Perform abdominal assessment, or risk missing life-threatening trauma injury

Don’t allow invisible’ injuries to escape detection in your ED

When a trauma patient comes to your ED, are head and extremity injuries the first thing on your radar screen? "Nurses often look for obvious trauma and forget to assess the abdomen — sort of like the saying out of sight, out of mind,’" says Kelly Arashin, RN, CEN, night charge nurse and trauma coordinator for the ED at Hilton Head (SC) Regional Medical Center. "To rule out injuries, don’t forget what’s going on inside."

Abdominal injury is a leading cause of death for adult and pediatric trauma victims, according to a new clinical policy from the Dallas-based American College of Emergency Physicians.1

"A leading cause of preventable trauma deaths is abdominal trauma, which is why a timely and accurate assessment is so important, particularly in the face of multiple injuries," says Tim Murphy, RN, MSN, APN,C, nursing director of the trauma program at Robert Wood Johnson University Hospital in New Brunswick, NJ.

Assessing trauma patients from head to toe, including the abdomen, will give you potentially life-saving baseline information, underscores Arashin. "What if the patient has a soft belly when he first arrives, then starts complaining of pain an hour later, and now he has a board-like abdomen and no bowel sounds — or vice versa?" she asks. To assess abdominal trauma, do the following:

1. Assess for bowel sounds and rigidity. These could indicate bleeding into the abdomen from vital organs, or intestinal injuries, says Arashin.

2. Look for abrasions or contusions. "If there are contusions, you have to rule out any internal injuries, such as ruptured organs or bleeding from the liver or spleen," she says.

3. Place a Foley catheter to assess for bleeding. Blood in urine from a catheter specimen can indicate kidney or bladder injury, Arashin advises.

4. Check for occult blood in stool. Blood in stool may indicate intestinal and colon injuries from lower abdominal trauma, such as from use of a lap belt, she says.

To improve care of abdominal trauma patients, use the following current recommendations for diagnostic tests:

• Focused abdominal sonograph for trauma (FAST).

The FAST is a noninvasive procedure and can be done at the patient’s bedside within minutes, says Steve Rasmussen, RN, of Virginia Commonwealth University Medical Center in Richmond. The ED uses a Hitachi EUB-525 ultrasound system, manufactured by Twinsburg, OH-based Hitachi Medical Systems.

"It’s portable, and there is relatively little training needed when compared to reading [computed tomography] scans," he says. The test is used to determine whether patients can be observed in the ED, admitted, or transported to a larger facility, he explains. Here are the steps that occur at Virginia Commonwealth:

  • If the FAST is negative, the patient is observed in the ED or admitted with serial exams to ensure the patient remains asymptomatic. An elective CT may be ordered.
  • If the FAST is positive and the patient is stable, he/she goes to CT.

    "The CT will demonstrate damage to solid organs, presence of fluid, and damage to surrounding bony structure," says Rasmussen.

  • If the FAST is positive and the patient is unstable, the patient usually goes to the OR for an angiogram. Whether the patient goes to the OR depends on the amount of fluid and the solid organ involved, says Rasmussen. For example, a liver injury would require OR intervention, unless the laceration was a grade 4 or 5, in which case an angiogram would be obtained for possible cauterization of the bleed, he explains.

However, FAST shows only the presence of fluid, without differentiating the type of fluid, says Rasmussen. "This could mean blood or free fluid such as ascites, urine from a ruptured bladder, or fluid in the pelvis of a female patient during her cycle," he notes.

FAST can help evaluate the trauma patient for fluid around the pericardium, around the liver or spleen, and the urinary bladder, says Murphy.

At Akron (OH) General Medical Center, a FAST scan of the abdomen is done within five minutes of the patient’s arrival with a SonoSite ultrasound machine (manufactured by Bothell, WA-based SonoSite), says Bill Woods, RN, BSN, an ED nurse at the facility.

