Page 140 - JSOM Winter 2021

The Management of Abdominal Evisceration

in Tactical Combat Casualty Care
TCCC Guideline Change 20-02

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Jamie Riesberg, MD ; Jennifer Gurney, MD ; Meg Morgan, MD ;
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D. Marc Northern, MD ; Dana Onifer, MD ; Bill Gephart, PA, RN, NRP ; Mike Remley, ATP ;
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Erin Eickhoff, DNP, RN ; Carl Miller, ATP, NRP ; Brian Eastridge, MD ;
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Harold R. Montgomery, ATP ; Frank K. Butler Jr, MD ; Brendon Drew, DO *
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ABSTRACT
Historically, about 20% of hospitalized combat injured pa- not attempt to reduce bowel that is actively bleeding or
tients have an abdominal injury. Abdominal evisceration may leaking enteric contents.
be expected to complicate as many as one-third of battle- • If unable to reduce, cover the eviscerated organs with
related abdominal wounds. The outcomes for casualties with water-impermeable, nonadhesive material (transparent
eviscerating injuries may be significantly improved with appro- preferred to allow ability to reassess for ongoing bleed-
priate prehospital management. While not as extensively stud- ing; examples include a bowel bag, IV bag, clear food
ied as other forms of combat injury, abdominal evisceration wrap, etc.), and then secure the impermeable dressing
management recommendations extend back to at least World to the patient using an adhesive dressing (e.g., Ioban,
War I, when it was recognized as a significant cause of mor- chest seal).
bidity and was especially associated with bayonet injury. More • Do NOT FORCE contents back into abdomen or ac-
recently, abdominal evisceration has been noted as a frequent tively bleeding viscera.
result of penetrating, ballistic trauma. Initial management of • Death in the abdominally eviscerated patient is typically
abdominal evisceration for prehospital providers consists of from associated injuries, such as concomitant solid or-
assessing for and controlling associated hemorrhage, assessing gan or vascular injury, rather than from the evisceration
for bowel content leakage, covering the eviscerated abdominal itself.
contents with a moist, sterile barrier, and carefully reassess- • Antibiotics should be administered for any open wounds,
ing the patient. Mortality in abdominal evisceration is more including abdominal eviscerating injuries. Parenteral er-
likely to be secondary to associated injuries than to the eviscer- tapenem is the preferred antibiotic for these injuries.
ation itself. Attempting to establish education, training, and
a standard of care for nonmedical and medical first respond- Keywords: abdominal injury; abdominal evisceration; battle-
ers and to leverage current wound management technologies, related abdominal wounds; prehospital management
the Committee on Tactical Combat Casualty Care (CoTCCC)
conducted a systematic review of historical Service guidelines
and recent medical studies that include abdominal eviscera-
tion. For abdominal evisceration injuries, the following princi- Proximate Reasons for This Proposed Change
ples of management apply: To date, the CoTCCC guidelines have not specifically ad-
• Control any associated bleeding visible in the wound. dressed the issue of abdominal evisceration. There had been
• If there is no evidence of spinal cord injury, allow the discussion by the Wilderness Medical Society at a Tactical
patient to take the position of most comfort. Combat Casualty Care (TCCC) workshop in the late 1990s.
• Rinse the eviscerated bowel with clean fluid to reduce However, the discussions of this topic at the WMS workshop
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gross contamination. were never integrated into the TCCC Guidelines. Given the
• Cover exposed bowel with a moist, sterile dressing or potential for prolonged casualty care (PCC) in future con-
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a sterile water-impermeable covering. It is important to flict, delayed surgical treatment may complicate the care of
keep the wound moist; irrigate the dressing with warm these patients. Initial assessment and resuscitation in trauma
water if available. management to effect ongoing PCC are included in the
• For reduction in wounds that do not have a substantial CoTCCC guidelines, reducing both initial mortality and sub-
loss of abdominal wall, a brief attempt may be made sequent morbidity. In the case of battlefield abdominal trauma,
to replace/reduce the eviscerated abdominal contents. current research efforts are largely focused on hemorrhage.
If the external contents do not easily go back into the Truncal and junctional hemorrhage remain a key focus due to
abdominal cavity, do not force or spend more than 60 the difficulty of managing these conditions in the prehospital
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seconds attempting to reduce contents. If reduction of environment, in the hope of preventing mortality. As a sub-
eviscerated contents is successful, reapproximate the component of abdominal wounding, the specific management
skin using available material, preferably an adhesive of abdominal evisceration includes initial hemorrhage control,
dressing like a chest seal (other examples include safety wound care, and continued reassessment including serial ex-
pins, suture, staples, wound closure devices, etc.). Do aminations to ensure eviscerated contents remain viable and
*Correspondence to brendon.g.drew.mil@mail.mil
1–13 Affiliations are given on page 142.

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