Author:
Frances E.Rudolf
Allyson A.Kreshak
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
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
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 & 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
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/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
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/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
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
ICD9
868.10 Injury to other intra-abdominal organs with open wound into cavity, unspecified intra-abdominal organ
ICD10
S31.609A Unsp opn wnd abd wall, unsp quadrant w penet perit cav, init
S31.639A 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)