**2. General examination**

If the abdomen is the probable source of exsanguinating hemorrhage, the patient should be transferred to the operating room for immediate laparotomy. The hemodynamically stable patient can be more meticulously assessed within the framework of the secondary survey. Evaluation always includes comprehensive physical examination with pelvic and rectal

Administer high flow oxygen and intubate the patient if necessary. Maintain cervical spine

Auscultate for breathe sounds. Inspect for asymmetry of chest wall movement, open wounds, or flail segments. Palpate the chest wall carefully as palpable crepitus may indicate a pneumo-

Stop gross external hemorrhage with direct pressure. Assess pulses, capillary refill, and blood pressure. Obtain intravenous access with at least two large bore (≥16 gauge) catheters. If

Complete a brief and focused neurologic examination to document the patient's baseline. The examination should include an assessment of pupillary size and reactivity, a determination of the patient's Glasgow coma scale (GCS) score, and notation of any focal neurologic deficits such as unilateral weakness or poor muscle tone. Ideally, perform the examination before

Completely undress the patient, although be careful to prevent or recognize and correct associated hypothermia. Begin a more thorough secondary survey, including examining all skin

Do not remove impaled foreign bodies because they may be providing hemostasis from a vascular injury. Foreign body removal should be performed with surgical consultation in a

Any penetrating injury below the nipple line warrants evaluation for intra-abdominal injury. In patients in motor vehicle collisions, look for ecchymosis or erythema in the area of clavicles

examinations and may require specific laboratory and radiologic tests.

thorax or rib fractures. Pulse oximetry and capnography may be useful.

peripheral intravenous access is inadequate, place a central venous catheter.

administering pain medications, sedatives, or paralytics.

folds, the back, and axillae for occult penetrating injuries.

immobilization until potential injury is ruled out.

**1.1. Airway**

76 Trauma Surgery

**1.2. Breathing**

**1.3. Circulation**

**1.4. Disability**

**1.5. Exposure**

more controlled setting.

Examine the abdomen for tenderness, distention, rigidity, or guarding.

Evaluate the pelvis for anteroposterior or lateral instability with gentle pressure; this does not require much force and should not be repeatedly performed. Examine the genitalia and look for blood at the urethral meatus, especially in males. Perform digital rectal examination in any patient with abdominal trauma. Look for gross blood, assess sphincter tone, and note any other evidence of trauma. If blood at the urethral meatus or a high riding prostate is present, placement of a urinary catheter is contraindicated, and a retrograde urethrogram is required to evaluate for potential urethral injury.

### **2.1. Laboratory evaluation**

Initial laboratory evaluation should include hemoglobin and hematocrit and platelet count to establish a baseline, and a blood type and screen in case transfusion of packed red cells are needed. A lactate level may be obtained and, if elevated, is an excellent indicator of shock. Base deficit is another indicator of shock. The role of amylase in abdominal trauma is uncertain. Examination of the urine may reveal gross hematuria, which suggests significant injury to the urogenital tract.
