HWN Suggests

Use of Abdominal CT in Stab Wounds to the Anterior Abdomen

In general, stab wounds to the anterior abdomen (like any penetrating injury to the area) demand further evaluation to make sure there are no significant injuries. In the old days, a stab to the abdomen mandated a trip to the operating room. Fortunately, we recognized that more than half of these operations led to negative explorations.

Nowadays we can be much more selective.

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 Trauma! Penetrating Abdominal Injury

Compared to stab wounds abdominal gunshot wounds are more likely to penetrate the peritoneum (80%), and those that do are more likely to cause intraperitoneal injury (90%). Also, bullets an similar missiles are higher velocity and may richocet resulting in unpredictable wound tracts. This modifies the approach compared with stab wounds.

Articles of Interest

Abdominal Stab Wound Assessment and Management

Computed tomography can be helpful to identify signs of intrabdominal injury, but 10-20% of injuries will be missed. Serial abdominal exams over 24hrs is a mainstay of management to monitor for peritonitis. Upper abdominal and epigastric wounds may result in thoracic and diaphragm injuries that require further assessment including CT imaging of the thorax.

How To Read A Stab Wound

Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.

Paucis Verbis card: Penetrating abdominal trauma

Gun shot wounds (GSW) – all require laparatomy exploration because of higher incidence of intra-abdominal injuries Stab wounds (SW) to anterior abdomen - can be observed vs laparotomy.

Penetrating Abdominal Trauma

26-year-old man brought in via bystanders after being found down outside of the ED. He has a penetrating wound to the abdominal left upper quadrant and the left flank. Free fluid is not initially seen on US. Has a shock index >1 at arrival.

Penetrating Abdominal Trauma, Selective Non-Operative Management of

Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs.

Penetrating Trauma: What We Miss and How We Can Improve

In the patient with a history of penetrating trauma we need to be aware of two injures that could have been missed: diaphragmatic tears and ureteral injuries. While CT scans can miss asymptomatic tears, they are quite good at diagnosing organs that have herniated through the diaphragm so if you are suspicious of it, order that CT scan. In any patient with abdominal or flank pain, fever, or urinary symptoms who has a history of penetrating trauma, consider ureteral injuries because you may need special imaging to diagnose it. Finally, despite advances in imaging, hollow viscus injuries continue to be a diagnosis that can be missed in the absence of observation and serial abdominal exams.

Prophylactic antibiotics for penetrating abdominal trauma: duration of use and antibiotic choice

At present, we are uncertain if there is a benefit to extending the duration of antibiotic prophylaxis for people undergoing laparotomy for penetrating abdominal trauma beyond 24 hours on abdominal surgical site infection rates, mortality, or intra‐abdominal infections. Likewise, we are uncertain whether some drug regimens are superior to others. All of the studies included in this review were at high risk of bias, and the majority were carried out several decades ago, making application of this evidence to current surgical practice difficult.

The Approach to Penetrating Abdominal Trauma

In summation, most patients with PAT, especially gunshot wounds, still require surgery. On initial survey, patients who are hemodynamically unstable, have diffuse abdominal pain, evisceration, or peritoneal findings must go to the operating room.46,47 Patients with an altered sensorium, head injury, inability to cooperate with serial abdominal exams, or patients who will be undergoing an operative procedure somewhere other than the abdomen may be explored as well, depending on the comfort level of the trauma surgeon.53 This leaves a clinical subset that can be managed nonoperatively. In these patients, SNOM can drastically reduce the rates of negative and nontherapeutic laparotomies and result in a cost savings and safety benefit to the patient.

When Can You Close That Stab Wound?

I find that many trauma professionals are nervous about closing stab wounds. They seem to worry a lot about infections and lean toward leaving the wound open to heal by secondary intention. But is this warranted? The answer is: probably not. Most knives used for assaults are clean, but not quite sterile. Yes, there are a few bacteria on the blade, but not very many. So if the usual wound management guidelines are followed, the patients generally do quite well.