Ave'ese le manava ma le tausiga o manu'a matala¶

An abdominal evisceration occurs when a full-thickness laceration through the skin, subcutaneous fat, rectus abdominis muscle, fascia, and parietal peritoneum allows internal organs (most commonly loops of the small intestine or the fatty greater omentum) to protrude outside the abdominal cavity. Evisceration can result from penetrating trauma (knife slashes, high-energy shrapnel, or animal horn gores), severe blunt blast forces, or the postoperative breakdown of surgical sutures after a laparotomy (surgical wound dehiscence).

While the sight of pink, glistening loops of intestine resting outside the body is terrifying for both the casualty and bystanders, evisceration itself does not kill instantly unless paired with major vascular hemorrhage. Instead, the three immediate prehospital threats to survival and organ viability are mesenteric strangulation and bowel desiccation (drying out), fulminant bacterial peritonitis if contaminated organs are shoved back inside, and rapid evaporative hypothermia triggering the Lethal Trauma Triad. Knowing how to flex the victim's knees to take tension off the abdominal wall, why you must never push protruding organs back into the abdomen, and how to construct a two-layer moist-plus-occlusive thermal barrier saves both the bowel and the patient's life.

Fai nei loa¶

1. Call your local emergency number immediately and request Advanced Life Support (ALS) paramedics for urgent surgical transport. Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, 000 in Australia, or check the directory of numera fa'afuase'i.
2. Fa'ata'oto le tagata manua i luga o latou tua ma o latou tulivae e punou (fa'ano'i) i le 30-i-45-tikeri le maualuga ma lagolago i luga o se aluga po'o se palanikeke ta'avale. O le punou o sulugatiti ma tulivae e malolo ai le rectus abdominis ma muso psoas, fa'aitiitia le mamafa i totonu o le manava, ma taofi fa'amalo faaopoopo o le manava mai le oomi i fafo o le manu'a.
3. NEVER attempt to push protruding intestines or organs back inside the abdominal cavity. Shoving exposed bowel back through a tight fascial defect kinks the delicate blood vessels in the mesentery (causing rapid bowel necrosis) and drives dirt, skin bacteria, and debris deep into the sterile peritoneal cavity. Only if a loop of bowel has spilled onto the ground beside the patient should you gently lift it onto the skin of the patient's own abdomen without twisting it.
4. Cover the exposed organs immediately with a large sterile dressing thoroughly moistened with sterile normal saline (0.9% sodium chloride) or clean drinking water. Never put dry gauze, paper towels, tissue paper, or fluffy absorbent cotton directly onto exposed bowel; dry fibers stick like glue to the wet serosal surface and rip the bowel wall when removed.
5. Apply a second outer occlusive moisture-and-heat barrier (clean plastic cling wrap, a sterile burn sheet, foil, or a dry multi-trauma dressing) loosely over the wet dressing. Tape the edges of the outer plastic or dry dressing to the surrounding skin without pressing down on the organs, locking in moisture and stopping massive evaporative heat loss.
6. Keep the patient strictly NPO (nothing by mouth) and wrap their entire body in warm blankets to prevent hypothermia and shock. Never give water, ice chips, food, or oral pain pills to a patient with an abdominal wound, even if they beg for water due to thirst from blood loss. Tell the patient to support the dressing gently with their hands if they feel an urge to cough or vomit.

Emergency decision tree for open abdominal wounds and evisceration¶

flowchart TD
    Start["Penetrating or Open Abdominal Trauma / Post-Surgical Dehiscence"]
    CallEMS["Call Emergency Medical Services (ALS Paramedics) Immediately<br/>Put on nitrile gloves and expose abdomen by cutting shirt"]
    Position["Position Patient Supine with Knees Flexed (Bent)<br/>Slide pillow or rolled blanket beneath knees to relax abdominal wall<br/>Keep patient strictly NPO (nothing by mouth)"]
    ImpaleCheck{"Is a Knife, Rod, or Object Still Impaled in the Abdomen?"}
    ImpaleProtocol["IMPALED ABDOMINAL OBJECT PROTOCOL<br/>1. DO NOT pull out the impaled object<br/>2. Press sterile gauze around base to control bleeding<br/>3. If bowel protrudes beside blade, cover bowel with moist saline gauze<br/>4. Stabilize blade with bulky twin-roll or ring dressing"]
    EviscCheck{"Are Internal Organs or Fatty Omentum Protruding<br/>Outside the Abdominal Wall (Evisceration)?"}
    OpenNoEvisc["OPEN ABDOMINAL WOUND WITHOUT EVISCERATION<br/>1. Control active external bleeding with firm direct pressure<br/>2. Cover wound with sterile dressing and tape securely<br/>3. Never probe the wound with fingers to see how deep it goes"]
    EviscCare["ABDOMINAL EVISCERATION TWO-LAYER DRESSING PROTOCOL<br/>1. DO NOT push organs back inside cavity<br/>2. Layer 1 (Inner): Cover organs with sterile saline-soaked non-adherent pad<br/>   (OR direct sterile plastic cling wrap if no saline is available)<br/>3. Layer 2 (Outer): Cover wet pad with clean plastic wrap or dry trauma pad<br/>4. Tape outer edges loosely without compressing organs"]
    ShockCare["Prevent the Lethal Trauma Triad (Hypothermia, Acidosis, Coagulopathy)<br/>1. Wrap patient head-to-toe in warm blankets / foil thermal blanket<br/>2. Re-wet inner dressing with warm sterile saline if it begins drying<br/>3. Monitor pulse, skin color, and breathing every 5 minutes"]

