Penetrating abdominal trauma

Most penetrating abdominal trauma in New Zealand occurs from stab wounds. Gun-shot and other missile/projectile injuries present less frequently.1

 

Penetrating abdominal trauma management algorithm 

Penetrating abdo flow website

 

Management pearls

 

  • Intraabdominal injuries from stab wounds should be considered if the wound is from the nipples (T4) to the groin crease anteriorly, and from the tips of scapulae (T4) to the gluteal folds posteriorly.

 

  • Gunshot wounds and projectiles are more likely to cause serious intraabdominal injury and can cause injuries or lodge quite distant from the entry wound
    • any entry wound on the torso could have a trajectory which could cause intra-thoracic injury.
    • The number of wounds + foreign bodies seen on AXR/CXR should be an even number (have a think about this!). If not you are
      • missing a wound
      • missing a bullet (expand imaging ie: image the neck, chest and abdo/pelvis)
      • or the patient has been shot before

 

  • If a stab wound is thought to be superficial, careful exploration in the ED can be performed. If the wound base is clearly seen in the subcutaneous tissue with no violation of the abdominal rectus fascia, the wound can be irrigated and closed (and the patient discharged if clinically appropriate). Do not probe wounds blindly.

 

 

Mechanism of injury – history

 

Stab wounds

  • Type of weapon
  • Length and diameter of blade
  • Estimation of how deeply object penetrated body
  • Direction of penetration

 

Gunshot wounds

  • Type of gun (eg: pistol, shotgun)
  • Calibre of bullet
  • Distance fired from

 

 

Clinical findings

Look

  • examine patient carefully for all wounds
    • don’t forget to look in the axilla, groin, perineum, between buttocks
    • in the case of projectiles: look for possible exit wounds

Palpate

  • examine abdomen for abdominal pain and peritonism
  • If the wound might have a trajectory across the rectum, a careful PR should be performed

 

Investigations

Bloods

Standard trauma blood tests looking in particular for a decrease in haemoglobin

Plain radiographs

  • An erect CXR may show intraperitoneal free air – however, this could be external air entrained into the peritoneal cavity by the penetrating object. It is most useful for determining potential thoracic injury.
  • If the injury is caused by a GSW or projectile – use a paperclip taped over the skin that is open for posterior wounds and closed for anterior wounds and request an AXR and CXR

eFAST

  • USS not validated for penetrating trauma
  • If free fluid is seen on FAST, this would be an indication for further evaluation
  • A negative FAST does not rule out intraabdominal injury in penetrating trauma
  • For patients with upper abdominal stab wounds or any projectile wound: if unstable – eFAST can be utilised to rapidly assess for cardiac tamponade or tension pneumothorax/massive haemothorax.

CT abdomen/pelvis with contrast

Stable patients with penetrating injuries to the back, flank or buttock should have a CT scan, ideally with rectal contrast.

 

While there has been an international trend towards selective non-operative management of anterior penetrating abdominal wounds, the NRTN advocates that most of these patient should proceed directly to laparoscopy +/- laparotomy. There will be circumstances where other investigations (eg: CT) might be obtained first, but this would be at the discretion of the trauma specialist on call
.

 

Management

  • Indications for immediate laparotomy
    • peritonism/diffuse abdominal tenderness
    • hypotension/shock
    • evisceration
    • penetrating object still in situ
  • Superficial wounds

Patients with superficial stab wounds with a wound base clearly visualised not penetrating the anterior rectus fascia can have their wounds repaired in ED and discharged if appropriate

  • Anterior wounds breaching fascia (patient stable)

Laparoscopy

  • Posterior/flank wounds (patient stable)

Guided by CT results

 

 

Disposition – interhospital transfer guidelines

 

penetrating abdo destination

 

References

 

  1. Bhagvan S, Ng A, Civil I. Penetrating thoraco‐abdominal injuries: the Auckland City Hospital experience. ANZ journal of surgery. 2011 Sep 1;81(9):595-600.

 

About this guideline

Published: February 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years