The phrenic nerve, which innervates the diaphragm, passes through the thorax along the posterolateral aspect of the pericardium on both sides and divides into anterior and posterior branches. The aorta passes through the diaphragm at the T12 level, the esophagus passes through at the T10 level, and the vena cava foramen is at T8. The diaphragm is a musculotendinous, dome-shaped structure attached posteriorly to the first, second, and third lumbar vertebrae anteriorly to the lower sternum and laterally to the costal margins dividing the thoracic and abdominal regions. The diaphragm also separates the thoracic and abdominal cavities, preventing herniation of organs. 5 This process is aided by the accessory intercostal muscles. 5 During expiration the diaphragm relaxes, returning to its original dome shape and reducing thoracic volume. Flattening and contraction of the diaphragm lengthen the thoracic cavity, increasing thoracic volume during inspiration. The diaphragm assists with inspiration and expiration by changing the thoracic volume during respiration. The esophageal wall lacks a serosal layer, which may affect the integrity of anastomoses, increasing the chance for leaking after surgical repair. There are three areas of narrowing that predispose the esophagus to injury: at the cricoid cartilage, at the arch of the aorta, and as it passes through the diaphragm. The anterior and posterior vagus nerves pass through the esophageal hiatus. The posterior surface of the intra-abdominal esophagus overlies the aorta, and the anterior surface is covered by peritoneum. The esophagus traverses the posterior mediastinum of the thorax through the esophageal hiatus in the central tendon of the diaphragm to join the stomach at the level of the tenth thoracic vertebra. Mucosal glands of the esophagus secrete mucus to lubricate and facilitate passage of the food bolus. The presence of food within the esophagus stimulates peristaltic action and causes food to move into the stomach. The esophagus, the first segment of the digestive process, carries food from the pharynx to the stomach.
BLUNT INJURY TO THE HEPATIC FLEXTURE SERIAL
Knowledge of the mechanism of injury, patient complaints, serial physical assessments, and timely diagnostic test results are the nurse’s resources for identifying potentially life-threatening abdominal injuries. 3 An organized, methodical approach to assessment, diagnosis, and intervention is necessary for the management of suspected abdominal injury. Unrecognized abdominal trauma is a frequent cause of preventable death. Frequent assessments and continual monitoring are essential components of the nursing process for detection of changes in the patient’s condition. The manifestations of abdominal injury are often subtle, requiring continual assessment and care modification as the patient progresses from the initial assessment to the critical care phase. The presence of abdominal tenderness or guarding, circulatory instability, lumbar spine injury, pelvic fracture, retroperitoneal or intraperitoneal air, or unilateral loss of the psoas shadow on radiographic examination should raise the question of visceral damage.Ībdominal trauma challenges even the most experienced nurse.
BLUNT INJURY TO THE HEPATIC FLEXTURE SERIES
Multiple organ involvement, with or without central nervous system depression, can present a complex series of symptoms that cloud normal assessment parameters, making definitive diagnosis more difficult. The diagnosis of blunt abdominal injury can be complex and challenging, especially in patients with multisystem injury. The most common mechanism of blunt injury is a motor vehicle crash.
There are two injury mechanisms for abdominal trauma: blunt and penetrating. Intra-abdominal trauma is seldom a single organ injury or single system injury therefore, a concomitant rise in morbidity and mortality rates is evident. 2 Death and disability from traumatic injury have become a significant health and social problem. 1 Abdominal injuries rank third among the causes of traumatic death, preceded only by head and chest injuries.
1 It is the leading cause of death for individuals between the ages of 1 and 44 years. Trauma is the fourth leading cause of death for all age groups in the United States.
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