Abdominal Trauma, Penetrating
History of the Procedure
The management of penetrating abdominal trauma (PAT) has evolved greatly over the last century.
Prior to World War I, penetrating trauma was managed expectantly. During World War II, however, studies showed that early laparotomy improved survival. By the late 1950s, laparotomy was the standard treatment of patients with PAT. In 1960, Shaftan suggested the selective management of patients with abdominal stab wounds after observing an increased rate of laparotomies without identifiable injuries. More recently, expectant management has also been used in the treatment of specific gunshot wounds (GSWs) to the abdomen.
The introduction and refinement of diagnostic procedures and imaging studies, including peritoneal lavage, laparoscopy, CT scan, and focused ultrasound, have directed the evolution of PAT management.
Penetrating abdominal injury implies that either a GSW or a stab wound has violated the abdominal cavity.
In the United States, suicide and homicide consistently rank in the top 15 causes of death. According to data published by the National Vital Statistics Reports, 30,318 people died of firearm injuries in 2002. Of these, 17,159 deaths were due to self-inflicted GSWs. Forty percent of homicides and 14% of suicides by firearm involved injuries to the torso.
Age-adjusted firearm death rates are 2-7 times higher for non-Hispanic black males as compared to males of other ethnicities. For non-Hispanic whites, most firearms deaths are due to suicide.
According to age-adjusted rates from 1990-1995, firearm mortality rates across the world vary widely, from 0.05 in Japan to 14.24 in the United States. Firearm associated homicide mortality is highest in Mexico at 10.35; firearm associated suicide is highest in the United States at 6.3.
A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can have an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy transfer. Close-range shotgun injuries often cause significant tissue damage and should be considered high-energy transfer injuries as well.
Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications.
Assessment of the patient begins at the scene of the incident by emergency medical service (EMS) personnel. Basic or advanced life support measures are applied at the scene and en route to the emergency department.
Upon arrival at the emergency department, communication of the incident history and the patient’s vital signs to the emergency or trauma team is of paramount importance. Advanced trauma life support protocols are initiated. Airway protection and ventilatory support are followed by circulatory resuscitation with fluid infusion. Patients who present with hypotension are already in class III shock (30-40% blood volume loss), and they should receive blood products as soon as possible.
Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple wounds may represent entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign objects may be retained within the body.
Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and guarding and rebound tenderness, which necessitate exploration without delay. Abdominal distension in an unresponsive patient may indicate active internal bleeding that also requires exploration, especially in combination with hypotension.
Rectal examination is performed on all patients with PAT, as blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.
When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and diagnostic and imaging studies.
GSWs are associated with a high incidence of intra-abdominal injuries. Nearly all patients with GSWs require laparotomy. Recent reports of nonoperative management of GSWs to the abdomen are discussed later in this article.
Stab wounds are associated with a significantly lower incidence of intra-abdominal injuries; therefore, expectant management is indicated in hemodynamically stable patients. Many protocols have been developed for determination of abdominal wall penetration of stab wounds to the torso (see Media file 1).
Each area of the torso has anatomical boundaries, as follows:
Thoracoabdominal area – Nipples to the 12th rib, between anterior axillary lines
Abdomen – Nipples to anus, between anterior axillary lines
Flank – Between ipsilateral anterior and posterior axillary lines
Back – Below the tip of the scapula, between posterior axillary lines
Intraperitoneal abdominal organs include the solid organs (ie, spleen, liver) and the hollow viscus organs (ie, stomach, ileum, jejunum, transverse colon).
Retroperitoneal organs include the duodenum, pancreas, kidneys, ureters, urinary bladder, ascending and descending colon, major abdominal vessels, and rectum.
Patients without recordable cardiac activity upon presentation should not be further resuscitated.