Abdominal Trauma, Penetrating

Basics

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

80% of gunshot wounds and 20–30% of stab wounds result in significant intra-abdominal injury. Commonly injured structures include:
  • Liver (37%)
  • Small bowel (26%)
  • Stomach (19%)
  • Colon (17%)
  • Major vessel (13%)
  • Retroperitoneum (10%)
  • Mesentery/omentum (10%)
  • Other:
    • Spleen (7%)
    • Diaphragm (5%)
    • Kidney (5%)
    • Pancreas (4%)
    • Duodenum (2%)
    • Biliary (1%)

Diagnosis

Signs and Symptoms

  • 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.

Essential Workup

  • 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

Lab
  • Hemoglobin or hematocrit:
    • Repeated measurements to assess for ongoing hemorrhage
  • Urinalysis for blood to assess for possible genitourinary tract damage
  • ABG:
    • Base deficit may be helpful in assessing hypovolemia and guide volume resuscitation.
  • Type and cross-match for all patients with significant intra-abdominal injuries.

Imaging
  • 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

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

Pre Hospital

  • Controversies:
    • Military antishock trousers (MAST) should not be used.
    • Titrate fluid resuscitation to clinical response.
  • 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

  • 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

Pediatric Considerations
  • 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.

Ed Treatment/Procedures

  • 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

Medication

  • 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:
    • Ampicillin/sulbactam:
      • Adults: 3 g q6h IV (peds: 50 mg/kg IV)
    • Cefotetan:
      • Adults: 2 g q12h IV (peds: 40 mg/kg IV)
    • Cefoxitin:
      • Adults: 2 g q6h IV (peds: 80 mg/kg q6h IV)
    • Piperacillin/tazobactam:
      • Adults: 3.375 g IV (peds: 75 mg/kg IV)
    • Ticarcillin/clavulanate:
      • Adults: 3.1 g IV (peds: 75 mg/kg IV)
  • Additional anaerobic coverage:
    • Clindamycin:
      • Adults: 600–900 mg IV (peds: 10 mg/kg IV)
    • Metronidazole:
      • 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 Care

Disposition

Admission 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

Discharge Criteria
Patients with stab wounds without fascial penetration may be discharged after observation in the ED.

Pearls and Pitfalls

Permissive 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.

Additional Reading

  • 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]

Codes

ICD-9

868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ

ICD-10

  • 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

SNOMED

  • 443183003 Penetrating wound of abdomen (disorder)
  • 283475002 Stab wound of abdomen (disorder)
  • 283545005 gunshot wound (disorder)

Authors

Stewart R. Coffman
Stephen R. Hayden


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