    Start --> CallEMS
    CallEMS --> Position
    Position --> ImpaleCheck
    ImpaleCheck -->|Yes: Object Impaled| ImpaleProtocol
    ImpaleCheck -->|No: No Object Present| EviscCheck
    EviscCheck -->|No: Organs Inside| OpenNoEvisc
    EviscCheck -->|Yes: Organs Protruding| EviscCare
    ImpaleProtocol --> ShockCare
    OpenNoEvisc --> ShockCare
    EviscCare --> ShockCare

Comparing abdominal trauma presentations and surgical emergencies¶

Abdominal injuries range from blunt hidden solid-organ ruptures to open penetrating slashes and post-surgical wound separations. Understanding what lies in each abdominal quadrant and how hollow versus solid organs behave helps rescuers anticipate shock and peritonitis.

Anatomy and physiology of an abdominal evisceration¶

Why the Small Intestine and Greater Omentum protrude first¶

The peritoneal cavity houses both fixed retroperitoneal organs (kidneys, pancreas, duodenum, abdominal aorta, and inferior vena cava) and mobile intraperitoneal organs suspended on flexible folds of tissue. When the muscular abdominal wall is sliced open and intra-abdominal pressure rises (as the victim cries out, tenses their core muscles, or coughs), the two most mobile structures inside the belly are immediately pushed out through the gap:

1. The Greater Omentum: A yellow-gold, lacy apron of vascular adipose (fat) tissue that hangs down from the stomach over the intestines like a protective curtain. In small stab wounds, a plug of yellow-pink omentum often herniates out first, partially plugging the hole.
2. The Small Intestine (Jejunum and Ileum): Roughly 6 meters (20 feet) of muscular, pinkish-tan peristaltic tubing attached to the back wall of the abdomen by a fan-shaped sheet of tissue called the mesentery, which carries the superior mesenteric artery branches, veins, and lymphatics.

The three physiological traps that threaten an eviscerated patient¶

1. Mesenteric Venous and Arterial Strangulation: As loops of bowel squeeze out through a narrow, 3-to-6-centimeter (1-to-2.5-inch) tear in the tough abdominal fascia, the edges of the fascia pinch the base of the protruding bowel and its mesentery like a tight ring. Because veins have thin walls and low pressure, venous outflow from the protruding bowel is pinched off first while high-pressure arterial blood keeps pumping in. Within minutes, the trapped loop of intestine swells up with edema, which makes the fascial ring even tighter, eventually cutting off arterial inflow and turning the pink glistening bowel dark purple or black (ischemic bowel necrosis / infarction). Trying to forcefully shove this swollen bowel back through the tight hole kinks and tears the mesenteric vessels completely.
2. Serosal Desiccation and Bacterial Translocation: Exposed to dry outdoor air, wind, or dry cotton bandages, the delicate serosal cells lining the outside of the intestine dehydrate and die within 15 to 30 minutes. Once the serosa dries out and cracks, bacteria inside the gut lumen translocate across the weakened wall, and post-surgical adhesions or intestinal fistulas become almost inevitable.
3. Massive Evaporative Heat Loss and the "Lethal Trauma Triad": The human peritoneal cavity and intestines receive nearly 25 percent of resting cardiac output and have a massive warm wet surface area. Exposing wet, vascular loops of bowel to ambient air acts like a giant evaporative radiator, dropping the patient's core body temperature rapidly. In trauma medicine, Hypothermia (core temperature below 35 degrees Celsius / 95 degrees Fahrenheit) inactivates blood-clotting enzymes, triggering Coagulopathy (uncontrollable microvascular bleeding) and Metabolic Acidosis from tissue hypoxia, a self-reinforcing downward spiral known as the Lethal Trauma Triad.

