Tactical Management of Abdominal and Pelvic Trauma

Abdominal and pelvic trauma account for a significant proportion of preventable deaths in combat and high-risk prehospital environments. These injuries, often resulting from blast, blunt force, or penetrating trauma, pose a unique challenge due to the potential for massive internal hemorrhage, delayed symptom onset, and the absence of immediate surgical or diagnostic support. This chapter presents a comprehensive and tactical approach to the assessment, stabilization, and management of abdominal and pelvic injuries using the MARCH algorithm, combining Tactical Combat Casualty Care (TCCC) and Advanced Trauma Life Support (ATLS) principles. The chapter begins by analyzing combat-relevant mechanisms of injury—such as improvised explosive devices (IEDs), gunshots, falls, and vehicular trauma—and their implications for internal organ damage. Emphasis is placed on recognizing injury patterns through clinical signs alone, particularly in austere settings where X-rays, Focused Assessment with Sonography in Trauma (FAST), or CT imaging are unavailable. Practical guidance is provided on managing non-compressible hemorrhage, open-book pelvic fractures, and hollow viscus injuries, including the use of pelvic binders, early tranexamic acid (TXA), permissive hypotension, and hemostatic resuscitation. Organ-specific management strategies are outlined for liver, spleen, bowel, diaphragm, and genitourinary trauma, with field-compatible decision points for surgical referral. Prolonged field care principles are incorporated, highlighting continuous reassessment, hypothermia prevention, pain control, and triage for tactical evacuation. A detailed combat case scenario illustrates step-by-step intervention from the point of injury through prolonged care and eventual evacuation. This chapter empowers medics, field surgeons, and tactical providers to make high-stakes decisions under fire, prioritize lifesaving care, and reduce mortality through timely, evidence-informed, protocol-based trauma management in the most resource-constrained environments.