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

Systemic Evaluation

United States Department of Defense

Evaluation of the combat casualty differs from evaluation in civilian practice. First, there always is a possibility of early evacuation secondary to factors beyond the surgeon's control. The military surgeon cannot assume that he will be able to re-examine the patient at a later time. A decision must be reached each time the surgeon and patient are separated. Procrastination, reflection, and consultation are luxuries seldom enjoyed by the forward surgeon. Second, sophisticated studies, such as arteriography and CT scans, will generally not be available in the forward hospital. Third, the surgeon must deal with distractions such as multiple casualties, massive wounds, logistics breakdowns, the possibility of hostile fire, and the general confusion of war. He must maintain a high index of suspicion and an appreciation of the subtle nature of the signs of serious intra-abdominal injury. All of these casualties can be evaluated rapidly yet carefully if the examination is performed in a systematic manner. The surgeon must appreciate that rapid pulse, narrowed pulse pressure, lowered blood pressure, poor capillary refill, and decreased urinary output are evidence of hypovolemia. In the absence of external evidence of blood loss or evidence of intrathoracic blood loss, these signs are presumptive evidence of intra-abdominal injury.

The History

In war, few individuals have an appreciation of anything beyond their own immediate environment. These conditions produce wildly inaccurate and often contradictory reports of time of Wounding, weapons used, and location of injuries. The surgeon is exposed to reports of local and strategic military activities that may or may not be true. It is wisest for the surgeon to believe only what can be seen or felt. The history is of value when the patient identifies the presence, absence, or the location of pain; allergies, and time of last meal. Any other information must be carefully evaluated before being seriously considered. The history is useful when received from other medical personnel, but this should be confined to clinical information.

Inspection

The casualty must be undressed. Mud and other material that can conceal a wound must be cleared. Illumination must be adequate. The surgeon must personally do the exam, but at least one person must assist him. The assistant must understand what the surgeon is trying to do. The surgeon must carefully inspect all of the abdomen from the nipples to the upper thigh, the flanks, the back, and the perineum. This cannot be done without turning the patient, abducting the lower extremities, and spreading the buttocks. The examining team must make allowances for other injuries while performing this examination.

Any evidence of a penetrating injury, no matter how innocuous, must be assumed to represent an intra-abdominal wound and treated accordingly. Missile tracts are unpredictable. Even though these wounds must be debrided, exploration of the wound itself is time consuming and more often than not reveals no definitive information. The surgeon must assume that a penetrating injury of the torso is evidence of an intra-abdominal wound unless the converse is proven. More discretion can be used if there is only evidence of blunt trauma.

Abdominal distension is abnormal in healthy soldiers and may be the only evidence of an intra-abdominal injury. The examining surgeon must consciously search for this most subtle of signs. Splinting of respiration is also abnormal and, excluding chest injury, should be considered strong evidence of intra-abdominal injury.

Palpation

Tenderness must be searched for systematically. This may be difficult to accomplish in an excited, apprehensive young soldier who might well have other painful injuries. The surgeon must be certain that he has the patient's attention and cooperation. Each abdominal quadrant should be examined separately. The presence of involuntary guarding confirms intra-abdominal injury, but this sign may be hard to define under these circumstances. Medial and lateral pressure on the iliac spine and pressure on the pubic symphysis are used to search for pelvic fractures. The presence or absence of femoral pulses should be noted. Abdominal tenderness is more often due to intra-abdominal injury than to abdominal wall trauma. If tenderness is present, the surgeon should reexamine the abdomen after a urinary catheter and a nasogastric tube are in place. Urinary retention and acute gastric dilation are not uncommon in these patients.

Auscultation

This is an essential part of the evaluation. Absent or significantly decreased bowel sounds are abnormal in a healthy young soldier and must be considered presumptive evidence of intra-abdominal injury.

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Operational Medicine 2001

Health Care in Military Settings

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