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CME

Penetrating Back Trauma - Emergency Management

General Information

General InformationGeneral Information

Background

  • Penetrating back trauma refers to stabbing, impaling, or a gunshot wound injury mechanism applied to the back, flank, or posterior chest

Anatomy

  • Thoracoabdomen: lungs, heart, mediastinal structures, diaphragm1
  • Back and flank1
    • Retroperitoneal structures: kidneys, ureters, pancreas, major vessels
    • Spinal column: vertebral bones, spinal cord
      • Gunshot wound (GSW) is the second most common cause of spinal cord injury2,3
    • Hollow viscous structures: retroperitoneal duodenum, sigmoid colon, rectum
    • Diaphragm
      • 20% of anterior and posterior thoracoabdominal wounds result in diaphragmatic injury4,5
    • Intraperitoneal structures: spleen, liver, small and large bowel, mesentery, inferior vena cava, aorta, and arterial branches
      • In general, penetrating flank wounds violate the peritoneum in 44% of cases
      • 15% of stab wounds to the back result in injury to peritoneal structures
  • Laparoscopy has been suggested as an alternative to emergent laparotomy in the stable patient with penetrating trauma above the 12th rib1,6

Epidemiology

  • Death from penetrating trauma is greatest in the United States in African American males aged 15-34 years1,3,7
  • Among non-Hispanic whites in the United States, suicide in males > 70 years old is the most significant contributor to penetrating trauma mortality1,3,7
  • Stab wounds are 3 times as common as gunshot wounds in the United States1,3,7

References

References

General references used

  1. Isenhour J, Marx J. Penetrating abdominal trauma. In: Wolfson A, ed. Harwood and Nuss’ Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:232-238
  2. Waters R, Sie I. Spinal cord Injury from gunshot wounds to the spine. Clin Orthop Relat Res. 2003 Mar;(408):120-5
  3. Sidhu GS, Ghag A, Prokuski V, Vaccaro AR, Radcliff KE. Civilian gunshot injuries of the spinal cord: a systematic review of the current literature. Clin Orthop Relat Res. 2013 Dec;471(12):3945-55full-text
  4. Powell BS, Magnotti LJ, Schroeppel TJ, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4
  5. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma. 2005 Apr;58(4):789-92
  6. Dissanaike S, Griswold JA, Frezza EE. Treatment of isolated penetrating flank trauma. Am Surg. 2005 Jun;71(6):493-6
  7. Conn, Alasdair KT. Penetrating trauma to the flank and buttock. In: Tintinalli J, ed. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill Professional; 2003:1620
  8. Bruns B, Lindsey M, Rowe K, et al. Hemoglobin drops within minutes of injuries and predicts need for an intervention to stop hemorrhage. J Trauma. 2007 Aug;63(2):312-5
  9. Callcut RA, Cotton BA, Muskat P, et al; Prospective Observational Multicenter Major Trauma (PROMMTT) Study Group. Defining when to initiate massive transfusion: a validation study of individual massive transfusion triggers in PROMMTT patients. J Trauma Acute Care Surg. 2013 Jan;74(1):59-65, 67-8; discussion 66-7full-text
  10. Vandromme MJ, Griffin RL, Weinberg JA, Rue LW 3rd, Kerby JD. Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage? J Am Coll Surg. 2010 May;210(5):861-7, 867-9
  11. Odom SR, Howell MD, Silva GS, et al. Lactate clearance as a predictor of mortality in trauma patients. J Trauma Acute Care Surg. 2013 Apr;74(4):999-1004
  12. Pham TN, Heinberg E, Cuschieri J, et al. The evolution of the diagnostic work-up for stab wounds to the back and flank. Injury. 2009 Jan;40(1):48-53
  13. Jawad H, Raptis C, Mintz A, Schuerer D, Mellnick V. Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma. AJR Am J Roentgenol. 2018 Apr;210(4):761-5
  14. Hope WW, Smith ST, Medieros B, Hughes KM, Kotwall CA, Clancy TV. Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center? J Emerg Med. 2012 Jul;43(1):190-5
  15. Demetriades D, Rabinowitz B, Sofianos C, et al. The management of penetrating injuries of the back. A prospective study of 230 patients. Ann Surg. 1988 Jan;207(1):72-4PDF
  16. Velmahos GC, Demetriades D, Foianini E, et al. A selective approach to the management of gunshot wounds to the back. Am J Surg. 1997 Sep;174(3):342-6
  17. MacLeod J, Freiberger D, Lewis F, Feliciano D. What is the optimal observation time for a penetrating wound to the flank? Am Surg. 2007 Jan;73(1):25-31
  18. Hadjipavlou M, Grouse E, Gray R, et al. Managing penetrating renal trauma: experience from two major trauma centres in the UK. BJU Int. 2018 Feb 13 early online
  19. Cotton BA, Guy JS, Morris JA Jr, Abumrad NN. The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock. 2006 Aug;26(2):115-21
  20. 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
  21. Tran A, Matar M, Lampron J, Steyerberg E, Taljaard M, Vaillancourt C. Early identification of patients requiring massive transfusion, embolization or hemostatic surgery for traumatic hemorrhage: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2018 Mar;84(3):505-516
  22. 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
  23. Dutton RP, Stansbury LG, Leone S, Kramer E, Hess JR, Scalea TM. Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997-2008. J Trauma. 2010 Sep;69(3):620-6
  24. Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. Systematic review of predictive performance of injury severity scoring tools. Scand J Trauma Resusc Emerg Med. 2012 Sep 10;20:63full-text
  25. 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

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How to cite

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  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T905757, Penetrating Back Trauma - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T905757. Registration and login required.

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