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CME

Penetrating Abdominal Trauma - Emergency Management

General Information

General InformationGeneral Information

Description

  • Injury caused by a weapon or object penetrating into the abdominal cavity
  • Injuries may also result from penetrating trauma to the lower chest, flank, or back

Anatomy

  • External anatomy
    • Anterior abdomen: area demarcated by anterior axillary lines laterally and by anterior costal margins and groin creases or inguinal ligaments
      • Intraperitoneal penetration may occur in anterior wounds as high as fourth intercostal space or lateral/posterior wounds up to the sixth or seventh intercostal space due to diaphragm excursion during expiration
    • Lower chest: bordered by the fourth intercostal space (nipple line), inferior scapular tip, and inferior costal margins
      • Consider both thoracic and abdominal penetration with penetrating wounds in the lower chest or upper abdomen; 10% of abdominal penetrating wounds involve the chest, 15% of penetrating low-chest wounds violate the peritoneum1
    • Flank: area between anterior and posterior axillary lines, inferior costal margin, and iliac crests
    • Back: bordered by posterior axillary lines, between the inferior scapular tip to the iliac crests
  • Internal anatomy
    • Peritoneal cavity: liver, spleen, stomach, transverse colon, diaphragm
    • Retroperitoneal space: duodenum, pancreas, abdominal aorta, inferior vena cava, kidneys, ureters, posterior ascending and descending colon
    • Pelvis: rectum, bladder, iliac vessels, female reproductive organs

Etiology

  • Injury caused by a weapon or object protruding into the abdomen
  • Injury can range from superficial to life-threatening
  • Stab wounds
    • Knives, ice picks, pens, screw drivers, any sharp object which can impale a victim
  • Projectile missiles
    • Impact velocity is a key determinant of injury, and depends on missile characteristics, muzzle velocity, and distance between the firearm and the victim
    • Low-velocity missiles: most civilian weapons
    • High-velocity missiles: usually used in military settings; bullet tract may cause wound contamination from dragged external debris, extensive tissue damage due to the temporary cavity created by the passage and pulsations within the tissue, and bullet fragmentation
    • Shotguns: involve multiple pellets; energy involved in wounding depends on pellet size, number of pellets, barrel choke (controlling the spread of pellets), type and amount of powder, and distance between the victim and the gun

Epidemiology

  • Stab wounds are 3 times more common than gunshot wounds2
    • Incidence: left upper quadrant (LUQ) is greater than right upper quadrant (RUQ)
    • 20% of cases involve multiple wounds1
    • Most commonly injured organs, in order of decreasing incidence: liver, small bowel, diaphragm, colon
    • Anterior abdominal stab wounds penetrate the peritoneum in 50%-75% cases, with 50%-75% of those cases requiring operative repair3
    • Flank and back stab wounds are associated with 15%-40% intraperitoneal organ injury4
  • Gunshot wounds are responsible for 90% mortality in penetrating trauma2
    • 80% gunshot wounds enter the peritoneal cavity
    • Most commonly injured organs, in order of decreasing incidence: small bowel, colon, liver, abdominal vasculature
  • High-risk population for mortality due to penetrating injury: African Americans and Hispanics aged 15-34 years (homicide), non-Hispanic whites age ≥ 75 years (suicide)4

References

References

General references used

  1. Moss L, Schmidt F, Creech O Jr. Analysis of 550 stab wounds of the abdomen. Am Surg. 1962 Jul;28:483-9
  2. Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. 2007 Aug;25(3):713-33, ix
  3. Biffl WL, Kaups KL, Pham TN, et al. Validating the Western Trauma Association algorithm for managing patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma. 2011 Dec;71(6):1494-502
  4. Chapter 39. Abdominal Trauma. In: Walls RM, Hockberger RS, Gausche-Hill M, et al (eds). Rosen’s Emergency Medicine, 9th ed. Philadelphia PA:Elsevier; 2017.
  5. Palmer LS, Rosenbaum RR, Gershbaum MD, Kreutzer ER. Penetrating ureteral trauma at an urban trauma center: 10-year experience. Urology. 1999 Jul;54(1):34-6
  6. Elliott SP, McAninch JW. Ureteral injuries from external violence: the 25-year experience at San Francisco General Hospital. J Urol. 2003 Oct;170(4 Pt 1):1213-6
  7. Governatori NJ, Saul T, Siadecki SD, Lewiss RE. Ultrasound in the evaluation of penetrating thoraco-abdominal trauma: a review of the literature. Med Ultrason. 2015 Dec;17(4):528-34
  8. Brenner M, Hicks C. Major Abdominal Trauma: Critical Decisions and New Frontiers in Management. Emerg Med Clin North Am. 2018 Feb;36(1):149-160
  9. Goodman CS, Hur JY, Adajar MA, Coulam CH. How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and meta-analysis. AJR Am J Roentgenol. 2009 Aug;193(2):432-7full-text
  10. Uranues S, Popa DE, Diaconescu B, Schrittwieser R. Laparoscopy in penetrating abdominal trauma. World J Surg. 2015 Jun;39(6):1381-8
  11. Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar;68(3):721-33
  12. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic shock resuscitation. Surg Clin North Am. 2012 Dec;92(6):1403-23
  13. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011 Mar;70(3):652-63
  14. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009 Nov;40 Suppl 4:S27-35
  15. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007 Feb;62(2):307-10
  16. Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its pathophysiology and treatment in the injured patient. World J Surg. 2007 May;31(5):1055-64
  17. Beekley AC. Damage control resuscitation: a sensible approach to the exsanguinating surgical patient. Crit Care Med. 2008 Jul;36(7 Suppl):S267-74
  18. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008 Sep;248(3):447-58
  19. Goldberg SR, Anand RJ, Como JJ, et al; Eastern Association for the Surgery of Trauma. Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S321-5

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T902786, Penetrating Abdominal Trauma - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T902786. Registration and login required.

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