Abdominal Trauma, Penetrating

Basics

Description

  • Penetrating wound from knife, gun, or other foreign object
  • 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

Etiology

Penetrating abdominal trauma most frequently results from gunshot wounds and stab wounds which cause significant intra-abdominal injury. The most commonly injured structures include:

  • Small bowel
  • Liver
  • Colon
  • Abdominal vascular structures

Diagnosis

Signs And Symptoms

  • Spectrum of presentation ranging from localized pain, abdominal distension, to peritoneal signs:
    • High-velocity projectile can cause extensive direct tissue damage
    • Exit wound may be larger than entrance wound, but small entrance and exit wounds can conceal massive internal damage
  • Hypotension, narrow pulse pressure, tachycardia may reflect blood loss and significant injury
  • Remember the borders of the abdomen: Superior from the nipples (anteriorly) or inferior tip of scapula (posteriorly) to inferior gluteal folds

Essential Workup

  • General evaluation and management of trauma patient
  • Thorough exam on front and back of the patient to assess for wounds
  • Indications for immediate laparotomy include:
    • Signs of peritonitis
    • Hypotension/hemodynamic instability
    • Evisceration of abdominal contents
    • Hematemesis or gross blood on rectal
  • Diagnoses of intra-abdominal injury from gunshot wounds to the abdomen are frequently made by laparotomy for unstable patients, stable patients may be candidates for computed tomography (CT) scanning and observation
  • Locally explore stab wounds to anterior abdomen:
    • If the wound penetrates the anterior fascial layer, the patient should undergo diagnostic peritoneal lavage, bedside US, or CT scanning. FAST exam has largely replaced DPL
  • Rectal exam should be done to assess for boney trauma or rectal or sigmoid penetration for lower abdominal injuries
  • Diagnostic laparoscopy is useful in diagnosing diaphragmatic injury and spleen and liver lacerations:
    • May help avoid unnecessary surgery
  • Inquire about use of anticoagulants
  • CT is useful in the evaluation of patients with a suspected retroperitoneal injury:
    • Not reliable for detection of hollow viscus or diaphragmatic injuries

Diagnostic Tests And Interpretation

Lab

  • Check hemoglobin or hematocrit:
    • Repeated measurements to assess for ongoing hemorrhage
  • Check coagulation markers (platelets, prothrombin time, and partial thromboplastin time)
  • Type and cross-match for patients with potential for significant intra-abdominal injuries
  • Chemistry panel
  • Urinalysis for blood to assess for possible genitourinary tract damage
  • ABG:
    • Base deficit may be helpful in assessing hypovolemia and guide volume resuscitation

Imaging

  • Plain films:
    • Obtain after placement of markers for localization of foreign bodies, missiles, associated fractures, and free air
  • Bedside abdominal US (FAST: Focused Abdominal Sonography for Trauma):
    • May reveal intraperitoneal blood or fluid
  • CT with IV contrast for stable patients:
    • Assess for possible retroperitoneal and solid organ injuries

Differential Diagnosis

  • 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

Treatment

Prehospital

  • Caution:
    • Apply sterile dressings to open wounds and moistened sterile dressings to eviscerated bowel
    • Secure impaled foreign objects in place; do not remove them

Initial-Stabilization

  • Ensure airway and breathing stabilization
  • 2 large-bore IV lines with crystalloid infusion
  • If no response to 1 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
  • Consider TXA for hemorrhage

Pediatric Considerations

  • Children in hypovolemic shock should receive 20 mL/kg boluses of crystalloid
  • Children in severe hypovolemic shock should receive 10 mL/kg of packed red blood cells

Ed Treatment

  • Nasogastric tube placement:
    • May decrease aspiration risk
    • May relieve respiratory distress in cases of diaphragmatic injury with herniated abdominal contents in the thorax
    • Blood in nasogastric tube may indicate gastric injury
  • Foley catheter placement:
    • Insert after ruling out urethral injuries
    • Facilitates rapid assessment of genitourinary injury
    • Assists in monitoring of urinary output

Medication

  • Tetanus: 0.5 mL IM
  • Tetanus immunoglobulin: 250 units IM for patients who have not had a complete series
  • Analgesia should be considered. Avoid nonsteroidal anti-inflammatory drugs due to risk of bleeding
  • IV antibiotics: Broad-spectrum antibiotics that provide aerobic and anaerobic coverage in patients requiring surgical management
  • Anticoagulation reversal, as needed

Follow-Up

Disposition

Admission Criteria

  • Patients requiring abdominal surgery
  • Some patients may require admission for expectant management and serial abdominal exams for 24 hr

Discharge Criteria

Patients with stab wounds without fascial penetration may be discharged after thorough evaluation in the ED and evidence of clinical stability

Pearls And Pitfalls

  • Completely exposing the patient and performing a thorough physical exam will minimize overlooking an injury
  • Do not delay the unstable patient going to the operating room in order to further stabilize
  • Spinal immobilization is unnecessary unless there is an obvious spinal cord injury

Additional Readings

  1. Charles K, Brohi K. Penetrating abdominal trauma: guidelines for evaluation. 2004. trauma.org/index.php/main/article/414/
  2. Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68(3):721–733.  [PMID:20220426]
  3. Iflazoglu N, Ureyen O, Oner OZ, et al. Complications and risk factors for mortality in penetrating abdominal firearm injuries: Analysis of 120 cases. Int J Clin Exp Med. 2015;8(4):6154–6162.  [PMID:26131219]
  4. 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]
  5. Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal gunshot wounds: a Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2019;87(5):1220–1227.  [PMID:31233440]
  6. Sarici İS, Kalayci MU. Is computed tomography tractography reliable in patients with anterior abdominal stab wounds? Am J Emerg Med. 2018;36(8):1405–1409.  [PMID:29402685]

Authors

Frances E. Rudolf

Allyson A. Kreshak