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Subsections
Penetrating Abdominal Trauma

Trauma: Abdomen

Penetrating Abdominal Trauma

Background

  1. Definition
    • Wound/trauma penetrating through the abdomen
  2. Synopsis
    • Caused by introduction of weapon or object into abdominal cavity
      • May occur from stabbing/gunshot wound
    • Injury size is equivalent to abdominal viscera affected and proximity to entrance site
    • Both intraperitoneal and extraperitoneal structures can be injured
      • Intraperitoneal structures
        • Liver
        • Spleen
        • Small bowel
        • Stomach
        • Transverse and sigmoid colon
        • Gallbladder
      • Extraperitoneal structures
        • Bladder, ureters, kidneys
        • Ascending and descending colon
        • Rectum
        • Pancreas
        • Duodenum
        • Aorta
        • Iliac arteries and veins
        • Vena cava

Pathophysiology

  1. Anatomy (View image)
    • Borders of abdomen
      • Anterior
        • Costal margins to groin
        • Laterally goes to anterior axillary lines
      • Back
        • Costal margins to groin
      • Flank
        • Tip of scapula to iliac crest
        • Laterally between posterior axillary lines
  2. Mechanism
    • Peritoneal injury can occur with lower chest/back wounds
      • Diaphragm moves upward during inspiration
        • 4th intercostal space anteriorly
        • 6th - 7th intercostal space posteriorly
    • Each type of injury has distinct injury patterns
      • Stab wounds
        • Can be caused by many instruments
          • Knives
          • Other implements
            • Ice picks
            • Industrial implements
          • Projectiles (not GSW)
            • High velocity
            • Low velocity
        • Organs commonly injured
          • Small bowel (29%)
          • Liver (28%)
          • Colon (23%)
        • Injury usually in direct path of instrument
        • Peritoneal penetration
          • Only about 1/3 of stab wounds
          • 50% of these require surgery
        • Important things to know
          • Number of wounds
          • Wound location
          • Weapon type / size
          • Likely path of instrument
            • Try to determine this
          • Is peritoneum violated?
    • Injury physiology
      • Tissue gets lacerated by the implement
      • Venous injuries
        • Surrounding tissue tamponades bleeding
      • Arterial injuries
        • Partial transections keep bleeding
        • Complete transections may contract and stop bleeding
      • Blood in peritoneum
        • Irritation/pain
        • May see tachycardia
        • May see bradycardia
          • Small amounts of blood loss
          • Large blood loss - preterminal event
      • Organ injury (solid/hollow)
        • Leak fluids into peritoneal space
        • Local wound pain
        • Somatic pain
          • Poorly localized
          • Often back or shoulder
      • Gunshot wounds
        • 85% penetrate the peritoneum
        • 95% require surgical intervention
        • Much broader pattern of injuries
        • Often see multiple organ injuries
          • Same organ injured > 1 time
            • Small bowel
          • Multiple organs injured
        • Anything in path of bullet has a loss of integrity
        • Injury can be away from path of projectile
          • Cavitation
        • Blood in peritoneum
          • Irritation/pain
          • May see tachycardia
          • May see bradycardia
            • Small amounts of blood loss
            • Large blood loss - preterminal event
        • Organ injury (solid/hollow)
          • Leak fluids into peritoneal space
          • Local wound pain
          • Somatic pain
            • Poorly localized
            • Often back or shoulder
  3. Etiology/Risk factors
    • Foreign object pierces the skin and enters the body creating a wound
    • Violence
      • Fragments of a broken bone
      • Gunshots
      • Knife wounds
      • Ballistic injuries
    • Industrial accidents
  4. Epidemiology
    • Incidence/Prevalence
      • 35% of pts admitted to urban trauma centers
      • 12% of those admitted in suburban/rural centers
      • 2-7x higher in non-Hispanic black males
      • 90% male gender
      • Increased incidence where
        • Weapons available
        • Active military conflicts
    • Morbidity/Mortality
      • 40% of homicides and 16% of suicides
        • Due to firearm involved injuries to the torso
      • Traumatic injury (as a whole)
        • 3rd leading cause of death
          • 1st in ages 1-44 years