Step-by-step technique: Managing an abdominal evisceration¶

Step 1: Scene safety, gloves, and knee-flexed positioning¶

1. Put on clean medical nitrile gloves (or wash your hands and use the cleanest barrier available if no gloves are present).
2. Lay the patient flat on their back (supine) on the ground, bed, or stretcher. Never let a patient with an abdominal evisceration stand up, walk to the ambulance, or sit upright at 90 degrees, as gravity and upright abdominal pressure will push massive amounts of additional bowel out of the wound.
3. Flex the knees and hips: Gently bend the patient's knees upward to a 30-to-45-degree angle and slide a thick rolled blanket, pillow, backpack, or folded coat underneath their knees so their legs rest effortlessly without muscle effort. This single maneuver takes mechanical tension off the rectus abdominis fascia and immediately reduces the squeezing pressure on the protruding bowel.

Step 2: Expose the wound and handle displaced loops safely¶

1. Use scissors or trauma shears to cut the shirt, belt, and waistband open around the wound. Never pull clothing upward over exposed organs; if a piece of cloth is stuck directly to the bowel, cut around it and leave the stuck patch in place to be soaked off with warm saline in the hospital.
2. Never push organs back inside the abdomen.
3. What if a loop of intestine is hanging off the side of the torso into dirt, gravel, or glass on the ground? While you must never push bowel back inside the abdominal cavity, you also cannot leave a loop of intestine dangling over the edge of the flank into dirty gravel or kinked sharply over the skin edge. Using two gloved hands (or a sterile saline-soaked dressing), gently rinse gross gravel off with sterile saline if available and lift the dangling loop without twisting it so it rests gently on top of the patient's own abdominal skin right next to the wound.

Step 3: Build the Two-Layer Moist-and-Occlusive Dressing¶

To keep the bowel viable, wet, and warm, build a two-layer sandwich dressing (or use the direct sterile cling-wrap method):

• Option A: The Classic Two-Layer Saline + Occlusive Sandwich (ATLS & Red Cross Standard)
• Inner Moist Layer: Take the largest sterile trauma dressing, sterile abdominal pad (ABD pad), sterile surgical towel, or clean lint-free cloth available. Pour sterile 0.9% normal saline (or clean potable drinking water if sterile saline is unavailable; warmed to body temperature 37 degrees Celsius / 98.6 degrees Fahrenheit if possible, never ice-cold) over the dressing until it is thoroughly dampened, then lay it gently over the entire mound of protruding organs.
• Outer Occlusive Vapor-and-Heat Barrier: Immediately cover the wet inner dressing with a sheet of clean plastic food cling wrap, a sterile plastic burn sheet, clean aluminum foil, a plastic bag cut open, or a thick dry multi-trauma dressing. This outer layer stops the wet inner dressing from drying out in the wind and stops evaporative cooling from chilling the patient into hypothermia.
• Tape the perimeter loosely: Tape the four outer edges of the plastic cover gently to the intact skin of the flanks and chest without pressing down on top of the bowel mound.
• Option B: Direct Clean Plastic Cling-Wrap Application (UK NHS, ANZCOR, and Paramedic Field Standard)
• If you do not have sterile saline and thick lint-free trauma pads immediately on hand, clean household polyvinyl chloride (PVC) kitchen cling wrap (pulled fresh after discarding the outer turn of the roll) or a sterile plastic burn sheet can be laid directly and loosely in longitudinal strips over the moist protruding bowel. Cling wrap is smooth, completely non-adherent (it will never stick to or tear the serosa), transparent (allowing trauma surgeons to inspect bowel color and perfusion immediately without unwrapping the patient), waterproof, and traps natural peritoneal moisture and heat. Never wrap cling wrap circumferentially tight around the torso.

Special scenario: Postoperative surgical wound dehiscence at home¶

Roughly half of all abdominal eviscerations seen by emergency medical services are not caused by stabbings or car crashes at all; they occur at home 5 to 10 days after a major abdominal surgery (laparotomy, C-section, bowel resection, or hernia repair) when the deep fascial stitches give way, an emergency called acute abdominal wound dehiscence or "burst abdomen".

The warning sign that precedes surgical evisceration by hours¶

Before a surgical incision pops completely open, the deep fascial layer typically separates first while the outer skin staples or stitches are still holding on: * The "Salmon-Colored Fluid" Sign: The patient feels a sudden painless "pop" or tearing sensation inside their incision after coughing, sneezing, vomiting, or getting out of bed, followed by a sudden soaking gush of pinkish-orange, watery fluid (serosanguinous peritoneal fluid, classically described by surgeons as "salmon-colored fluid") soaking through their shirt or surgical bandage. * Whenever a post-surgical abdominal incision suddenly leaks a large volume of pinkish-orange watery fluid, fascial dehiscence has occurred and full bowel evisceration is imminent.

