1. A 20-year-old male was stabbed in the abdomen with a 10 cm knife during a fight. He was hemodynamically stable on arrival to the emergency room. 2. The emergency physician attempted to examine the wound but could not determine if it penetrated the peritoneum due to its depth. A CT scan or FAST exam was recommended to check for internal bleeding before deciding on observation or surgery. 3. For hemodynamically stable patients with abdominal stab wounds, selective non-operative management is usually recommended initially. Further examination with CT scan is important to identify any internal bleeding before deciding on observation versus laparotomy.

1. 2014/9/20 Huang Guan-Lin M.D.

2. 20歲男性周末狂歡
跟旁人對傳播妹爭風吃醋
步入急診室，據傳被用長達10公分的扁鑽刺入
生命徵象BP:130/85 HR:98 BT:37.6
急診醫師嘗試床邊診視傷口但因為傷口較深而無法得知是否深入腹膜
且傷口附近持續在滲血, no peritoneal sign

3. How to manage this patient?

4. Indications for laparotomy
• Hemodynamic unstable
• Peritoneal irritation/diffuse abdominal pain >> S/S
• Fascia penetration
• Gunshot wound with transperitoneal path
Symptoms?
Yes No
Hemodynamic
stable
Yes OP OP
no OP ????

5. • Hemodynamic stable
 Knife/gunshot
 Distance
 Blood loss
• Gun shot injury: 98% peritoneal penetration
• Stabbing injury: 30% intraperitoneal injury

6. What do I do in ER?

7. • Seems no emergent OP problem/active bleeding now
• On IV, check the CBC, prepare blood
• FAST / abdominal CT >internal bleeding/emergent OP indication

20. • Seems no emergent OP problem/active bleeding now
• On IV, check the CBC, prepare blood
• FAST / abdominal CT >internal bleeding/emergent OP indication
• Patient easy, CT report. Intend to let him MBD in AM8:00
• Duty VS consult GS CR…

21. • My question is …
Other examination?
How long in obs room?
Is there any evidence support the Tx?
Possibility of laparotomy in obs pts?

23. Symptoms?
Yes No
Hemodynamic
stable
Yes OP OP
no OP NOM
NOM=
SELECTIVE NON OPERATIVE MANEGEMENT

24. Q1:
In stable stab wd pts,
rationale for early laparotomy?

25. Nancy(1969), New Orleans charity hospital
Unnecessary laparotomy Complication in
Unnecessary laparotomy
Early laparotomy 66% 24%
Clinical judgement 25% 0%
Friedmann(1968):70%negative laparotomy rate in mandatory laparotomy
Lee(1984): 7.8% negative laparotomy rate in selective management
initial presentation and examination accuracy: 88%

26. Morbidity of
nontherapeutic laparotomy

27. • Complications of laparotomy(41.3%)
 Atelectasis:41.3%
 Pleural effusion:9.8%
 Pneumothorax:5.2%
 Pneumonia:3.9%
Mortality:0.8%
• Hospital stay:
Uncomplicated : 5.1days
Complicated: 11.9 days
J Trauma. 1995;38:350-356
Am surg 1994;60:744-747

28. Q2:
Gun-shot injury on selective NOM?

29. • Still in controversy
• If NOM was chosen, need other examination
Lowe, 1977, retrospective review of 362 pts with GSW
108 pts Tangential injury, NOM
254 pts Suspect penetrating visceral cavity
97.6% need surgical repair
Velmahos, 2001, retrospective 792 pts with NOM GSW
80 pts Delayed laparotomy, therapeutic rate:72%
712 pts NOM
Routine
laparotomy
47% false negative

30. Q3:
Local wound exploration feasible?

31. • Negative fascia penetration: conservative TX
• Positive fascia penetration: mandatory op?
 Fabian(1993): negative laparotomy rate 50%
• Still further investigation if fascia penetration

32. Q4:
Better adjuncts examination for selective NOM?

33. • ECHO: not enough data
• Angiography: not enough data
• DPL: high sen, spe, accuracy in old times
• CT:
 Shanmuganathan(2004)
 Sen:97%, spe:98%, accuracy:98% in penetrating stab wds
 Velmahos(2005)
 GSW: Sen 90.5, Spe: 96%
Radiology 2004:231:775-784
J trauma 2005:59:1155-1161

34. Q5
How long would be the observation time?

35. • MBD after 24hrs obs with minimal or no
abdominal tenderness
• Alzamel(2005)
 Retrospective 650pts with NOM and delayed
laparotomy in 12hrs
• Velmehos(1997)
 stable, tolerate food after 24hrs(1856pts)

36. TAKE HOME MESSAGE
NOM indication
Stab wound: rationale for NOM
Gun shot wound: still in debates
Examination: CT
OBS time:24hrs
Huang Guan-Lin M.D.
Kaohsiung CGMH urology department

37. • Stab wound:
liver > small bowel > diaphragm >colon
• Gunshot wound:
small bowel > colon > liver >abdominal
vascular

38. ATLS textbook
• Easy miss diagnosis
 Hollow viscus rupture
 Solid organ bleeding
 Bony pelvis bleeding
• Significant blood loss may present in
 No dramatic change in appearance
 No obvious change in peritoneal sign