Page 665 - ACCCN's Critical Care Nursing

642 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

may be performed on a patient with unexplained persis- appropriate treatment to control haemorrhage and repair
tent signs of shock (hypotension ± tachycardia); where organ injury (laparotomy). When this procedure is con-
the abdominal clinical examination and FAST is incon- sidered appropriate, rapid transit to the operating room
clusive; where there is a high index of suspicion of should be undertaken. As the consequences of missed or
intraabdominal injury; or alternative diagnostic evalua- delayed diagnosis of abdominal injury can be catastrophic
tion such as CT is unavailable. Disadvantages of the DPL for the patient, opening the peritoneal cavity to exclude
include the high level of invasiveness and associated injury in selected cases is a necessity.
complications, its inability to detect retroperitoneal inju-
ries, the high rate of non-therapeutic laparotomies and its
low specificity or high number of false-positive results. 22 Collaborative practice: embolisation
Interventional radiology is a treatment option in the
Prior to DPL, time permitting, the bladder should be
decompressed with an indwelling urinary catheter and management of abdominal trauma. Via an arterial
the stomach decompressed with an enterogastric tube. approach, the interventional radiologist can insert can-
The DPL procedure involves an incision below the umbi- nulae to identify arterial blushes (bleeders). Once identi-
licus, then a catheter passed into the peritoneal cavity and fied, the vessel can be ligated via mechanical coiling
aspirated to determine peritoneal contents. Differing or blocked chemically. Embolisation has been shown
results in terms of colour and volume indicate different to be effective and safe for a wide range of patients in
potential injuries. When blood, red blood cells, white the setting of splenic trauma, renal trauma and pelvic
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blood cells, bacteria, faecal matter, bile or food particles trauma. The patient undergoing embolisation as a treat-
are aspirated, the peritoneal lavage is considered to be ment option for the control of haemorrhage requires
positive. 22 meticulous monitoring and an ability to respond imme-
diately to hypovolaemic shock should the bleeding
Collaborative practice: abdominal worsen.
computed tomography
Abdominal computed tomography (CT) is recognised as Collaborative practice: management of
having high sensitivity and specificity in the setting of the patient with an open abdomen
abdominal trauma and is therefore accepted as a diagnos-
tic mainstay in this group of patients, particularly for In cases of severe abdominal trauma, the abdominal
blunt trauma. The main exception to this is where the trauma patient may be returned to the ICU with an open
results of a FAST examination are positive and the patient abdomen, or laparostomy, covered with a temporary
is taken to surgery urgently. Abdominal CT is used less wound-closure system. There are various types of open
often in patients with penetrating trauma, primarily due abdominal dressings, but the principal aim of the dress-
to its lower sensitivity in diagnosing the hollow visceral ing is to provide a coverage for the contents of the peri-
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injuries common in penetrating trauma. An important toneum if these are too swollen to fit beneath the closed
pitfall for CT imaging in abdominal trauma occurs when skin or where there is a need for repeated opening of the
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the patient has arrived at the scanner so quickly after the abdomen. Ultimately, the aim is to close the skin as
injury that major blood loss is not apparent and the soon as possible, when the patient’s physiological status
extent of the injury is missed or underevaluated. A high normalises. It is possible for these abdominal dressings
index of suspicion in the setting of a negative CT and to cause a secondary ACS if they are too restrictive.
extensive abdominal trauma should remain, particularly The primary aims of managing a patient with an open
if signs of shock develop. abdomen include minimising complications of pro-
Debate currently exists as to the role of oral contrast in longed immobility, observing for signs of ongoing ACS,
the trauma patient who must remain supine and immo- restoring the patient’s physiology to normal and support-
bilised in a cervical collar. It is essential that nursing ing the patient and family through a psychologically-
assessment for the risk of aspiration be conducted, and distressing time. Understandably, both the patient and
to be prepared to manage the vomiting patient. Any their family can be distressed by the appearance of an
supine patient given radiographic contrast should not be open abdomen. There are no specific position restrictions
left unattended, and there should be sufficient staff avail- for a patient with an open abdomen, but haemodynamic
able at short notice to roll the patient onto their side if status is often labile so that care must be taken with side-
he/she vomits. The healthcare team should discuss the lying and hygiene care.
risk of vomiting prior to ordering the test so that an
informed decision can be made regarding the risk–benefit
ratio on an individual case basis. Oral contrast has been Specific Abdominal Injuries: Spleen
demonstrated to be highly effective in revealing hollow The spleen is the solid organ most commonly injured in
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viscus injury, and therefore has a place in the diagnostic blunt trauma. Its location (under the ribs) also makes
evaluation of abdominal trauma. it vulnerable to secondary injury from fractured ribs.
Splenic injury should always be suspected in those
Collaborative practice: laparotomy/laparoscopy patients who have sustained a direct blow to the abdomen,
The role of diagnostic operations such as laparotomy/ as it is a large organ. Signs of splenic injury are generally
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laparoscopy is well described in the literature, and is pain over the left upper quadrant. There may be no
essential to aid diagnosis (laparoscopy) and provide changes to vital sign parameters until the patient has