Penetrating Abdominal Trauma Emergency Management

Case Presentation-Penetrating Abdominal
Trauma
by Dr. Nikita
Dr. Anjali
Case Study
● 23 year old male
● Fell directly on fragment of wood with pointy end which entered his abdomen
● Ambulance called by family members
● On Emergency arrival,his vitals were stable
● On examination of the abdomen, part of the ntestine was protruding out through the
external wound
● Patient taken to OT for emergency laparotomy

Background
● Stab wounds (SW) are more common than
gunshot wounds (GSW)
● SW have a lower mortality due to the lower

energy transmitted.
● The most common organs injured are the small

bowel (50%), large bowel (40%), liver (30%),
and intra-abdominal vasculature(25%)
Background continue - A little history…
Prior to World WarI, PAI was managed expectantly. During

World War II, studies showed that early laparotomy inmproved
Survival.
By the late 1950's, routine laparotomy was the standard treatment
for PAI.
Over the last 30 years the pendulum has shifted towards selective
management.
The introduction and refinement of diagnostic procedures and
imaging studies, such as laparoscopy, CT scan, and focused
abdominal sonography for trauma (FAST), has contributed
significantly in the new trends of PAI management.
Background (contd)
Laparotomy now thought unnecessary in 70% of
abdominal stab wounds due to increased complication rates,
length of stay, costs
Immediate laparotomy indicated for:

1. Peritonism
2. Evisceration
3. Haemodynamic ins tability
4. Penetrating object is still in situ
5. GI bleeding following PAI
Which wounds should be considered potential penetrating
abdominal wounds??
Any wound between the nipple line (T4) and

the groin creases anteriorly, and from T4 to the
curves of the iliac crests posteriorly
However, if the wound was caused by a

projectile, then a PAI could result from an entry
wound in almost any part of the body
What are the 4 important regions of the abdomen to
consider in penetrating injury??
1. Anterior abdomen Between the anterior axillary lines; bound by the costal
margin superiorly and the groin crease distally
2. Thoracoabdominal area Area delimited by the costal margin
inferiorly and superiorly by the fourth intercostal space anteriorly, sixth intercostal
space laterally and eighth intercostal space posteriorly. Note: injuries in this area
increase likelihood of diaphragmatic, chest and nmediastinal injuries.
3. Flanks Bound by anterior axillary line and posterior axillary line, inferior
costal margin superiorly to iliac crests
4. Back Between posterior axillary lines extending from costal margin to the iliac
crests
Pathophysiology of PAI
Stab wounds -
- Knives, ice picks, pens, coat hangers,
broken
bottles
- Liver, small bowel, spleen
Gunshot wounds
- small bowel, colon, liver
- often multiple organ injuries, bowel
perforations
Initial Management
Airway
Breathing
Circulation
Disability
Exposure
Initial Management
General Trauma principles:

Airway management, 2x large bore IVs, fluid
resuscitation, major haemorrhage protocol.
Cover penetrating wounds and eviscerations

with sterile dressings.
Prophylactic Abx: Decrease risk of

intraabdominal sepsis
In general, leave foreign bodies in and remove

in theatre.
Evaluation
Pulseless
Arrive without pulses but with witnessed recent or current

signs of life (e.g. PEA)
Major vascular injury most likely
Need immediate laparotomy in theatre within 5 minutes of
arrival
Second option is thoracotomy in ED and cross-clamp aorta.
Both have very low functional survival yields.
Haemodynamically Unstable
Require immediate laparotomy!

Includes non-responders and transient responders to initial
fluid bolus
Unnecessary investigations or interventions should be avoided.
CXR and FAST scan can help if unsure that abdomen is source
The decision to perform laparotomy may be
Complicated if.....
There are multiple stab wounds/gunshot wounds

to multiplecavities
The wounds are at, or cross, junctional zones

(e.g. costal margin,Groin,Buttock wounds
There is evidence or the possibility of cardiac

tamponade
The diagnosis of massive haemothorax may be

made clinically,
with a FAST scan, chest tube or CXR
Management of the Haemodynamically normal
patient with PAI
Selective management used to reduce the number of

Laparotomies
Investigations to determine if there is intraperitoneal

injury requiring operative repair
Strategy depends on abdominal region
Note: Haemodynamically normal patients with clinical signs of peritonitis, or with evisceration of
bowel should be takenimmediately to theatre
Algorithms...
The goal of any algorithm for PAI should be to identify injuries requiring surgical repair,
and avoid
unnecessary laparotomy with its associated morbidity.
There are several options for evaluating PAI in the hemodynamically normal trauma
patient without signs of peritonitis.
Many of these patients will have some superficia tenderness around the wound site, but
no signs of peritoneal injury/inflammation.
Options to assess peritoneal penetration:
CXR - penetration is confirmed by free air
under diaphragm, but absence of free air does not rule it
out.
Ultrasound (FAST) - Looking for free fluid in the
abdomen or evidence of abdominal fascia violation.
However, there are false negatives for intra-abdominal
injury...
FAST is not great at picking up small amounts of fluid
which may be associated with a hollow viscus injury.
So, a positive FAST indicates peritoneal penetration
but a negative FAST does not exclude significant
injury and so should be used in combination with other
investigations
Local wound exploration
Can be performed in the ED as follows:
universal precautions
perform procedure under sterile conditions
Local anesthesia is injected at the wound site
The wound track is followed through the layers of the abdominal
wall or until its termination.
The goal is to identify the end point of the tract, this usually
requires extension of the wound to allow adequate visualisation.
A positive result is penetration of the posterior rectus fascia or the
transversus fascia below the rectus line.
Note: Wounds overlying the rib cage should not be explored (may
cause pneumothorax).
Diagnostic Peritoneal Lavage (DPL)
The role of DPL in the haemodynamically normal patient is to