"This gives a very quick and accurate look at the abdomen for any gross amount of intra-abdominal bleeding," he reports. "If positive, a diagnostic peritoneal lavage may be performed, or the trauma surgeon may choose to go directly to the OR for exploratory surgery."

ED nurses ensure that the equipment is ready to go the instant the patient arrives, says Woods. This includes making sure the machine is properly charged, checking the paper to make sure it is full for printed images, checking that ultrasound gel is filled and with the machine, and possibly turning the lights off for improved visibility, says Woods. "We also use the SonoSite in a full arrest situation to check for cardiac activity, as even heart valve movement can be visualized at times," he says.

• Diagnostic peritoneal lavage (DPL).

"DPL is the old gold standard, but the FAST is now becoming the new gold standard for rapid assessment of intra-abdominal bleeding," says Rasmussen.

Robert Wood Johnson University Hospital uses DPL much less often than in the past, reports Murphy. "While it will show that there is bleeding in the peritoneum, it is nonspecific in the sense that it does not tell you what is bleeding," he says.

However, DPL still may be a useful exam in the hemodynamically unstable patient, Murphy adds.

• Abdominal CT scan.

Currently, abdominal CT is the "gold standard" diagnostic test for hemodynamically stable trauma patients at risk for blunt abdominal trauma, says Murphy.

Unlike the FAST scan, a CT scan requires oral and injectable contrast, notes Rasmussen. "If you have a patient with a kidney injury, it can further complicate your situation," he explains. "Injectable contrast can be toxic to renal patients, but contrast is still given, since the renal artery is generally where the injury occurs." Also, CT is a poor indicator of diaphragmatic injuries, and these may be missed, he says.

With the new scanners, a quick, high-resolution image can be obtained to assess injury severity, says Murphy. Recently, he treated a 30-year-old male unrestrained driver after a motor vehicle collision. The man sustained multiple injuries of the chest and abdomen, including a flail chest, splenic laceration, and liver injury.

The use of abdominal CT allowed the patient, who was hemodynamically stable, to be treated without surgery, says Murphy. "The patient was managed on a ventilator for the flail chest for several days, but an abdominal operation was avoided and probably led to a reduced length of stay," he says.

The patient was subsequently discharged to a rehabilitation facility and has had a good outcome, reports Murphy. "Since a DPL and FAST exam are nonspecific, they would have most likely been positive and led to an operation," says Murphy. "Since we were able to assess the severity of internal injury, the decision could be made to treat the patient nonoperatively."

The CT scan provides a high-resolution image that allows you to noninvasively determine what organs are injured and assess the severity with a reasonable amount of reliability, notes Murphy. "The other tests will tell us that there is a problem in the peritoneum, but not where or how bad,’ he explains. "They also don’t tell us anything about the retroperitoneum."

Only the CT scan is useful in detecting a retroperitoneal injury, says Murphy. "Both the FAST and the DPL could lead to a missed diagnosis," he adds.

Reference

1. American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med 2004; 43:278-290.

Sources

For more information about improving care of abdominal trauma patients, contact:

  • Kelly Arashin, RN, CEN, Trauma Coordinator, Hilton Head Regional Medical Center, 25 Hospital Center Blvd., Hilton Head Island, SC 29926. Telephone: (843) 689-6122, ext. 8281. E-mail: KelRN24@aol.com.
  • Tim Murphy, RN, MSN, APN,C, Nursing Director, Trauma Program, Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, New Brunswick, NJ 08903-2601. Telephone: (732) 418-8095. Fax: (732) 418-8097. E-mail: Timothy.Murphy@rwjuh.edu.
  • Steve Rasmussen, RN, CEN, Clinical Coordinator, Emergency Department, Virginia Commonwealth University Medical Center, 1250 E. Marshall St., Richmond, VA 23298. Telephone: (804) 828-7330. E-mail: srasmussen@mcvh-vcu.edu.
  • Bill Woods, RN, BSN, Emergency Department, Akron General Medical Center, 400 Wabash Ave., Akron, OH 44310. Telephone: (330) 344-6611. E-mail: austin121102@msn.com.