Approach Considerations

The approach to patients with penetrating abdominal trauma depends on

whether the injury is a gunshot wound (GSW) or a stab wound and the
patient’s hemodynamic status. GSWs are associated with a high incidence of
intra-abdominal injuries and nearly always mandate laparotomy. 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, one of which is shown in the diagram
below.

Management of penetrating
abdominal trauma. CT = computed tomography; DPL = diagnostic peritoneal
lavage; RBC = red blood cells.
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Patients with penetrating abdominal trauma generally require complete
laboratory profiles in case of need for emergent operation. Many imaging
modalities can be useful in the evaluation of a patient with penetrating
abdominal trauma. The imaging needs of each patient differ, depending on
hemodynamic stability and associated injuries.
Blood and Urine Studies
In case of need for emergent operation, all patients with penetrating
abdominal trauma should undergo certain basic laboratory testing, as follows:
 Blood type and crossmatch
 Complete blood count (CBC)
 Electrolyte levels
 Blood urea nitrogen (BUN) and serum creatinine level
 Glucose level
 Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
  Venous or arterial lactate level
 Calcium, magnesium, and phosphate levels
 Arterial blood gas (ABG)
 Urinalysis
 Serum and urine toxicology screen
Patients who arrive in shock should be typed and cross-matched for 4-8 units
packed red blood cells. The CBC provides a baseline value for later
comparison, even though it may not reveal the extent of active bleeding. The
basic chemistry profile reveals any baseline renal insufficiency or electrolyte
abnormalities. Coagulation studies (PT with international normalized ratio
[INR] and PTT) may indicate development of coagulopathy. The importance of
early coagulopathy of trauma has recently been emphasized. Up to 30% of
patients present to the ED with established coagulopathy prior to any
resuscitation. Moreover, these patients have significantly increased mortality.
The ABG permits calculation of the anion gap (reference range, 8-12 mmol/L)
and base deficit (reference range, ±4 mmol/L) as guides to hypoperfusion. It
provides important information regarding acid-base balance and, thus, the
hemodynamic stability of the patient.
Urine dipstick testing may reveal occult blood indicative of genitourinary tract
injuries. Female patients should have urine pregnancy testing.
Ethanol and drug screens are also standard practice in trauma patients.
Studies have shown that even brief intervention and counseling in patients at
the time of admission for trauma injury has positive outcomes.
Plain Radiography
A chest radiograph is obtained on all patients because penetration of the
chest cavity cannot be ruled out, even with abdominal stab wounds or even-
numbered GSWs (ie, apparent entrance and exit wounds) outside the chest.
Chest radiographs can reveal hemothorax or pneumothorax or irregularities of
the cardiac silhouette, which can be a sign of cardiac injury or great vessel
injury. Air under the diaphragm indicates peritoneal penetration. Chest
radiography is relatively specific, although insensitive, for diagnosing
diaphragmatic injury.
Abdominal radiographs in 2 views (ie, anterior-posterior [AP], lateral) are also
obtained on all patients with GSWs to help determine missile trajectory and to
account for retained missiles (ie, bullets, shrapnel, and foreign bodies) in
patients with odd-numbered GSWs. If all foreign bodies are not accounted for,
consider the possibility that the foreign body is intraluminal or intravascular,
and thus is a potential source of emboli distant from the site of entrance.
Ultrasound
Ultrasonography has been widely used in the assessment of patients with
blunt trauma, but it has only recently been used in the assessment of patients
with penetrating injuries. In these cases, the study is performed using the
focused assessment with sonography for trauma (FAST). FAST has gained
acceptance in the evaluation of penetrating abdominal trauma because of its
speed, noninvasiveness, and reproducibility in diagnosing intraperitoneal
injury that requires laparotomy.
FAST uses 4 views of the chest and the abdomen (ie, pericardial, right upper
quadrant, left upper quadrant, pelvis) to evaluate for pericardial fluid indicative
of cardiac injury and for free peritoneal fluid. Free fluid in the abdomen can be
a sign of hemorrhage secondary to liver or splenic laceration or, less
commonly, of spillage secondary to hollow viscus injury.
While FAST has been found to be 94-98% specific for abdominal injury in
penetrating abdominal trauma, its sensitivity of 46-67% is not good. [15, 16] That
is, a positive FAST result in the setting of penetrating trauma is usually an
indication for laparotomy due to the high positive predictive value for a