identify hollow viscus injury (stomach, small bowel, colon) or
diaphragmatic injury.
Disadvantages: It is invasive, does not evaluate the retroperitoneum
has a significant false positive rate.
A positive result is >100,000 RBCs for anterior abdominal wounds

and 10,000 RBCs for thoracoabdominal wounds.
DPL is now used only if FAST and CT not available.

CTabdomen (with IV contrast)
Optimal method for determining both peritoneal penetration and

intra-peritoneal injury unless emergency laparotomy is indicated
97% sensitive for peritoneal violation
Of all the diagnostic modalities CT gives the best assessment of

retroperitoneal structures.
Be aware that some diaphragmatic injuries will be missed on CT -

although sensitivity is approaching 95% with new CT scanners -
Patients require close observation and consideration of other tests
(e.g. the laparos copy)
Serial physical Examination
Best sensitivity and negative predictive value of all modalities.
Patient is admitted under the General Surgeons for 24 hours. Hourly obs. Regular
abdominal examination for signs of developing peritonitis
If patient develops any signs of haemodynamic instability or peritonitis then a

larotomy is performed
If the patient is well the following day they start a normal diet and are discharged
once diet is tolerated.
Special considerations...
Thoracoabdominal wounds - Big concern is

diaphragmnatic injury- occurs in around 7% of thoracoabdominal
wounds. Where there is evidence of thoracic and abdominal injury
there must, by definition, be an injury to the diaphragm.
If concerned, Laparoscopy/thoracoscopy is recommended.
Flank or back wounds - Be highly suspicious for injury

to retroperitoneal organs e.g. Colon, kidney, lumbar vessels. Colon
is the injury most often missed. Consider triple-contrast CT scan +/-
Laparotomy.
Back to the case study..
A 23 year old male,with penetrating

abdominal injury with evisceration
of intestine
Vitals normal
On arrival
On arrival, ABCDE
Wide bore cannulae bilaterally
Fluid resuscitation
CXR- No haemothorax/pneumothorax
IVAbx -
Tranexamic acid 1g
Patient taken to theatre for Laparotomy

During Laparotomy….
Done under spinal anaesthesia

Abdomen opened through lower midline incision which was extended
beyond external wound
Herniated portion of the intestine was freed from the surrounding
Jejunal rent was found through which proximal jejunum was protruding out
(intusucception 2 feet)
Herniated segment was gangrenous.
Resection and anastomosis done.
Wound closed in layers after putting the drain.
POST OPERATIVE
DAYS
No postoperative complications
Vitals stable
Nasogastric tube removed on POD-3
Drain output minimal
Flatus passed on POD-3
Patient is on semisolid diet and is

recovering well.
THANK YOU!!

Penetrating Abdominal Trauma Emergency Management

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Case Presentation-Penetrating Abdominal

● 23 year old male

● Ambulance called by family members

● On Emergency arrival,his vitals were stable

● Patient taken to OT for emergency laparotomy

● SW have a lower mortality due to the lower

● The most common organs injured are the small

Prior to World WarI, PAI was managed expectantly. During

Immediate laparotomy indicated for:

Any wound between the nipple line (T4) and

However, if the wound was caused by a

General Trauma principles:

Cover penetrating wounds and eviscerations

Prophylactic Abx: Decrease risk of

In general, leave foreign bodies in and remove

Arrive without pulses but with witnessed recent or current

Require immediate laparotomy!

There are multiple stab wounds/gunshot wounds

The wounds are at, or cross, junctional zones

There is evidence or the possibility of cardiac

The diagnosis of massive haemothorax may be

Selective management used to reduce the number of

Investigations to determine if there is intraperitoneal

Strategy depends on abdominal region

Can be performed in the ED as follows:

The role of DPL in the haemodynamically normal patient is to

A positive result is >100,000 RBCs for anterior abdominal wounds

DPL is now used only if FAST and CT not available.

Optimal method for determining both peritoneal penetration and

97% sensitive for peritoneal violation

Of all the diagnostic modalities CT gives the best assessment of

Be aware that some diaphragmatic injuries will be missed on CT -

Best sensitivity and negative predictive value of all modalities.

If patient develops any signs of haemodynamic instability or peritonitis then a

Thoracoabdominal wounds - Big concern is

Flank or back wounds - Be highly suspicious for injury

A 23 year old male,with penetrating

Wide bore cannulae bilaterally

Patient taken to theatre for Laparotomy

Done under spinal anaesthesia

Nasogastric tube removed on POD-3

Drain output minimal

Flatus passed on POD-3

Patient is on semisolid diet and is

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