Penetrating Abdominal
Trauma
Introduction
The evaluation of abdominal trauma for the GMO requires only the determination that
an intra-abdominal injury may be present. In the case of penetrating injury, this task is
relatively simple.
Primary Survey
-
Evaluate the patient for the presence of a patent airway, adequate breathing, and intact
circulation (ABCs) per ATLS guidelines.
-
Immobilize the head and neck, and maintain the cervical spine in a neutral position.
Assume a cervical spine injury is present until proven otherwise by palpation and
radiological examination.
-
Disability exam (neuro) for level of consciousness and pupil exam.
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Exposure: fully undress the patient
-
Determine pre-hospital care already delivered
-
Mechanism of injury.
-
Pain - presence, absence, location..
Secondary Survey
An "AMPLE" history per ATLS.
Environment and events related to patients
injury(s)
-
Inspection for penetrating injuries from the nipples to the thighs, flanks, back,
buttocks, and perineum. Note any impaled foreign bodies. Also inspect for contusions,
abrasions, and lacerations.
-
Auscultation for absent or markedly diminished bowel sounds.
-
Palpation for tenderness, guarding (voluntary and involuntary), and peritoneal
irritation.
-
Perform a digital rectal exam for blood, integrity of bowel wall, position of prostate,
foreign bodies, and sphincter tone.
-
Perform a genital exam for male and females to include examination for blood at the
urethral meatus, foreign bodies, and palpation for bony fragments. Vaginal bleeding in the
pregnant patient warrants early consultation with an obstetrician and general surgeon.
Testing and Resuscitation
NG tube placement for decompression of the stomach
-
Examine contents for blood.
-
Caution is recommended when facial fractures are suspected. Placement should be directed
through the mouth with efforts aimed at avoiding unintentional intracranial insertion.
Urinary catheter placement for bladder decompression and urinary output monitoring.
-
An examination of genitalia and a rectal exam should be performed before insertion of
the catheter. Contraindications to placement include blood at the meatus, scrotal
hematoma, and a high riding prostate.
Lateral and KUB x-rays may help confirm intra-abdominal position of radiopaque foreign
bodies.
-
Mark skin with a radioopaque object if penetrated by a stab or gun shot wound (GSW)
-
Confirm NG tube placement below diaphragm
-
Rule out free, intra-abdominal air
Local wound exploration may be considered for stab wounds. If anterior fascial
penetration is found, then abdominal penetration must be presumed.
Diagnosis
The diagnosis of potentially serious intraabdominal injury must be presumed with any
wound penetrating the anterior abdominal fascia. If fascial penetration has not occurred,
but there is blood found in any part of the exam, significant tenderness or peritoneal
irritation, or absent bowel sounds, then abdominal injury must be presumed and surgical
consultation obtained immediately.
-
In the absence of fascial penetration, or other grave signs, the patient can be followed
with serial exams and Hgb/Hct determinations.
-
Do not close wounds primarily
-
When there is any doubt, refer to a surgeon immediately
Remember that a normal initial exam of the abdomen does not exclude a significant
intrabdominal injury. Always do serial exams.
If asymptomatic after 24 hours, the patient may be returned to duty with superficial
wound debridement on each follow up exam.
Treatment of Penetrating Abdominal Trauma
-
ABCs, resuscitation, and stabilization as per ATLS.
-
Ensure stomach and bladder are intubated and emptied.
-
Evacuate emergently as a litter patient to a facility with surgical capabilities.
-
Impaled objects should be secured and left in place.
Summary
The essence of diagnosing and treating intraabdominal injury for the GMO is to presume
that any penetrating wound, no matter how innocuous, has caused injury. If untreated,
these injuries will result in death for the patient. After standard assessment and
resuscitation, these patients should be evacuated.
References
-
Abdominal Trauma, Chapter 5, Advanced Trauma Life Support for Doctors, Student Course
Manual, American College of Surgeons Committee on Trauma, 1997.
-
Wounds of the Abdomen, Chapter XXIX, Emergency War Surgery, 2nd U.S. Revision, 1988. http://www.vnh.org/EWSurg/EWSTOC.html .
Revised by CDR Lawrence H. Roberts, MC, USN, Trauma Training Coordinator for the Navy,
Department of General Surgery, Naval Medical Center San Diego, San Diego, CA (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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