therapeutic laparotomy. Unfortunately, a negative FAST result cannot rule out
the need for laparotomy and cannot be relied on to exclude important
intraperitoneal injury; these patients require further testing to rule out occult
injury. [15, 17]
Sonographic evaluation of penetrating wounds also has been evaluated in the
detection of fascial defects resulting from anterior abdominal stab injuries,
reducing the need for local wound exploration. In one prospective trial, a
positive fascial sonogram result obviated invasive wound exploration because
such patients were then taken to the operating room (OR). However, a
negative fascial sonogram result did not rule out a penetration of the
peritoneum. [18, 19]
Computed Tomography
CT scanning is used in the evaluation of patients with stab wounds to the flank
and the back and in the evaluation of selected patients with abdominal stab
wounds and penetrating, nontangential GSWs. Abdominal CT is the most
sensitive and specific study in identifying and assessing the injury severity to
the liver or spleen. [1] The presence of a contrast blush on CT or ongoing
hemorrhage is an indication for laparotomy or angiography and
embolization. [20]
Triple-contrast helical CT has been evaluated as a diagnostic modality in
hemodynamically stable patients with penetrating torso trauma. Oral,
intravenous, and rectal contrasts are administered, and the images are
reviewed for evidence of peritoneal penetration and visceral injuries.
Triple-contrast CT has been found to be 97% accurate in the evaluation of
penetrating flank and back wounds. Exploration of these wounds is more
difficult, less reliable, and therefore not indicated. [21] One study of CT with IV
contrast only found it useful for patients with GSW to the abdomen selected
for nonoperative management. [22]
Specific signs of peritoneal penetration on CT include the following:
 A wound tract outlined by hemorrhage, air, or bullet or bone fragments
that clearly extend into the peritoneal cavity
 The presence of intraperitoneal free air, free fluid, or bullet fragments
 Obvious intraperitoneal organ injury
The diagnosis of significant penetrating injury should not be delayed by
routinely obtaining CT scans of the abdomen and pelvis. Instead, patients with
an appropriate history, physical examination or vital sign abnormalities, in
particular with a positive FAST, should undergo expeditious
exploration. [23] There is no place for CT scanning in hemodynamically unstable
patients with penetrating abdominal injury.
The primary limitation of CT is lack of sensitivity in diagnosing mesenteric,
hollow visceral, and diaphragmatic injuries, all of which are common in
penetrating trauma. Therefore, unless the wound is clearly superficial on CT
scan, admission and serial observation is indicated, even with a negative CT
result for injury. [24]
No absolute indications exist for CT in anterior penetrating trauma. Some
centers use CT as a screening tool to complement physical examination,
while others perform serial examination or diagnostic peritoneal lavage (DPL).
In a prospective study of 200 patients, CT was found to be 97% sensitive and
98% specific for peritoneal violation. [25] Laparotomy based on CT findings in
38 of these patients was considered therapeutic in 87%, nontherapeutic in
8%, and negative in 5%. These results were comparable to others obtained
with the use of clinical examination, DPL plus local wound exploration, and
DPL alone. [26, 27, 28]
Patient selection is extremely important when considering CT as a diagnostic
adjunct in patients with penetrating abdominal trauma. The availability and
quality of the CT scan and the experience of the examining radiologist are
also key considerations.
Other Imaging Studies
Other imaging studies that may be used in patients with penetrating
abdominal injury include the following:
 Skeletal survey for associated fractures
 CT scan of the brain for coincident head injuries
Retrograde urethrogram or cystogram in a stable patient who has blood at the
urethral meatus or evidence of urethral or bladder injury from penetration
Intravenous pyelography is most often used intraoperatively to assess
contralateral renal function in a patient with kidney damage necessitating
nephrectomy. Nuclear medicine studies have no role in the acutely injured
abdominal trauma patient.
Diagnostic/Therapeutic Procedures
In patients with penetrating abdominal trauma, certain procedures that are
necessary for treatment may at times provide diagnostic information.
All patients undergoing endotracheal intubation require decompression of the
stomach to decrease the risk of aspiration. Blood in the nasogastric tube can
indicate upper gastrointestinal injury.
Foley catheterization insertion is required to monitor the fluid resuscitation
status of the patient with penetrating abdominal trauma. The presence of
blood in the urine is a sign of genitourinary tract injury.