follow

Make no attempt to replace them back into abdo, cover the eviscerated intestines with moist, sterile large,bulky dressings and if possible seal with a sterile occlusive dressing and transport

The blunt trauma injury in the abdomen due to one part of an organ being free to move and the other part being restricted to movement are through:

Shear impact

Tears in the diaphragm may cause compromise during respiration and also:

Force parts of the liver into the thoracic cavity

Patients with renal injuries may have pain in the:

Back

The ligamentum teres restrains the:

Liver from forward motion.

The mesentery provides the bowel with circulation, attachment, and

Innervation

Penetrating trauma to the lateral abdomen is likely to injure the

Large bladder

To help protect the mother from hypovolemia in the third trimester, the maternal vascular volume can increase by up to:

45 percent

In anticipation of shock due to a serious mechanism of injury, start a large bore IV line with normal saline to be prepared to deliver a bolus of:

20 cc per kilogram.

Volvulus

Twisting of intestine on itself

Presentation of Hepatitis

URQ abdominal tenderness May radiate into right shoulder Loss of appetite, weight loss, malaise Clay-colored stool, jaundice, scleral icterus Photophobia, nausea/vomiting May appear jaundiced May have fever due to infection or tissue necrosis May reveal liver enlargement

HEV

Hepatitis E; Waterborne infections, Epidemic in Africa, Mexico and other less-developed nations

HDV

Hepatitis D; less common Pathogen is dormant until activated by HBV

HCV

Hepatitis C; Pathogen most commonly responsible for spreading hepatitis through blood transfusions Marked by chronic and often debilitating damage to the liver

HAV

Hepatitis A; Most common, Infectious hepatitis, Spread by oral-fecal contamination, Self limiting, lasting ~2-8 weeks, Rarely causes severe hepatic injury and thus has a low mortality

HBV

Hepatitis B; Serum hepatitis, Blood borne pathogen, Can stay active in body fluids outside the body for days, ~310 million carriers worldwide, Effects may be minimal but can also range to severe liver ischemia and necrosis

Hepatitis

Injury to hepatocytes associated with infection of inflammation

Cholecystitis

Inflammation of the gallbladder

What most often causes Appendicitis

Obstruction of the appendiceal lumen by fecal material.

Tx for Appendicitis

Recognition and supportive care, Hemodynamically stable as long as appendix hasn’t ruptured Follow general management guidelines

S&S - Frequently misdiagnosed due to wide variety of presentations Early Diffuse colicky pain with nausea and vomiting, Tenderness and guarding, Often localized to periumbilical region As the appendix continues to dilate, Pain migrates to McBurney’s point, Rebound tenderness

Appendicitis

Inflammation of the vermiform appendix at the juncture of the large and small intestines

S&S of Hiatus hernia

Burning sensation like heart burn, sharp easily localized pain

Hiatus Hernia

When the esophageal spincter allows the top of the stomach to herniate through the diaphragm into the esophagus

Adhesion

Union of normally separate tissue surfaces by a fibrous band of new tissue

Intussusception

Condition that occurs when part of the intestine slips into the part just distal to itself

What is the most dangerous hernia

Strangulate hernia

Hernia

Protrusion of an organ through its protective sheath

What causes hemorrhoids

Idiopathic, from pregnancy, or external may result from heavy lifting

What are common causes of Bowel obstruction

Hernia – intestine has pushed through muscle wall • most dangerous is strangulate hernia Intussusception Adhesion Volvulus  Chronic as in tumour growth or adhesion or

Tx for Bowel Obstruction

BOMB Fluid resuscitation

S&S - Diffuse poorly-localized pain –palpation will reveal tenderness, Decreased appetite, Fever, malaise, N/V, wt loss, Peritonitis if ruptures, Maybe shock, May vomit feces if long standing, Maybe distention, Look for surgery scars and ecchymosis

Bowel Obstruction

Blockage of the hollow space within the intestines; Can be catastrophic if not rapidly diagnosed and treated. - The most dangerous result is sepsis.

What does this Presentation -Limited bright red bleeding and painful stools. -Consider lower GI bleeding.

Hemorrhoids

Small masses of swollen veins that occur in the anus or rectum

S&S > Pts will complain of localized lower left sided colicky pain (95% of offending diverticula are in the sigmoid colon) - Often called left sided appendicitis - Low grade fever- N/V- Tenderness on palpation -Sx of shock (CPC, tachy) - Bright red and bloody feces (hematochezia)- c/o perception they cannot empty their rectum even after defecation

Diverticulitis

Most common cause of lower GI bleeding

Diverticulosis

Presence of diverticula, with or without associated bleeding

Diverticulitis

Inflammation of the diverticulosis : secondary to infection - Small outpockets that push through the outermost mucosal and submucosal lining (muscle) secondary to infection, Bleeding or infection

Tx for Crohn's

BOMB, Airway management,Transport to hospital, Usually hemo stable so Tx is usually pallative

S&S > GI bleeding, Recent weight loss, Intermittent abdominal cramping/pain, N/V, Diarrhea, Fever, Flare ups are rapid with severe acute onset of abdo pain, Difficult to differentiate as pain is nonspecific with diffuse tenderness

Crohn's Disease

Idiopathic inflammatory bowel disorder associated with the small intestine

When can you administer gravol

If your PT has N/V >25 and unaltered Has no allergy or sensitivity to dimenhydrinnate or other antihistamines did not overdose on antihistamines or anticholinergics or tricycilic antidepressants

Structures of the lower GI tract

Jejunum, ileum, large intestine, rectum, anus

Functions of lower GI tract

Absorbing nutrients, reabsorption of water, formation of wastes

With severe peritoneal irritation how with PT usually be positioned

Will be lying as still as possible usually in the fetal position

Where does upper GI tract bleeds occur

Proximal to the ligament of Treitz

S&S > Vary widely, PT may be asymptomatic or may have wide range of abdo complaints including hematemesis.

Gastritis

General complaints of Upper GI bleed

Malaise, weakness, syncopal and near syncopal, tachycardia, indigestion

Referred pain

Pain originates in a region other than where it is felt

Conditions that cause upper GI bleeding

Peptic ulcer disease, Gastritis, Esophageal varicies, Mallory-Weiss tear, Esophagitis, Doudenitis