Page 128 - Journal of Special Operations Medicine - Winter 2016

ampicillin with ertapenem if the patient further de- considered, and only with expert consultation from
compensated. On hospital day 3, coordination with an a surgeon. “Watchful waiting” (i.e., patiently moni-
NGO facilitated patient transfer to a healthcare facil- toring the patient without procedural intervention) is
ity with surgical capability. Upon last report, the patient an acceptable approach until or unless a patient de-
was doing well after emergent thoracotomy for hemo- velops signs of peritonitis on physical examination.
thorax and was later discharged home. These include rigid abdomen with distention, severe
pain, fever, and progressive tachycardia. The primary
therapy for peritonitis is surgery. 2
Teaching Points
Lessons Learned
Penetrating Abdominal Trauma
• Management of penetrating injury to the abdomen • This was a quick and robust response to a complicated
depends on if the wound has penetrated the fascia, the clinical scenario in a remote area with a multidisci-
wound projectile, the zone of the abdomen injured, plinary team of providers to assist with management.
and the presence of any blast/cavitary effect. Wounds • All parties made contact with the provider in-country
that penetrate the fascia often require surgical man- within 1-2 hours after initial contact.
agement and should be treated with antibiotics until • Use of initial e-mail with images of the patient pro-
surgical consultation has been obtained. In the set- vided complete and concise information regarding the
ting of low-velocity projectiles or stab wounds, the case, which was able to be forwarded to various spe-
location of abdominal penetration may suggest injury cialists to assist in management plan.
to underlying structures, whereas high-velocity pro- • There is continued difficulty regarding availability of
jectiles (e.g., gunshot wound or fragmentation from secret methods of communication for providers who
blasts) may travel great distances inside the body and are on call for VC3.
the location of penetration does not predict ultimate • Providing a list of potential subspecialty physicians
injury pattern. on call for this consult service could reduce delays in
• In a resource-limited environment, a plain radiograph consultative care for patients downrange.
can provide , basic information (e.g., presence of free
air, diaphragmatic injury, pneumothorax, fragment References
projectile). If these are found, surgery is most likely
necessary. 1. Brierley J, Carcillo JA, Choong K, et al. Clinical practice pa-
• Ultrasound can also be very informative anatomically rameters for hemodynamic support of pediatric and neonatal
septic shock: 2007 update from the American College of Criti-
and may help explain physiologic changes (as in this cal Care Medicine. Crit Care Med. 2009;37:666–688.
patient). A positive FAST examination suggests the 2. Como JJ, Bokhari F, Chiu WC, et al. Practice management
need for emergent surgery if it is performed before re- guidelines for selective nonoperative management of penetrat-
suscitation. Delayed FAST examinations, as in this pa- ing abdominal trauma. J Trauma. 2010;68:721–733.
tient, can be misleading because they may result from
inflammatory effects of the injury or from fluid resus- Disclaimer
citation. Physical examination that demonstrates signs The views expressed are those of the author(s) and do
of peritonitis (discussed below) indicates a probable not reflect the official policy or position of the US Army
injury to a hollow viscus that requires surgical repair.
• Concern for stomach or intestinal injury (based on Medical Department, Department of the Army, Depart-
ment of the Air Force Department of Defense or the U.S.
clinical signs) warrants IV antibiotics, which should Government.
be continued through definitive surgical care.
• A nasogastric tube can be therapeutic if there is a gas-
tric or intestinal injury, and can be diagnostic if there Disclosures
is a diaphragmatic injury and the tube is seen diverg- The authors have nothing to disclose.
ing into the chest on radiograph. Gastric decompres-
sion also helps prevent aspiration.
• Blind drain placement was considered in this case,
but it is not a substitute for surgical management and CPT McLeroy is at Madigan Army Medical Center, Joint
Base Lewis-McChord, Washington.
could potentially be harmful. Although image-guided
drain placement via ultrasound for a bowel injury has CPT Ellis is with the 528th Sustainment Brigade (SO) (A),
the potential to control peritoneal sepsis, it will likely Fort Bragg, North Carolina.
result in an enterocutaneous fistula, and is not rec-
ommended. All surgical options should be explored SFC Karnopp is with the 528th Sustainment Brigade (SO)
and exhausted before such an approach could be (A), Fort Bragg, North Carolina.

112 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016