Penetrating Abdominal Trauma
Guidelines for Evaluation

Immediate Laparotomy if: Shock Peritonitis (clinical examination) Evisceration

else:

Problems:

• Retroperitoneal colon injury
• Renal / ureteric injury

Investigation of potential colon injury:
There is no good radiological investigation for this injury.
Serial physical examination is the most important.
Consider CT scan with rectal contrast.
Even if normal maintain a high index of suspicion. Continued management as for abdominal stab wound but will require longer period of observation, watching closely for signs of sepsis.

Investigation of renal injury:
In the presence of haematuria proceed to CT scan with intravenous contrast.
Absence of haematuria does not exclude an injury to the urinary tract. Maintain a high index of suspicion during observation.

2. Stab at Costal Margin
If shocked - use FAST to exclude haemopericardium
Haemothorax/pneumothorax and free fluid in abdomen implies a diaphragmatic injury.
Consider next-day laparoscopy for all lower left chest stabs to exclude diaphragm injury.

3. Tangential Gunshot Wounds
In general, most gunshot wounds will require laparotomy. However, if:

• Haemodynamically normal
• No clinical signs
• Possible tangential gunshot wound track

Consider CT scan or laparoscopy exclude/confirm peritoneal penetration.

References

      General

• Evaluation of a comprehensive algorithm for blunt and penetrating thoracic and abdominal trauma.
  Bishop M, Shoemaker WC et al; Am Surg 1991;57:737-46
• Diagnostic modalities in abdominal trauma. Peritoneal lavage, ultrasonography, computed tomography scanning, and arteriography.
  Feliciano DV; Surg Clin North Am 1991;71:241-56
• Penetrating abdominal trauma.
  Marx JA; Emerg Med Clin North Am 1993;11:125-35

  Ultrasound
  

• Sonographic examination of abdominal trauma by senior surgical residents.
  Kern SJ, Smith RS; et al. Am Surg, 1997;63:669-74
• Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians.
  Ma OJ; Mateer JR; Ogata M et al. J Trauma 1995;38:879-85
• Use of ultrasound to determine need for laparotomy in trauma patients.
  Porter RS; Nester BA et al. Ann Emerg Med 1997;29:323-30
• Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients.
  Rozycki GS; Ballard RB; Feliciano DV et al. Ann Surg 1998;228:557-67

  Laparoscopy
  

• A prospective analysis of diagnostic laparoscopy in trauma.
  Fabian TC; Croce MA; Stewart RM et al. Ann Surg 1993;217:557-64; discussion 564-5
• Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises.
  Guth AA; Pachter HL. J Soc Laparoendosc Surg 1998;2:123-7
• A critical evaluation of laparoscopy in penetrating abdominal trauma.
  Ivatury RR; Simon RJ; Stahl WM. J Trauma 1993;34:822-7; discussion 827-8

  Thoracoabdominal wounds
  

• Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries.
  Murray JA; Demetriades D; Cornwell EE 3rd; Asensio JA et al. J Trauma 1997;43:624-6

  Flank wounds
  

• Penetrating posterior abdominal trauma.
  Burns RK; Sariol HS; Ross SE. Injury 1994;25:429-31
• A prospective, randomized comparison of computed tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank.
  Easter DW; Shackford SR; Mattrey RF. Arch Surg 1991;126:1115-9

  Urinary tract injury
  

• Penetrating ureteric injuries.
  Azimuddin K; Milanesa D; Ivatury R; Porter J et al. Injury 1998;29:363-7
• Ureteral injury due to blunt and penetrating trauma.
  Campbell EW Jr; Filderman PS; Jacobs SC. Urology 1992;40:216-20
• Ureteral trauma: preoperative studies neither predict injury nor prevent missed injuries.
  Medina D; Lavery R; Ross SE; Livingston DH. J Am Coll Surg, 1998;186:641-4
• Radiographic assessment of renal trauma: our 15-year experience.
  Miller KS; McAninch JW. J Urol 1995;154:352-5

  Tangential gunshot wounds

• Laparoscopy in 121 consecutive patients with abdominal gunshot wounds.
  Sosa JL; Arrillaga A et al. J Trauma 1995;39:501-4; discussion 504-6

(updated) Karim Brohi, trauma.org 8:7, July 2003