Management Guidelines For Penetrating Abdominal Trauma: Walter L. Biffl and Ernest E. Moore
Management Guidelines For Penetrating Abdominal Trauma: Walter L. Biffl and Ernest E. Moore
Management Guidelines For Penetrating Abdominal Trauma: Walter L. Biffl and Ernest E. Moore
Purpose of review
Patients with penetrating abdominal trauma are at risk of harboring life-threatening
injuries. Many patients are in need of emergent operative intervention. However,
there are clearly patients who can be safely managed nonoperatively. This review
evaluates the literature to identify management guidelines for patients with penetrating
abdominal trauma.
Recent findings
Accumulating evidence supports nonoperative management of patients with stab
wounds to the thoracoabdominal region, the back, flank, and anterior abdomen.
Furthermore, select patients with gunshot wounds can be safely managed
nonoperatively.
Summary
Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating
abdominal trauma. Thoracoabdominal stab wounds should be further evaluated
with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the
back and flank should be imaged with CT scanning. Anterior abdominal stab wound
victims can be followed with serial clinical assessments. The majority of patients
with gunshot wounds are best served by laparotomy; however, select patients may be
managed expectantly.
Keywords
abdominal trauma, guideline, nonoperative management, penetrating trauma,
thoracoabdominal trauma
Curr Opin Crit Care 16:609617
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295
Introduction
The optimal management of patients with penetrating
abdominal injuries has been debated for decades, since
mandatory laparotomy (LAP) gave way to the concept of
selective conservatism [1]. There is little disagreement
that hemodynamic compromise, peritonitis, impalement, or evisceration mandate prompt LAP. But there
is considerable divergence of opinion regarding the
approach to a hemodynamically stable, asymptomatic
patient. Furthermore, the concept of selective nonoperative management has recently been applied to gunshot
wounds (GSWs). The current review will focus on
the selective nonoperative management of penetrating
abdominal trauma.
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610 Trauma
Injuries in the thoracoabdominal region may create injuries in both the chest and the abdomen, including the
diaphragm. Whereas blunt diaphragmatic injuries may be
relatively easy to diagnose, penetrating injuries are typically occult. The presence of a small knife wound in the
diaphragm can elude detection by the most sensitive
imaging modalities. A prospective series from the Maryland Shock-Trauma Center included 50 patients with CT
findings suggesting a potential diaphragm injury [4]. The
authors considered the CT findings to be specific in just
40% of patients; such findings included contiguous organ
injury on either side of the diaphragm, and herniation of
abdominal fat through a defect in the diaphragm. Nonspecific findings included a wound tract extending up to
the diaphragm, thickening of the diaphragm from blood
or edema, and apparent defect in the diaphragm without
herniation or adjacent hematoma. Seventeen (34%)
patients had surgical evaluation of the diaphragm
LAP in 12 and thoracoscopy in 5 and diaphragmatic
injury was confirmed in only 12 (71%) of that subgroup.
Of note, two patients with specific findings had no
diaphragmatic injury.
Diagnostic peritoneal lavage (DPL) has been employed
to help detect diaphragmatic wounds. Moore and
Marx [5] proposed a red blood cell (RBC) threshold of
Penetrating
thoracoabdominal
trauma
Upright CXR
FAST
CXR ()
FAST ()
CXR (+)
FAST ()
CXR ()
FAST (+)
CXR (+)
FAST (+)
DPL
Thoracoscopy
Laparoscopy/
laparotomy
Tube thoracostomy
Laparoscopy/
laparotomy
Normal
>5000 RBC/ml
>500 WBC/ml
Enteric contents
(+) Diaphragm
injury
Discharge if no
other indications
for admission
Laparoscopy/
laparotomy
Laparoscopy/
laparotomy
CXR (), hemothorax or pneumothorax; DPL, diagnostic peritoneal lavage; FAST (), hemoperitoneum.
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CT findings
Intervention
Low
No penetration
Penetration into subcutaneous
tissue
Penetration into muscle
Retroperitoneal hematoma,
not near critical structure
Contrast extravasation from colon
Major extravasation from kidney
Hematoma adjacent to major
retroperitoneal vessel
Free air in retroperitoneum, not
attributed to wounding object
Evidence of injury above and
below diaphragm
Free fluid in peritoneal cavity
Discharge from ED
Moderate
High
Serial clinical
assessments
Laparotomy
as expected in 24% of patients [7,8] LAP or laparoscopy is performed to exclude injury below the diaphragm [6]. If there is a () FAST, LAP or laparoscopy
is necessary.
Back/flank
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612 Trauma
Nontherapeutic
Shock
Evisceration
Peritonitis
Other
3
5
5
0
(13%)
(14%)
(29%)
(0%)
Therapeutic
21
31
12
4
ED D/C
OR
8/108 (7%)
0 (0%)
2/32 (6%)
n/a
23/120 (19%)
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TEST
CT
FAST
LWE
DPL
SCA
145
132
125
45
26
Nine patients underwent laparoscopy. Seven were NONTHER. Both cases requiring therapeutic interventions
were converted to open.
35
29
25
11
2
PTP
SENS
SPEC
PPV
NPV
(24%)
(22%)
(20%)
(24%)
(8%)
77%
21%
100%
82%
100%
73%
94%
54%
88%
96%
47%
50%
35%
69%
67%
91%
81%
100%
94%
100%
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614 Trauma
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Anterior abdominal
stab wound
OR
YES
Shock
Peritonitis
Evisceration
NO
D/C
Negative
23-Hour observation:
serial physical exam,
CBC q8 hrs
OR
YES
Peritonitis
Hemodynamic instability
NO
CT, DPL
or OR
YES
Feed
D/C
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616 Trauma
Gunshot wounds
Mandatory LAP has long been considered the standard of
care for management of abdominal GSWs, given that over
90% of patients with peritoneal penetration have an
injury requiring operative management [46]. In recent
years, however, a number of reports have identified a
subset of patients who may be candidates for nonoperative management [4749,50]. Stable, asymptomatic
patients are candidates for CT scanning. Those who have
clear evidence of extracavitary trajectory can be discharged from the ED. Patients with isolated solid organ
injuries may be candidates for nonoperative management. However, the setting must be appropriate, as
the patients condition could change abruptly. As much
of the literature has come primarily from two centers, this
approach should be undertaken with caution.
Renz BM, Feliciano DV. The length of hospital stay after an unnecessary
laparotomy for trauma: a prospective study. J Trauma 1996; 40:187
190.
Moore EE, Marx JA. Penetrating abdominal wounds: rationale for exploratory
laparotomy. J Am Med Assoc 1985; 253:27052708.
Uribe RA, Pachon CE, Frame SB, et al. A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma. J Trauma
1994; 37:650654.
Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm:
prospective evaluation of laparoscopy in penetrating injuries to the left lower
chest. J Am Coll Surg 1998; 187:626630.
Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult
diaphragm injury after penetrating abdominal trauma. J Trauma 2005;
58:789792.
10 Boyle EM Jr, Maier RV, Salazar JD, et al. Diagnosis of injuries after stab
wounds to the back and flank. J Trauma 1997; 42:260265.
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