Historically, armed conflict with bladed weapons have created many organ eviscerations from abdominal wounds that result in high mortality due to hemorrhagic shock and peritonitis. In World War I, bayonets were used for close-quarters combat, and many surgeons considered patients with abdominal penetration injury to be triaged as expectant (not expected to live). More recently in military conflicts in Iraq and Afghanistan, abdominal wounds were ~9.4% of all combat injuries. It was reported that 81% of all abdominal injuries were from bomb fragments, 17% from gunshot wounds (GSWs) and 2% from motor vehicle accidents (MVAs). It is estimated that 20% of combat casualties have abdominal trauma, and about one-third of those casualties have an evisceration. In civilian trauma, the abdomen is the third most injured region associated with bowel or mesenteric injury, primarily caused by MVAs. An organ evisceration is often considered a secondary injury that is more common with penetrating injury, and significantly less observed with blunt trauma.
With frequent evisceration observed during combat, and a gap of Tactical Combat Casualty Care (TCCC) management recommendations, a recent working group from the Committee on Tactical Combat Casualty Care (CoTCCC) developed new recommendations in 2020 (see Tactical Field Care – Section 12 Inspect Wounds). In 2021, a follow-on TCCC evisceration management article was published in the Journal of Special Operations Medicine. Thus, it is our intent to highlight the evisceration management recommendations with specific comments about the relevance to wilderness medicine providers.
The Wilderness Medical Society (WMS) has a long history with military medicine due to the key similarities of wilderness medicine with austere environments, limited manpower and resources, and delayed evacuation. Starting in the late 1990s, the WMS hosted a preconference, “Wilderness Medicine Scenarios for Military Special Operations”. Dr. Frank Butler, Jr. and others from the TCCC group wrote 11 tactical medical scenarios with relevance to wilderness medicine. The conference organizers invited 15 subject matter experts (SMEs) to address how to manage these patient scenarios by using the 1st generation of the TCCC guidelines in 1996. Each scenario was presented by one SME and then discussed by the panel members, and the attendees. In Scenario 6: Gunshot Wound to the Abdomen, a casualty had an evisceration as a secondary complication associated with the GSW. Even though this scenario addressed how to manage the GSW and the evisceration, the original 1996 TCCC guidelines did not specifically list evisceration management recommendations. Additionally, subsequent TCCC guidelines updates did not address abdominal evisceration until 24 years later. All 11 tactical scenarios and medical management approaches can be viewed in a 1998 special issue of the Wilderness and Environmental Medicine.
In February 2019, the CoTCCC Evisceration Working Group reviewed how each military service teaches abdominal evisceration management to their medics/corpsmen. They also conducted literature searches for prehospital evisceration management. A series of questions were addressed and presented with their key findings – see Table 1.