Emergency Medicine

ABDOMINAL AND PELVIC TRAUMA

Surgical Emergencies 241

(b) there is scattering of shot if the shotgun is fired from >7 m,

perforating structures within the abdomen

(c) a shot from >40 m may not even penetrate the peritoneal cavity.

3 An entr y wound may be obv ious, w it h ev isceration of bowel, or may be dif f i-
cult to f ind especia lly if hidden by a glutea l fold or in t he perineum.

4 The most important signs to look for are hypotension and shock.

5 Abdominal examination is often unreliable as abdominal tenderness on
exa minat ion is absent in up to 50% of pat ients w it h acute haemoperitoneu m.
(i) Positive examination findings include local rigidity and guarding
with reduced bowel sounds.

6 Remember that an associated chest injury can occur with any wound above
the umbilicus.

7 Insert a large-bore i.v. cannula and send blood for FBC, U&Es, lipase/
amylase and cross-match.

8 Request a CXR to look for associated thoracic injury, and an abdominal
X-ray (AXR) to assess for metallic foreign bodies.

9 Test gastric aspirate and urine for blood, although haematuria indicating a
urologica l injur y is an unreliable sign.

10 Arrange a CT scan with i.v. contrast particularly if non-operative manage-
ment is considered.

MANAGEMENT

1 Cover any exposed bowel with saline-soaked pads.

2 Give oxygen, and replace f luid initially with normal saline. Titrate analgesic
requirements by administering 2.5–5.0 mg morphine i.v.

3 Commence broad-spectrum antibiotics, e.g. gentamicin 5 mg/kg i.v.,
ampicillin 1 g i.v. and metronidazole 500 mg i.v. Give tetanus prophylaxis.

4 Refer all patients to the surgical team for urgent admission and laparotomy
for all gunshot wounds and the vast majority of stab wounds.

Pelvic injury

The major complication of a pelvic fracture is massive blood loss, with up to 3 L or
more of concealed haemorrhage, which may continue despite resuscitation.

DIAGNOSIS

1 Pelvic injuries usually result from high-energy blunt trauma in road traffic
crashes, crush injuries and from falls.

2 Associated bladder, urethral, rectal and vaginal injuries occur, which
account for further morbidity. A ruptured diaphragm must also be excluded.

3 There is local pain, tenderness and bruising. Bony instability demonstrated
by distracting the iliac crests is an unreliable sign that may increase bleeding.