If a PATIENT IS BROUGHT IN LATE, more than 18 hours after an injury, manage him like this:
If he looks well, feels well, his temperature is normal, he has no signs of peritonitis or abscess formation, and if the site of his wound is only minimally tender, a laparotomy may not be necessary. None of his viscera may have been perforated, or the perforations may have sealed themselves off. Watch him, and if he deteriorates, operate.
If his condition is not good, but he looks as if he could withstand an operation, operate.
If he is in severe shock, resuscitate him. Give him intravenous fluids, and antibiotics. Pass a nasogastric tube. He will probably die anyway, but give him a chance. Operate, unless he clearly has only minutes to live. If you refer him, resuscitate him first.
If a patient’s PULSE RATE RISES POSTOPERATIVELY, and his abdomen becomes increasingly tender and rigid, there is sepsis inside it. After an abdominal injury a patient is in danger from: (1) Generalized peritonitis (6.2). (2) Subphrenic (6.4) or other abdominal abscesses (6.3). (3) Retroperitoneal abscesses.
Treat peritonitis as in Section 6.2. Prevent it by: (1) closing lacerations in a patient’s small gut carefully, (2) managing injuries to his large gut as in Section 66.11, (3) inserting drains appropriately, (4) cleaning out his injured peritoneum with saline before you close it, and (5) using perioperative antibiotics as in Section 2.7.
If a FISTULA forms, treat it as in Section 9.14. Sometimes you cannot avoid one, so prepare for one deliberately: (1) After a bladder injury do a suprapubic cystostomy (22.6 and 22.7). (2) After pancreatic or duodenal injuries, insert a drain. (3) When the large gut has been injured, do a colostomy (9.5).
If his ABDOMiNAL WOUND BECOMES INFECTED and sloughs, lay it open, treat him with antibiotics, hypochlorite (’Eusol’) dressings, and delayed skin grafting. This may happen when: (1) His unprepared colon or ileum has been opened. (2) There has been major trauma. (3) Much blood has been lost. (4) Perioperative antibiotics have not been given, or have not been properly timed. Delayed suture of the abdominal wall will make infection less likely.
If parts of a patient’s LUNG COLLAPSE, or an entire lung collapses, treat him as in Sections 9.9 and 9.10. Prevent lung complications after any laparotomy by early breathing exercises. Occasionally, you may need to slap his chest, or bronchoscope him to remove mucus plugs. Very rarely, you may need to do a tracheotomy, or to ventilate him artificially. This is one of the complications of any operation under general anaesthesia. It is more common after an abdominal injury because: (1) His chest may have been injured at the same time. (2) Major abdominal wounds make breathing difficult.
