Penetrating Abdominal Trauma
Penetrating Abdominal Trauma
Bullet
Wound
Bullet
Fragments
FAST
Advantages
Speed
Noninvasiveness
Reproducibility
Disadvantages
Negative FAST does not rule out need for
laparotomy
User dependent
FAST
Diagnostic Peritoneal Lavage (DPL)
Hemodynamically unstable patients with negative
FAST
Sensitive but NOT specific
Positive if 10ml gross blood, 100,000 RBCs/ml,
500 WBCs/ml, bacteria, bile, food particles
Lower for GSW 5000 RBCs (disagreement)
Disadvantage
Invasive
Inability to evaluate retroperitoneum
High false positive rate
DPL
CT Scan
Sensitive and specific for assessing injury and
severity to solid organs
Limitation is lack of sensitivity in diagnosing hollow
visceral, and diaphragmatic injuries
No indication for anterior penetrating trauma
Useful for tangential, flank and back wounds
Intraabdominal injuries and bullet trajectory can
identified with >90% sensitivity and specificity*
Triple contrast may increase accuracy
HR 130-150s, BP 90/50s
Antibx given, taken emergently to OR
Massive transfusion protocol activated
Initial AXR
Bullet
Fragment
Bullet
Wound
Initial OR
Exploratory laparotomy
Massive hemoperitoneum
Significant zone I, II, & III hematoma
Patient became hypotensive
All four quadrants packed
Emergent left thoracotomy
Cross-clamp descending aorta
Massive transfusion
Performed Kocher maneuver
Large anterior infra-hepatic IVC injury at level of
caudate lobe
Pringle maneuver performed
OR Continued
Cardiothoracic surgery called
Placed variant form of veno-veno bypass
IVC (inferior to injury) to L main PA
Repair of IVC injury
Weaned from bypass, decannulated
Continued significant bleeding in mid and pelvis
Iliac arteries/veins accessed no bleeding
Mattox maneuver performed
Aorta to L renal vein no injury
Concern for lumbar artery bleeding
Decision to move to IR
Damage control chest/abd
Interventional Radiology
Patient hypotensive during travel
Continued massive transfusion, warming
Aortic run-off performed
Large aorto-IVC fistula discovered
Active extravasation from aorta
Aortic balloon inflated above injury
Aortic covered stent placed by IR
Unsusccessful
Initial Runoff
Aorto-IVC
Fistula Aortic
Injury
Runoff Following Stent Placement
Continued
Aorto-IVC
Fistula
Return to OR
From IR to OR with angio capability
Vascular placed second stent, fistula still open
Patient more stable, but on vasopressors and in rapid a-fib
Reopening of laparotomy
Repair of medial IVC injury and posterior aortic injury (stent
visible)
Bowel dusky
Damage control
After fistula closure, a-fib resolved
Patient cold and coagulopathic
Planned return to OR in am
Management Controversies
Stab wounds Nonoperative management
Prospective study showed 47% patients could be managed non-
operatively
GSW Nonoperative management
Solid organ injuries CT scan
Left thoracoabdominal injuries
Laparoscopy for patients without indications for laparotomy
GSW 59% had diaphragm injury
Asymptomatic patients 24% occult diaphragm injury
Antibiotics for penetrating injury
Regardless of contamination and degree of injury, 24 hrs adequate