Abdominal Trauma, Penetrating
80% of gunshot wounds and 20–30% of stab wounds result in significant intra-abdominal injury. Commonly injured structures include:
- Solid organ injury usually results in hemorrhage.
- Hollow viscus injury can lead to spillage of bowel contents and peritonitis.
- Associated conditions:
- Injury to both thoracic and abdominal structures occurs in 25% of cases.
- Liver (37%)
- Small bowel (26%)
- Stomach (19%)
- Colon (17%)
- Major vessel (13%)
- Retroperitoneum (10%)
- Mesentery/omentum (10%)
- Spleen (7%)
- Diaphragm (5%)
- Kidney (5%)
- Pancreas (4%)
- Duodenum (2%)
- Biliary (1%)
- Penetrating wound from knife, gun, or other foreign object
- Spectrum of presentation ranging from localized pain to peritoneal signs:
- High-velocity projectile can cause extensive direct tissue damage.
- Secondary missiles and temporary cavitation of effected structures
- Exit wound may be larger than entrance wound, but small entrance and exit wounds can conceal massive internal damage.
- Remember the borders of the abdomen: Superior from the nipples (anteriorly) or inferior tip of scapula (posteriorly) to inferior gluteal folds.
- Diagnosis of intra-abdominal injury from gunshot wounds to the abdomen are made by laparotomy in the operating room.
- Locally explore stab wounds to anterior abdomen:
- If the wound penetrates the anterior fascial layer, the patient should undergo diagnostic peritoneal lavage or bedside US.
- Diagnostic laparoscopy is useful in diagnosing diaphragmatic injury and spleen and liver lacerations:
- May help avoid unnecessary surgery.
- CT is useful in the evaluation of patients with a suspected retroperitoneal injury:
- Not reliable for detection of hollow viscus or diaphragmatic injuries
- If 10,000 RBC/mm3 or more are found in the diagnostic peritoneal lavage fluid, the patient should undergo laparotomy.
- If <10,000 RBC/mm3 are present, the patient should be observed for 8–24 hr for the development of peritoneal signs.
Diagnostic Tests and Interpretation
- Hemoglobin or hematocrit:
- Repeated measurements to assess for ongoing hemorrhage
- Urinalysis for blood to assess for possible genitourinary tract damage
- Base deficit may be helpful in assessing hypovolemia and guide volume resuscitation.
- Type and cross-match for all patients with significant intra-abdominal injuries.
- Plain films:
- Obtain after placement of markers for localization of foreign bodies, missiles, associated fractures, and free air.
- IV pyelogram:
- For possible renal injury
- Bedside abdominal US (FAST: Focused abdominal sonography for trauma):
- May reveal intraperitoneal blood or fluid
- CT with IV contrast in experienced facilities and with stable patients:
- For possible retroperitoneal and solid organ injuries
- In cases of upper abdominal wounds, consider the possibility of intrathoracic injury.
- In cases of wounds to the lower thoracic area, consider the possibility of intra-abdominal injury.
- Military antishock trousers (MAST) should not be used.
- Titrate fluid resuscitation to clinical response.
- Apply sterile dressings to open wounds and moistened sterile dressings to eviscerated bowel.
- Secure impaled foreign objects in place; do not remove them.
- 2 large-bore IV lines with crystalloid infusion
- If no response to 2 L of crystalloid, infuse 2–4 units packed red blood cells:
- May use O negative blood initially if patient is unstable
- Type-specific and cross-matched blood when it becomes available
- 100% oxygen by nonrebreather face mask
- Children in hypovolemic shock should receive 20 mL/kg boluses of crystalloid.
- Children in severe hypovolemic shock should receive 1 mL/kg of packed red blood cells.
- Age <8 yr is a relative contraindication for diagnostic peritoneal lavage.
- Nasogastric tube placement:
- Will decrease aspiration risk
- Place nasogastric tube before performing diagnostic peritoneal lavage to decompress stomach and reduce risk of iatrogenic injury.
- May relieve respiratory distress in cases of diaphragmatic injury with herniated abdominal contents in the thorax
- Foley catheter placement:
- Insert after ruling out urethral injuries
- Facilitates rapid assessment of genitourinary injury
- Assists in monitoring of urinary output
- Tetanus if appropriate; tetanus immunoglobulin if primary tetanus series not administered
- Tetanus: 0.5 mL IM
- Tetanus immunoglobulin: 250 units IM for patients who have not had a complete series
- IV antibiotics: Antibiotics with coverage against gram-negative and anaerobic organisms:
- Adults: 3 g q6h IV (peds: 50 mg/kg IV)
- Adults: 2 g q12h IV (peds: 40 mg/kg IV)
- Adults: 2 g q6h IV (peds: 80 mg/kg q6h IV)
- Adults: 3.375 g IV (peds: 75 mg/kg IV)
- Adults: 3.1 g IV (peds: 75 mg/kg IV)
- Additional anaerobic coverage:
- Adults: 600–900 mg IV (peds: 10 mg/kg IV)
- Adults: 1 g IV (peds: 15 mg/kg IV)
- Combination therapy:
- Adults: Ampicillin 500 mg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 1 g IV
- Peds: Ampicillin 50 mg/kg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 15 mg/kg IV
Ongoing CareAdmission Criteria
- Patients requiring abdominal surgery
- Observe the following patients for at least 8 hr:
- Patients with negative findings on diagnostic peritoneal lavage, CT, or US. During hospitalization, the following are necessary:
- Frequent abdominal exam
- Repeated hematocrit levels at regular intervals
Patients with stab wounds without fascial penetration may be discharged after observation in the ED.
Pearls and PitfallsPermissive hypotension is gaining support as a resuscitative principle:
- Avoid normal or near normal BP.
- Avoid overaggressive resuscitation with crystalloids.
- Completely exposing the patient will minimize overlooking an injury.
- Spinal immobilization is unnecessary unless there is an obvious spinal cord injury.
- Goodman CS, Hur JY, Adajar MA, et al. How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and meta-analysis. AJR Am J Roentgenol. 2009;193(2):432–437. [PMID:19620440]
- Kirkpatrick AW, Sirois M, Ball CG, et al. The hand-held ultrasound examination for penetrating abdominal trauma. Am J Surg. 2004;187:660–665. [PMID:15135687]
- Oyo-Ita A, Ugare UG, Ikpeme IA. Surgical versus non-surgical management of abdominal injury. Cochrane Database Syst Rev. 2012;14(11):CD007383.
- Sebesta J. Special lessons learned from Iraq. Surg Clin North Am. 2006;86(3):711–726. [PMID:16781278]
868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ
- Unsp opn wnd abd wall, unsp quadrant w penet perit cav, init
- Pnctr w/o fb of abd wall, unsp Quadrant w penet perit cav, init
- 443183003 Penetrating wound of abdomen (disorder)
- 283475002 Stab wound of abdomen (disorder)
- 283545005 gunshot wound (disorder)
Stewart R. Coffman
Stephen R. Hayden
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Abdominal Trauma, Penetrating
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