4-72
Plan:
Treatment
- IV uids (see Shock: Fluid Resuscitation)
- Antibiotics: Cefotetan 2 grams q 12 hours.
- Evacuation: Elevate head and ex knees.
- If evacuation is not possible or imminent, consider appendectomy (see following Appendectomy procedure
guide). Perforation rate climbs steeply after 24 hours of pain. Evaluate abdominal pain expeditiously and
explore promptly before perforation occurs.
Patient Education
General: Appendectomy should cure the patient of symptoms.
Diet: No dietary restrictions.
Follow-up Actions
Return evaluation: Reevaluation for symptoms of pain, fever, diarrhea. Return for evaluation if appendec-
tomy does not lead to prompt restoration of baseline good health.
Evacuation/Consultation Criteria: Evacuate urgently for surgery. Needs routine postoperative surgical
follow up, then primary care management.
GI: Emergency Field Appendectomy
LTC John Holcomb, MC, USA and SFC Dominique Greydanus, USAWhat: The removal or drainage of a suppurative or perforated appendix through an emergency laparotomy
When: Only when the patient has failed 48-72 hours of appropriate antibiotic therapy, absolutely cannot
be evacuated in time, is having high spiking fevers, has an elevated WBC count and peritonitis, and will die
without the operation. Tell your commander this is a life or death maneuver, and the patient has only a small
chance of living despite this operation.
Background: The ultimate goal should be to avoid operating in this environment. In a field setting
without dedicated surgical support, acute appendicitis is optimally treated with IV antibiotics until evacuation is
possible (you may avoid operating on up to 80% of such patients). If evacuation is not possible, the majority
of acute appendicitis patients can still be treated with IV antibiotics (only 30% will recur later). The patient
with perforated appendicitis presents more difficulty, however they can still be treated with IV antibiotics in a
non-operative fashion, and only 50% of these patients will require an emergency operation. The decision to
perform an appendectomy without the support of personnel proficient in intra-abdominal surgery is extremely
dangerous. This is essentially a triage decision, maximizing your limited resources, personnel and surgical
experience by treating the majority of patients with antibiotics alone. Once the decision has been made to
operate, it is important to adequately prepare the personnel assisting you. Discuss all steps of the procedure
extensively and review all reference material available. No one on the surgical team should have more than
one job. Practice on an animal immediately before doing the appendectomy. After all this preparation, it is
still likely that unintentional complications (and perhaps death) will result from this type of field surgery. These
guidelines apply to both US and local national patients.
What You Need:
Personnel: A dedicated anesthesia technician is required, who is experienced or knowledgeable in perform-
ing intravenous anesthesia or general endotracheal anesthesia. The patient cannot move around and the
abdominal wall must be relaxed during surgery. Two surgical assistants are required.
Supplies: Surgical preparation solution (for the abdomen), sterile gloves (>3 sets), silk ties or ligatures, 0
(zero)-Vicryl (for the fascia) on a taper needle, sterile bandages (to pack the wound), sterile gauze bandages
(for incisional bleeding), a large volume (6-10 liters) of sterile saline or water (to irrigate the peritoneal cavity),
suction device, NG tube, Foley catheter