Diagnosis

  1. History/Symptoms
    • Timing of injury
    • Distance from attacker
    • Type of weapon
      • Stab wounds
        • Type / size of implement
        • Number of times stabbed
      • Gunshot wounds
        • Number of shots fired
        • Caliber of weapon
        • Distance from assailant
        • Determine trajectory
          • Important!
          • Did bullets traverse peritoneal cavity
    • Amount of external bleeding at scene
    • Initial level of consciousness
  2. Physical Exam/Signs
    • Note:
      • Negative exam does not preclude injury
    • Unreliable!
    • Perform serial exams
    • External inspection
      • Count number of entrance/exit wounds
        • Odd number may indicate retained bullet
      • Remember that the diaphragm moves
        • Descends to L2 - L3 posteriorly
        • Rises to T4-T6
      • Injuries lateral to anterior axillary line
        • May involve only retroperitoneum
        • May involve intraperitoneal structures
          • Depends on patient position relative to weapon
      • Log roll the patient (View Video)
        • Check back, buttocks
    • Signs of intra-abdominal injuries
      • Often show need for surgery (in setting of penetrating trauma)
        • Hypotension
        • Tachycardia
        • Tachypnea
        • Narrow pulse pressure
        • Increasing pain
        • Peritoneal signs
        • Poorly localized pain that does not resolve (serial exams)
          • Central abdominal pain - midgut injuries
          • Lateral/low abdominal pain - hindgut injuries
          • Intrascapular pain - diaphragmatic irritation
          • Boring mid-epigastric pain - pancreas
        • Tympany of abdomen
          • Hollow viscus injury
          • R/O esophageal intubation
        • Dullness to percussion
          • Intra-abdominal fluid/blood
        • Abdominal distention
          • Especially if unresponsive hypotension
        • Evisceration
    • Pelvic exam in female patients
    • Rectal exam
      • Tone
      • Blood
  1. Labs/Tests
  2. Imaging
    • X-rays
      • Chest, abdomen, pelvis
      • CXR may show
        • Hemo/pneumothorax
        • Free air under diaphragm
      • Abdominal X-ray
        • Place marker clips at all entrance/exit wounds
        • Helps determine track of bullet
    • U/S
      • Used in hemodynamically unstable pts
      • FAST exam to visualize hemoperitoneum/hemothorax
      • Advantages
        • Rapid/noninvasive
      • Disadvantage
        • Not very useful for diagnosing solid organ injury
    • CT imaging
      • Abdominal Evisceration Axial View (View image)
      • Knife stab Axial View (View image)
      • Preferred method for hemodynamically stable pts
      • IV contrast used to highlight vascular anatomy, vessel patency, and organ structure (Go to Evidence-Based Inquiry)
      • Oral contrast for GI organs in the abdomen and pelvis; rectal admin of contrast enhances images of the distal GI tract (Go to Evidence-Based Inquiry)
      • Better for evaluating solid organ injury
      • Allows localization and evaluation of extent of injury
        • Help decide conservative vs surgical management
      • Noninvasive
      • Disadvantage:
        • Need for transport, time, cost, contrast
      • Contraindication
        • Obvious need for laparotomy
    • Diagnostic Peritoneal Lavage (DPL)
      • Has largely been replaced with U/S and CT
      • Contraindications
        • Obvious need for laparotomy
        • Pregnancy
        • Pelvic fracture
      • Positive if:
        1. > 10 cc gross blood, enteric contents
        2. Bloody lavage effluent
        3. > 100,000 RBC/mm3 or >500 WBC/mm3
        4. Amylase > 175 IU/dl
        5. DPL fluid exits through CT or Foley catheters
        6. Bacteria, vegetable fibers or food present
  3. Differential Diagnosis

Treatment

  1. Initial/Prep/Goals
    • ATLS as usual
    • DO NOT remove impaling objects
      • Must be done in operating room
    • FAST scan/DPL
    • NG tube/foley PRN
    • Principles of surgery
      • Management of bleeding
      • Quick identification of any serious injury
      • Rapid control of contamination
      • Reconstruction when possible
    • Consult with a vascular surgeon is highly recommended
      • If assoc/ vascular injury
  2. Surgical/Procedural
    • Rapid surgical evaluation and intervention
      • Absolute indications for surgery:
        • Hemodynamic instability
        • Major vascular injury
          • Includes devascularized organs
        • Evisceration
        • Peritoneal signs
        • Pneumoperitoneum
        • Evidence of injury to the diaphragm
        • Neurologic injury with cord compromise
        • Significant intraperitoneal blood
        • Evidence of hollow viscus perforation
    • Frequently reassess patient
  3. Medical/Pharmaceutical
  4. Local Wound Exploration
    • Only experienced practitioners surgeons
      • Trauma/surgery help
    • Stab wounds only
    • Best for lacerations over rectus abdominus muscles
    • Not recommended for flank wounds
    • A sterile procedure
      • Prep and drape
      • Anesthesia
        • Lidocaine with / without epi
      • Widen wound with gentle traction
      • Gently probe with hemostat
        • See if tract exists
      • May extend wound slightly
        • Use # 10 blade
      • Identify posterior rectus sheath
        • White layer directly under muscle
      • Peritoneum violated if
        • You see yellow fat
      • Formal surgery needed
  5. Complications
    • Open wounds
    • Sepsis
    • Fistulas
    • Wound dehiscence
    • Colostomy/ileostomy
    • Short bowel syndrome
  6. Prevention
    • Firearm training/education

Disposition

  1. Admission Criteria
    • Admit all until cleared for discharge
  2. Consult(s)
    • Surgery, radiology as needed
  3. Discharge/Follow-up Instruction
    • May possibly discharge if:
      • Superficial wound that does not penetrate fascia
    • Follow-up as per care team orders

Evidence-Based Inquiry

  1. When is contrast indicated for thoracic and abdominal computed tomography scanning?

References

  1. Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC et al. The Trauma Manual 2nd edition. Lippincott Williams and Wilkins. 2002
  2. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. Student Course Manual 1997. 6th edition. American College of Surgeons
  3. Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A comprehensive Study Guide. 6th edition. American College of Emergency Physicians. McGraw Hill
  4. MATRAC Trauma Guideline Manual. Buechler CM. St. Joseph Health System. Asheville, North Carolina 2000-07
  5. Cayten CG, Nassoura ZE: Abdomen. In: Ivatury RR, ed. The Textbook of Penetrating Trauma. 1st ed. Williams & Wilkins; 1996:281-299
  6. Penetrating Abdominal Trauma. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK459123/. [Accessed October 2024]

Contributor(s)

  1. Singh, Ajaydeep, MD
Updated/Reviewed: October 2024