Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIX: Wounds of the Abdomen

Classification of the Patient

United States Department of Defense

The surgeon must classify the patient at specific points during examinations. This allows "weighing" of the data collected during the exam. This classification applies to the patient at hand. This is not triage, even though these actions can be similar to the decision-tree used by a triage officer who is sorting multiple casualties. Mandatory classification of the patient at specific points forces even the inexperienced surgeon to safely and rapidly collect as much information as is needed to care for the patient. This allows the surgeon to act decisively and quickly, but without carelessness.

As each step in the collection of information is completed, the patient should be unequivocally classified as:

Priority I patients should be prepared for operation immediately. There is no need for further collection of data. Actions described as "Secondary Evaluation" (urinary catheter, nasogastric tube, rectal exam, and X-rays) must be completed.

Priority II patients should have "Secondary Evaluation" completed and then operated upon in most cases.

Priority III patients should be systematically examined according to the text, but secondary evaluation is seldom necessary. Any patient can be moved to a more urgent priority at any time. Each step in the evaluation must be used to prioritize these patients.

If there is evidence of hypovolemic shock and no other apparent injury, to include the chest, the patient is classified as Priority I. If there is hypovolemic shock and evidence of other injuries, no matter how sever, the patient is considered Priority II.

Inspection

If there is evidence of evisceration, omentum, stool, bile, or urine leaking from a penetrating wound or if there is loss of tissue from the abdominal wall, the patient is classified as Priority I.

If there is evidence of penetrating wounds. significantly contused tissue, or abdominal distension, the patient is a Priority II. Patients with altered mental states are Priority II. If the abdomen appears normal. the patient is classified as Priority III.

Palpation

A patient with significant tenderness, abdominal rigidity, or pelvic tenderness is Priority II.

Auscultation

A patient with absent or significantly decreased bowel sounds is Priority II.

Further Evaluation

A patient with bloody urine, bloody nasogastric aspirate, blood in the rectum, X-ray evidence of free air, or intraabdominal foreign bodies is classified Priority I.

This simple approach to evaluation of the soldier with an intra-abdominal injury will ensure that each patient has the benefit of mature surgical judgment despite urgency and distractions.

The patient who is classified Priority II at the completion of the secondary evaluation presents a dilemma. There is no simple resolution; however, a third set of actions, namely, consideration of extenuating circumstances, may help the surgeon to decide whether or not to operate.

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Operational Medicine 2001

Health Care in Military Settings

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