Penetrating abdominal trauma requires prompt evaluation and surgical exploration if the patient has abdominal rigidity, hemodynamic compromise, or a gunshot or shotgun wound that penetrates the peritoneal cavity. Stab wounds to the abdomen between the costal margin and pubic symphysis or flank and back areas that penetrate the peritoneum or retroperitoneum also require exploration. Computed tomography can be used to evaluate trajectory and potential organ involvement for isolated wounds to the liver or retroperitoneum.
2. PENETRATING WOUND TO THE ABDOMEN
It is not necessary to
determine which intra-
abdominal organs are
injured in the ED- except
when EL is necessary.
(+)Abdominal rigidity and
hemodynamic compromise
> Prompt surgical
exploration
Minimal evaluation is
required before Laparotomy
for GS or Shotgun wounds
that penetrate the peritoneal
cavity
Anterior truncal gunshot
wounds between 4th ICS
and pubic symphysis whose
trajectory as determined by
radiograph or wound
location indicates peritoneal
penetration > Laparotomy
Penetrating Trauma isolated
to the RUQ
(hemodynamically stable)
with trajectory confined to
the liver by CT scan > non-
operative management is
reasonable
3. • Obese patients – If GSW is
thought to be tangential through
the SQ tissues > CT scan can
delineate the tract and exclude
peritoneal violation
• Laparosocpy- another option to
assess peritoneal penetration for
tangential wounds.
• If in doubt- always safer to explore
abdomen.
4. • GSW (flank and back area) > Triple-contrast CT scan
(more difficult to evaluate due to the retroperitoneal location)
can delineate the trajectory of the bullet and identify peritoneal
violation or retroperitoneal entry, but may not identify the specific
injuries.
• In contrast, SW that penetrate the peritoneal cavity are less
likely to injure intra-abdominal organs.
5. • Anterior abdominal stab wounds (from costal to inguinal
ligament and bilateral midaxillary lines) > should be explored
under local anesthesia in the ED (to determine if the fascia is
violated)
• Injuries that do not penetrate the peritoneal cavity do not require
further evaluation> patient may be discharged from the ED
• Pts with FASCIAL PENETRATION> further evaluation (
because up to 50% chance of requiring laparotomy)
6. • SW to the RUQ > can undergo CT scan (to determine trajectory
and confinement to the liver for potential non operative care)
• SW to the flank and back area> SHOULD undergo triple
contrast CT scan (assess potential risk of retroperitoneal
injuries of the colon, duodenum, and urinary tract)
• GSW or SW to the Left lower chest > SHOULD be evaluated
with diagnostic laparoscopy or DPL (to exclude diaphragmatic
injury)
7. • DPL evaluation – lab value cutoffs to rule out diaphragm injury
• RBC count of >10,000/uL > (+) finding > indicated for abdominal
evaluation
• DPL RBC count of 1000/uL and 10,000/uL > SHOULD undergo
laparoscopy or thoracoscopy.
• Diagnostic Laparsocopy < preferred in pts with (+) chest
radiograph (hemothorax or pneumothorax) or in those who
would not tolerate a DPL.