Immediate home first aid for surgical dehiscence or evisceration¶

1. Have the person lie flat on the bed or floor immediately with a pillow under their bent knees. Do not let them walk to the bathroom or car.
2. Teach "Pillow Splinting" for coughing or vomiting: If the patient feels another cough, sneeze, or dry heave coming on, have them gently hold a soft bed pillow or folded bath towel across the surgical dressing with both hands to support the abdominal wall so more bowel is not forced out.
3. Cover any exposed bowel or open incision with a clean towel soaked in sterile saline or cooled boiled/bottled drinking water, covered loosely with kitchen cling wrap.
4. Call 911 / 112 / 999 for ambulance transport back to the surgical hospital and keep the patient strictly NPO (nothing to eat or drink).

Recognizing internal abdominal bleeding and protecting against shock¶

Because 70 to 80 percent of traumatic abdominal eviscerations are accompanied by internal lacerations to the liver, spleen, mesentery, or major retroperitoneal blood vessels, you must continuously monitor the patient for hypovolemic hemorrhagic shock:

Early vs. Late signs of abdominal hemorrhagic shock¶

• Early Compensated Shock: Anxiety, restlessness, pale cool clammy skin, rapid heart rate (tachycardia > 100 bpm), slightly rapid breathing, and intense thirst (remember: never give water to drink, even when the patient begs; you may only lightly moisten their dry lips with a damp cloth).
• Signs of Peritoneal Irritation (Hemoperitoneum / Peritonitis): Diffuse tenderness, involuntary guarding (the abdominal muscles clamp down rigid like a wooden board even when touched lightly), progressive abdominal distension (though note that the belly can hold 2 to 3 liters of blood before visibly expanding), and Kehr's sign (sharp pain felt at the tip of the left shoulder caused by blood from a ruptured spleen irritating the phrenic nerve).
• Late Decompensated Shock: Falling blood pressure (weak or absent radial pulse at the wrist), confusion or lethargy, mottled bluish skin, and rapid shallow gasping breaths.

Active thermal management¶

1. Insulate beneath AND above the patient: Cold pavement or metal floors drain body heat three times faster by conduction than cold air does by convection. Slide a folded blanket, cardboard, or jacket underneath the patient's back and legs if possible without jarring their torso.
2. Wrap head-to-toe in warm blankets: Cover the chest, arms, legs, and head with wool or fleece blankets and a metallic foil space blanket to stop shivering and preserve blood clotting function until the patient reaches the operating room.

Four-quadrant abdominal organ map and referred pain patterns¶

Even when an abdominal wound is small or when blunt trauma leaves the skin completely intact, clinicians divide the abdomen into four anatomical quadrants centered at the umbilicus (navel) to predict which solid or hollow organs are injured and why pain often radiates to distant body sites:

First aid care for an open abdominal wound requires calm composure when everyone else at the scene may panic at the sight of the injury. Consider taking a certified first aid, Stop the Bleed, or emergency medical responder course through your national Red Cross or Red Crescent society, the American College of Surgeons, or St John Ambulance.

Fesili e fai soo¶

Punavai ua siaki¶

• American College of Surgeons (ACS, United States): Advanced Trauma Life Support (ATLS) Student Course Manual: Abdominal and Pelvic Trauma, Evisceration, and Hemorrhagic Shock.
• National Association of Emergency Medical Technicians (NAEMT, United States): Prehospital Trauma Life Support (PHTLS): Management of Abdominal Evisceration and the Lethal Trauma Triad.
• Committee on Tactical Combat Casualty Care (CoTCCC / Joint Trauma System, United States): TCCC Guidelines for Medical Personnel: Penetrating Abdominal Trauma and Evisceration Management.
• National Health Service (NHS, United Kingdom) & Joint Royal Colleges Ambulance Liaison Committee (JRCALC): Clinical Practice Guidelines: Abdominal Trauma, Evisceration, and Occlusive Cling-Film Dressings.
• Australian and New Zealand Committee on Resuscitation (ANZCOR, Australia and New Zealand): First Aid Management of Open Abdominal Injuries and Evisceration.
• International Federation of Red Cross and Red Crescent Societies (IFRC, International): International First Aid, Resuscitation, and Education Guidelines: Severe Bleeding and Penetrating Torso Injuries.

Taiala fa'atatau¶

• Fa'asalaina ma fa'apipi'i fa'amautu mea mai fafo
• Su'e manu'a fatafata ma pa'u le mama fesoasoani muamua
• Severe bleeding control and tourniquets
• Shock recognition and emergency care
• Hypothermia and cold exposure prevention
• Numera o fa'alavelave fa'afuase'i ma fe'au fa'ava-o-malo