Page 55 - 2022 Ranger Medic 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 or 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. SECTION 2

Initial Assessment & Management
Visible evidence of abdominal trauma may not always be immediately present (especially when associated with blunt
MOIs). 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 due to 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, and signs of shock.
Palpation: Palpation of the abdomen can reveal tenderness, guarding, and rigidity. Assess all abdominal quadrants for
superficial, deep and rebound tenderness. If an obvious evisceration is present, palpation should be deferred. Involun-
tary guarding is a reliable sign of peritoneal irritation. Pelvic stability should be assessed especially when blunt trauma is
the mechanism of injury. A pelvis that is determined to be unstable should not be subjected to repeated manipulation to
test for stability. If possible, a rectal examination should be done in all patients with suspected abdominal injuries. Gross
blood indicates gastrointestinal hemorrhage or perforation of the bowel, a high riding prostate is suspicious for urethral
injury, and poor rectal tone indicates neurological injury.
Auscultation: Auscultation is difficult and misinterpreted in the tactical setting and should not be used as a singular
diagnostic measure. Absent or decreased bowel sounds are commonly associated with injury to abdominal viscera.
However, patients with audible bowel sounds can still have significant underlying abdominal injuries. Auscultation of
bowel sounds in the thorax is suggestive of diaphragmatic injury.
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 (adhesive dressing, sutures, or staples) and cover abdominal wound with dressing. If bowel is unable to be
reduced, cover bowel with a non-adherent and water impermeable dressing. If uncontrolled abdominal hemorrhage is
suspected, immediately begin resuscitation with whole blood or blood products in a 1:1:1 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 overresuscitation. The patient who is hemodynamically unstable and requires ongoing large- volume
resuscitation is probably bleeding from an intra-abdominal or intrathoracic source.
Extended Care
Eviscerated bowel and omentum should be covered with a non-adherent and water-impermeable dressing. 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. A nasogastric (NG) tube should be placed
to decompress the stomach in order to decrease the risk of vomiting and aspiration. The NG tube may be reserved
for those patients who are vomiting or have a distended abdomen. A Foley catheter may be useful in patients who are
unstable in order to monitor urine output and to obtain urine samples to evaluate for blood. Worsening pain or worsen-
ing signs of shock, peritonitis, or sepsis indicate deterioration and should accelerate efforts to evacuate the patient
to a location where surgical care is available. Anti biotic therapy should be initiated as soon as a penetrating injury is
suspected. Administer ertapenem 1g IV.

2022 RANGER MEDIC HANDBOOK 41