Chapter 17
Penetrating Abdominal Trauma

Jesse M. Pines^1,2 and Ali S. Raja³

¹ US Acute Care Solution, Canton, OH, USA

² Department of Emergency Medicine, Drexel University, Philadelphia, PA, USA

³ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

Highlights

Patients with penetrating stab wounds to the abdomen and high‐risk clinical signs, including unstable vital signs, evisceration, or peritonitis, should be taken for immediate laparotomy.
In patients with penetrating thoraco‐abdominal injuries, CT can miss diaphragmatic injuries, so additional testing (thoracoscopy or laparoscopy) should be considered.
In patients with penetrating back and flank wounds, fewer than 5% will have intraperitoneal injury, and the absence of apparent injury on CT scan can rule out these injuries.
In patients with penetrating anterior abdominal trauma, both CT and focused assessment with sonography in trauma (FAST) have imperfect sensitivity and specificity in detecting intraperitoneal injuries and should not be used as the only basis to rule out injuries. In these patients, local wound exploration (LWE), when done properly, is highly sensitive and can rule out peritoneal violation.
Diagnostic peritoneal lavage (DPL) is not useful to rule in or rule out injuries. Because of its invasiveness and the availability of other diagnostic strategies, it should not be a part of the evaluation of stable abdominal stab wounds.

Background

Over the past 150 years, there has been a major revolution in the management of penetrating abdominal injuries. Prior to the Civil War and into the latter nineteenth century, penetrating injuries were managed with observation; significant organ injuries that led to peritonitis, or other serious infections, were almost universally fatal. During World Wars I and II, early laparotomy became the treatment of choice. Laparotomy involves surgical exploration of intra‐abdominal injuries and repair or removal of damaged structures. Early exploration has led to dramatic improvements in survival. However, not all patients with penetrating abdominal injuries have serious injuries. Using early laparotomy or potentially less invasive laparoscopy for all cases of penetrating abdominal trauma may be the most conservative strategy, but it is not always necessary. In certain subsets of patients with penetrating wounds, such as stab wounds, the rate of negative laparotomy can approach 70%.¹

In the past 25 years, there has been a proliferation of availability of rapid diagnostic testing in emergency departments (EDs). In hemodynamically stable patients with abdominal stab wounds, management strategies have been developed to provide more rapid and less invasive ways to risk‐stratify intra‐abdominal injuries.² It is important to distinguish stab wounds from penetrating gunshot wounds (GSWs). Because of the high prevalence of peritoneal penetration in abdominal GSWs, most surgeons will perform immediate laparotomy in GSW cases.³ It is also important to distinguish which patients can be managed conservatively and the importance of the physiology and anatomy of the injury. This is particularly true in high‐volume trauma centers where the presence of multiple patients with severe injuries at once (i.e., multiple GSW cases) can overwhelm operating room (OR) resources. Indications for immediate surgical exploration include signs of evisceration, unstable vital signs such as hypotension and tachycardia, and clinical signs of peritonitis, all of which are evidence of significant injury to the intra‐abdominal organs or vasculature.

By contrast, patients with abdominal stab wounds with otherwise stable vital signs and without peritonitis present a diagnostic challenge. Some patients will have injuries requiring immediate repair, others can be managed expectantly without invasive laparotomy. Anterior abdominal wounds can be explored with local wound exploration (LWE). In addition, contrast‐enhanced computed tomography (CT) and focused assessment with sonography in trauma (FAST), and serial clinical assessment (SCA) are commonly used modalities to help risk‐stratify stable patients with penetrating abdominal injuries. Historically, diagnostic peritoneal lavage (DPL) performed at the bedside in the ED has been used to risk‐stratify these injuries; however, this modality is mostly of historical interest in hospitals with advanced technology. However, without access to FAST or other technology, DPL may still be a useful tool.

Clinical question

What is the sensitivity of different types of diagnostic testing and management strategies (including CT, ultrasound, LWE, DPL, and SCA) to detect important injuries in stable patients with penetrating abdominal stab wounds?

Because management strategies can vary by body site, it is important to divide injuries into three separate regions, the anterior abdomen, the thoraco‐abdomen, and the flank and back region.

Thoraco‐abdominal injuries

Thoraco‐abdominal stab wounds can damage structures in the chest and abdomen, including the diaphragm (Figure 17.1). Diaphragmatic injuries due to stab wounds frequently do not result in specific signs and symptoms, requiring diagnostic testing. Diaphragmatic injuries can sometimes go unnoticed during an initial hospitalization and can cause delayed sequelae. Using radiography to diagnose these injuries alone can be a problem because even small injuries can go undetected using advanced radiography. In a case series at the University of Maryland Shock Trauma Center, 50 patients had CT findings of potential diaphragmatic injuries and only 40% were termed as “specific,” including contiguous organ injury and/or herniation of abdominal fat through a diaphragmatic defect.⁴

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