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Objective The aim of this study was to determine the impact of abdominal prehospital ultrasound (PHUS) on patient care in a Dutch physician-staffed Helicopter Emergency Medical Service (HEMS) and to determine its diagnostic performance. Patients and methods We carried out a retrospective analysis of abdominal ultrasound (US) examinations performed by the HEMS of Nijmegen, the Netherlands, from January 2007 until December 2016. Data including patient demographics, type of incident, abdominal US findings, impact on treatment decisions, and the physicians' narrative report were retrieved from the HEMS database and analyzed. PHUS diagnostic performance was compared with computed tomography scan or laparotomy. Results Of 17 077 recorded scrambles and 8699 patients treated, 1583 underwent 1631 abdominal US examinations. After eliminating missing data, 251 impacts on treatment in 194 out of 1539 PHUS examinations were identified (12.6%, 95% confidence interval: 10.9-14.3). This affected 188 out of 1495 (12.6%) patients. The four main categories of treatment decisions impacted by PHUS were information provided to the destination hospital (45.4%); mode of transportation (23.5%); choice of destination hospital (13.1%); and fluid management (11.6%). The sensitivity of prehospital abdominal US for hemoperitoneum was 31.3%, specificity was 96.7%, and accuracy was 82.1%. Conclusion Abdominal PHUS in our setting impacts treatment decisions significantly. Therefore, it is a valuable tool in the Dutch HEMS setting and probably beyond.