Page 76 - 2021 Advanced Ranger First Responder Handbook

Abdominal Trauma
Penetrating abdominal injuries are characterized by a violation of the peritoneal or retroperitoneal spaces by any variety
of low- to high-velocity objects. Injuries represent a spectrum that includes impalement with foreign objects, stab,
gunshot, and fragment wounds. Tissues are crushed and torn by the penetrating missile or they are injured indirectly
by stretching and cavitation. Multiple abdominal organs are commonly damaged as a result of penetrating trauma. The
management of abdominal trauma in the field centers on adequate resuscitation, pain control, and intravenous antibiot-
ics with the goal of evacuating the patient to a location where surgical care is available. Wound care and other supportive
measures should also be given.

Initial Assessment & Management
Visible evidence of abdominal trauma may not always be immediately present (especially when associated with blunt
mechanisms of injury). Abdominal pain is not always a reliable indicator of abdominal injury as it may be mimicked by
fractures of the ribs and pelvis, or not be readily evident because of decreased mental status from associated head
or spinal cord injury. Furthermore, severe pain from other injures such as extremity fractures may mask the patient’s
perception of pain in the abdominal area.
Inspect for: Entrance and exit wounds, contusions and abrasions, distention, protruding bowel or omentum, gastro-
intestinal hemorrhage (bloody emesis or rectal bleeding), hematuria, signs of shock.
Palpation: Palpation of the abdomen can reveal tenderness, guarding, and rigidity. Assess all abdominal quadrants for
tenderness. If an obvious evisceration is present, palpation should be deferred. Involuntary guarding is a reliable sign of
peritoneal irritation. Pelvic stability should be assessed especially when blunt trauma is the mechanism of injury. A pelvis
determined to be unstable should not be subjected to repeated manipulation to test for stability.
Control any visible hemorrhage from bowel using approved hemostatic agent or gauze. Irrigate gross debris off of
exposed bowel. Attempt to gently reduce bowel back into abdominal cavity. If bowel is reduced, approximate
skin (sutures or staples) and cover abdominal wound with dressing. If bowel is unable to be reduced, cover bowel
with moist dressing. If uncontrolled abdominal hemorrhage is suspected, immediately begin resuscitation with whole
blood or blood products in a 1:1 ratio. Resuscitation efforts should be directed at maintaining cerebral perfusion as
indicated by patient’s mental status if there is no associated head injury. If there is no associated head injury, a systolic
blood pressure of 90–100mmHg is adequate and will prevent rebleeding from over resuscitation. The patient who is
hemodynamically unstable and requires ongoing large volume resuscitation is probably bleeding from an intraabdominal
or intrathoracic source.
Extended Care
Eviscerated bowel and omentum should be covered with a bandage moistened with saline or Ringer’s lactate solution.
Drinking water may be used if sterile fluids are not available. The wound should be reassessed and remoistened every
1–2 hours. Clamps for hemorrhage control should be applied only to easily seen bleeding vessels. Do not attempt to
pull out more bowel or omentum.
Worsening pain, or worsening signs of shock indicate deterioration and should accelerate efforts to evacuate the patient
to a location where surgical care is available. Antibiotic therapy should be initiated as soon as a penetrating injury is
suspected. Administer ertapenem 1g IV.

MISC

66 SECTION 7 MISCELLANEOUS PROTOCOLS