Abdominal trauma with haemodynamic instability and peritoneal signs

Patient Information

Dispatch: You are called to the first aid post at Optus Stadium during an AFL match. A 33-year-old female was struck by a metal barrier that fell from the terracing and is now complaining of severe abdominal pain. (Sarah Kowalski)
Patient: Sarah Kowalski — 33yr (65kg)
Incident History: Pt was standing near the terracing when a loose metal crowd-control barrier tipped and struck her across the lower abdomen. Bystanders assisted her to the FAP. She is pale, sweaty, and says the pain is getting worse.
Emergency Contact: Tom Kowalski (Husband) — 0412 774 391

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil obstructions. Nil stridor. Patient speaking in short sentences.
Breathing: Shallow and rapid. Increased respiratory rate. Nil audible wheeze or crackles. Patient splinting abdomen with arms.
Circulation: Radial pulse rapid and weak. Skin pale, cool and diaphoretic. No visible external haemorrhage. Abdomen tender on inspection.
Disability: GCS 14 (E4V4M6). Alert but anxious. Oriented to person and place; slightly confused about time.
Exposure: Visible bruising and abrasion across lower and mid abdomen. Abdomen rigid on gentle palpation. Marked guarding across all four quadrants. Right shoulder tip pain reported. Nil visible penetrating injury. Nil distension noted at this stage.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Moderate	24	118	88/60	3s	14	4 4 ++	36.9	6.4 mmol/L	9
10 mins	98% (O2 NRB 15L)	Moderate	26	128	80/50	4s	13	4 4 ++	36.9	6.4 mmol/L	9

History Taking

Treatment Response

Diagnosis

This patient is suffering from significant blunt abdominal trauma with haemodynamic instability secondary to suspected internal haemorrhage, and developing peritonitis indicated by guarding, rigidity, and Kehr's sign (right shoulder tip pain from diaphragmatic irritation).

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not note the right shoulder tip pain or fail to recognise Kehr's sign: patient volunteers 'my right shoulder is killing me too — is that weird?' prompting reassessment of abdominal injury significance.)
! (If oxygen is not applied within 3 minutes of assessment: SpO2 drops to 93% on room air, respiratory rate increases to 28, patient becomes more anxious and restless.)
! (If trainees do not recognise haemodynamic instability — low BP 88/60, HR 118, CRT 3s, pale/diaphoretic — and fail to treat as time critical or call CSP for urgent ambulance support within 5 minutes: patient's GCS drops to 12 (E3V3M6), BP falls to 78/50, HR rises to 134, patient becomes increasingly confused.)
! (If trainees attempt to palpate the abdomen forcefully or repeatedly: patient cries out in pain, becomes distressed, and attempts to pull away — reinforce that gentle single palpation of four quadrants is sufficient and repeated examination increases patient distress.)
! (If trainees fail to recognise guarding and rigidity as signs of peritoneal irritation and do not flag this as a time-critical finding: facilitator prompts — 'What does the rigidity of the abdomen tell you about what may be happening internally?')
! (If trainees attempt to remove or cover the abdominal bruising area without first exposing and fully assessing all four quadrants: facilitator prompts — 'Have you completed your full exposure and secondary survey of the abdomen?')
! (If trainees do not minimise on-scene time and attempt lengthy procedures before transport: facilitator states — 'It has now been 8 minutes on scene. What is your priority here?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE on approach.
2 Perform Primary Survey with c-spine consideration — mechanism involves significant blunt force but patient is ambulant; apply clinical judgement regarding spinal precautions given abdominal injury presentation.
3 Recognise haemodynamic instability: BP 88/60, HR 118, CRT 3s, pale/cool/diaphoretic skin — identify this patient as time critical.
4 Immediately call CSP for urgent ambulance support and provide patient details, mechanism, and clinical findings to CSP — minimise on-scene time.
5 Manage airway: confirm patent airway, patient maintaining own airway; reassess continuously.
6 Administer oxygen via non-rebreather mask at 15 litres per minute — titrate to target SpO2 94–98%. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
7 Perform gentle palpation of all four quadrants of the abdomen — identify tenderness, guarding and rigidity; do NOT repeat palpation unnecessarily.
8 Recognise right shoulder tip pain as Kehr's sign — indicative of diaphragmatic irritation from intra-abdominal pathology (e.g. splenic or hepatic injury with blood tracking to diaphragm).
9 Do NOT apply direct pressure to the abdomen — this will worsen peritoneal irritation and patient distress.
10 Position patient supine or in position of greatest comfort; avoid unnecessary movement.
11 Perform vital sign survey: BP, HR, RR, SpO2, GCS, CRT, temperature — document all findings.
12 Perform Secondary/CNS Survey — assess for any additional injuries (chest, pelvis, long bones) given significant mechanism.
13 Do NOT administer oral fluids or anything by mouth — surgical intervention is likely.
14 Monitor persistently: record full observations every 5 minutes given time-critical status — note any deterioration in GCS, BP, or HR.
15 Reassess airway and breathing continuously — if patient deteriorates to GCS ≤8 or stops protecting airway, prepare to assist ventilations with BVM.
16 Provide continuous reassurance to patient — explain all interventions, keep patient calm and warm.
17 Handover to ambulance crew using IMISTAMBO: Identity, Mechanism, Injuries found, Signs and vitals, Treatment given, Allergies, Medications, Background history, Other relevant information.
18 Scenario ends on arrival of ambulance and IMISTAMBO handover.
19 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Abdominal Trauma · Haemorrhage · Hypovolemic Shock · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Trauma Management Principles

How did you go?