Practice Essentials
Penetrating abdominal trauma typically involves the violation of the abdominal cavity by a gunshot wound (see the image below) or stab wound.
Penetrating abdominal trauma. Tangential gunshot wound to the liver.
Signs and symptoms
Signs and symptoms of penetrating abdominal trauma depend on various factors, including the type of penetrating weapon or object, the range from which the injury occurred, which organs may be injured, and the location and number of wounds.
Close-range injuries transfer more kinetic energy than those sustained at a distance, although range is often difficult to ascertain when assessing gunshot wounds. A gunshot wound is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can involve an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. 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.
See Clinical Presentation for more detail.
Diagnosis
Initial examination (primary survey, or ABCDEs) 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
Type of penetrating weapon or object
Amount of blood loss
The secondary survey is a complete head-to-toe physical examination in hemodynamically stable patients and includes external inspection with respect to anatomic landmarks; abdominal evaluation for tympany, dullness to percussion, bowel sounds, and/or distention; and a digital rectal and genitourinary evaluation. In patients with life-threatening injuries, the secondary survey may be delayed for operative therapy.
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 testing
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 studies
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
Other radiologic studies that may be useful include the following:
Skeletal survey: To detect any associated fractures
Brain CT scanning: To detect any coincident head injuries
Retrograde urethrogram/cystogram: To detect any urethral or bladder injury
Intraoperative intravenous pyelography: To assess contralateral renal function in patients with kidney damage necessitating nephrectomy
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
See Workup for more detail.
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.
Pharmacotherapy
The following medications may be used in the management of patients with penetrating abdominal trauma:
Analgesics (eg, morphine sulfate, fentanyl citrate)
Anxiolytics (eg, lorazepam, midazolam hydrochloride)
Antibiotics (eg, cefotetan, metronidazole hydrochloride, gentamicin sulfate, vancomycin hydrochloride, ampicillin sodium-sulbactam sodium)
Neuromuscular blocking agents (eg, succinylcholine, vecuronium bromide)
Immune enhancement (eg, tetanus toxoid adsorbed or fluid)
See Treatment and Medication for more detail.