Description

• 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

• Small bowel
• Liver
• Colon
• Abdominal vascular structures

Signs and Symptoms

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

• Thorough exam on front and back of patient to assess for wounds
• Diagnoses 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
• Rectal exam should be done to assess for boney trauma or rectal or sigmoid penetration
• 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

• 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

• 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

Pre Hospital

• 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/Therapy

• 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

• 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/Procedures

• Nasogastric tube placement:
  • Will 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
• Anticoagulation reversal, as needed

Disposition

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