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.

• Exposure: fully undress the patient

• Determine pre-hospital care already delivered

• Mechanism of injury.

• Pain - presence, absence, location..

An "AMPLE" history per ATLS.

• Allergies

• Medications taken by the patient

• Past medical history

• Last meal

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.

• Diagnostic peritoneal lavage (DPL) should not be attempted by the GMO; it should be performed only by a surgeon.

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.

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.

1. Abdominal Trauma, Chapter 5, Advanced Trauma Life Support for Doctors, Student Course Manual, American College of Surgeons Committee on Trauma, 1997.

2. Wounds of the Abdomen, Chapter XXIX, Emergency War Surgery, 2nd U.S. Revision, 1988. http://www.vnh.org/EWSurg/EWSTOC.html .