Penetrating

Abdominal
trauma
Introduction

 Penetrating abdominal trauma typically involves

the violation of the abdominal cavity by a
gunshot wound (GSW) or stab wound.
 Damage control surgery (laparotomy with
physiologic resuscitation in the intensive care unit
and staged abdominal reconstruction and
treatment of abdominal compartment syndrome
have had major impacts on care of the severely
injured
Anatomy

In evaluating patients with penetrating abdominal

trauma, the abdomen is classically divided as follows:
 Anterior abdomen - Anterior costal margins to
inguinal creases, between the anterior axillary lines
 Intrathoracic abdomen or thoracoabdominal area -
Fourth intercostal space anteriorly (nipple) and
seventh intercostal space posteriorly (scapular tip) to
inferior costal margins
 Flank - Scapular tip to iliac crest, between anterior
and posterior axillary lines
 Back - Scapular tip to iliac crest, between posterior
and axillary line
Anatomy
Gunshot wounds

 The severity of shotgun wounds depends on the

distance of the victim from the weapon. When the
distance is less than 3 yd, the injury is considered
high velocity; if the distance exceeds 7 yd, most of
the buckshot penetrates only the subcutaneous
tissue.
 In penetrating abdominal trauma due to gunshot
wounds, the most commonly injured organs are as
follows :
Small bowel (50%)
Colon (40%)
Liver (30%)
Abdominal vascular structures (25%)
Stab Wounds

 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.
 In penetrating abdominal trauma due to stab
wounds, the most commonly injured organs are as
follows :
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Physical Examination

Initial examination in patients with penetrating

abdominal trauma includes assessment of the
following:
- Airway, breathing, circulation (ABCs): Includes vital
signs
- Level of consciousness (D, disability): To detect
neurologic deficits
- Location(s) of the wound(s) (E, exposure): Inspect
all body surfaces, and document all penetrating
wounds
Physical Examination
The secondary survey is a complete head-to-toe physical
examination in hemodynamically stable patients and includes
external inspection

Immediate surgical exploration is warranted for evidence of

significant intra-abdominal injury, especially vascular trauma, such
as the following:
 Hypotension (with or without abdominal distention)
 Narrow pulse pressure
 Tachycardia
 High or low respiratory rate
 Signs of inadequate end organ perfusion
 Peritoneal signs (eg, pain, guarding, rebound tenderness)
and/or peritonitis
 Diffuse and poorly localized pain that fails to resolve
Laboratory test
In case emergent operation is necessary, all patients with penetrating
abdominal trauma should undergo certain basic laboratory testing, as
follows:
 Blood type and cross-match
 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
Imaging
The following imaging studies may be used to evaluate
patients with penetrating abdominal trauma:
 Chest radiography: To rule out penetration of the chest
cavity
 Abdominal radiography in 2 views (anterior-posterior,
lateral)
 Chest and abdominal ultrasonography: Focused
assessment with sonography for trauma (FAST); includes
4 views (pericardial, right and left upper quadrants,
pelvis)
 Abdominal CT scanning (including triple-contrast helical
CT): Most sensitive and specific study in identifying and
assessing liver or spleen injury severity
X-ray
FAST

 Morrison’s pouch (hepatorenal space)

FAST

 Splenorenal space
FAST

 Pouch of douglas
FAST

 Pericardium
FAST
Advantages:
 Portable, fast (<5 min),
 No radiation or contrast
 Less expensive

Disadvantages
 Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
 Limited by obesity, substantial bowel gas, and subcut air.
 Can’t distinguish blood from ascites.
 high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture
Diagnostic Peritoneal
Lavage
 Largely replaced by FAST and CT
 In blunt trauma, used to triage who is HD unstable and has
multiple injuries with an equivocal FAST examination
 In stab wounds, for immediate dx of hemoperitoneum,
determination of intraperitoneal organ injury, and detection
of isolated diaphragm injury
 In GSW, not used much
Diagnostic Peritoneal
Lavage
1. attempt to aspirate free peritoneal blood
 >10 mL positive for intraperitoneal injury
2. insert lavage catheter by seldinger, semiopen, or
open
3. lavage peritoneal cavity with saline
Positive test:
 In blunt trauma, or stab wound to anterior, flank,
or back: RBC count > 100,000/mm3
 In lower chest stab wounds or GSW: RBC count >
5,000-10,000/mm3
Procedures
The following may be diagnostic and/or therapeutic
procedures in patients with penetrating abdominal trauma:
 Gastric decompression in intubated patients: To prevent
aspiration
 Foley catherization: To monitor fluid resuscitation
 Peritoneal lavage (open or closed): To identify hollow
viscus or diaphragmatic injury
 Tube thoracostomy: To relieve hemothorax/pneumothorax
 Local wound exploration: Diagnostic aid to determine the
track of penetration through the tissue layers
 Laparoscopy: To evaluate and treat intra-abdominal
injuries, including stab wounds to the anterior abdomen or
those with uncertain peritoneal penetration
Management
The approach to patients with penetrating abdominal trauma
depends on the following factors:
 Mechanism and location of injury
 Hemodynamic and neurologic status of the patient
 Associated injuries
 Institutional resources
Most trauma centers use an algorithm with multiple diagnostic
modalities whose uses are based on the pattern of injuries and the
clinical status of the patient.
Gunshot wounds 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.
Abdominal
compartement syndrome
 Common problem with abdominal trauma
 Definition: elevated intraabdominal pressure (IAP)
of ≥20 mm Hg, with single or multiple organ system
failure
 Primary ACS: associated with injury/disease in
abdomen
 Secondary (“medical”) ACS: due to problems
outside the abdomen (eg sepsis, capillary leak)
Abdominal
compartement syndrome
Effects of elevated IAP
 Renal dysfunction
 Decreased cardiac output
 Increased airway pressures and decreased
compliance
 Visceral hypoperfusion
Abdominal
compartement syndrome
Management
 Surgical abdominal decompression
 Nonsurgical: paracentesis, NGT, sedation
 Staged approach to abdominal repair
 Temporary abdominal closure
Concluscion

 Watch out for implements and missiles violating the

abdomen
 Laparotomy is mandatory if shock, evisceration, or
peritonitis
 Diagnostic studies used to determine need for
laparotomy in abdominal trauma
 FAST is noninvasive, quick and accurate way to
evaluate for intraperitoneal blood
 Damage Control is a principle of staged operative
management with control and resuscitation prior to
definitive repair
 Abdominal compartment syndrome is a common
problem in abdominal trauma
References

 Biffl WL, Moore EE. Management guidelines for penetrating

abdominal trauma. Curr Opin Crit Care 2010;16:609-617
 Bailey J, Shapiro M. Abdominal compartment syndrome. Crit
Care 2000, 4:23–29
 Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic
laparoscopy decreases the rate of unnecessary laparotomies
and reduces hospital costs in trauma patients. J Laparoendosc
Adv Surg Tech A. 2001 Aug. 11(4):207-11.
 Biffl WL, Kaups KL, Cothren CC et al (2009) Management of
patients with anterior abdominal stab wounds: a Western
Trauma Association multicenter trial. J Trauma 66:1294–1301
 Biffl WL, Kaups KL, Pham TN et al (2011) Validating the Western
Trauma Association algorithm for managing patients with
anterior abdominal stab wounds: a Western Trauma
Association multicenter trial. J Trauma 71:1494–1502
Thank you