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

Secondary Evaluation

United States Department of Defense

If there is any reason to suspect an intra-abdominal injury, secondary evaluation is necessary. The surgeon must convince himself that there is clear and unequivocal evidence that there is no intra-abdominal injury. If this is the case, attention can be directed to other problems.

Indwelling Urinary Catheter

If there is no evidence of urethral injury, an indwelling urinary catheter should be inserted and the absence or presence of blood in the urine noted.

Nasogastric Tube

A nasogastric tube should be passed and connected to some type of drainage. The absence or presence of blood in the aspirate should be noted.

Rectal Exam

A digital rectal exam is of critical importance in patients with a lower abdominal or perineal wound. The presence or absence of blood in the rectum is determined. The value of a more sophisticated exam, such as endoscopy or barium enema, is limited by the usual presence of stool in the rectum of most of these patients and the time needed to perform the exam. The position of the prostate should be noted.

Re-examination

The abdomen should be re-evaluated when these procedures are completed. An acutely distended urinary bladder or stomach can be the cause of abdominal pain or tenderness.

X-rays

Simple KUB and lateral films of the abdomen are of great assistance in the search for radiopaque fragments. The films are of value only if positive. Normal X-rays do not rule out injury. If exploratory laparotomy is contemplated, a "single shot" intravenous pyelogram is important to determine if there are two functioning kidneys and if there is evidence of extravasation of urine.

Further studies, such as angiography, are not likely to be available. Other studies, such as peritoneal lavage, often require more time than the surgeon has to devote to one patient.

It is best for the surgeon to base decisions on the information available at this point in the evaluation. Further studies can be valuable, but the forward surgeon in a mobile hospital must be able to function with the information obtained by this evaluation. The opportunity for more detailed and sophisticated evaluation should be used when available, but the dimension of time, the press of more casualties, and the resource limitations must be considered before resorting to these studies.

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Operational Medicine 2001

Health Care in Military Settings

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