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Abdominal Trauma, Penetrating: Workup
Updated: Jun 12, 2007
Workup
Laboratory Studies
All patients should undergo certain basic laboratory testing, as follows:
- Complete blood count (CBC) provides a baseline value for later comparison, even though it may not reveal the extent of active bleeding.
- Basic chemistry profile (BMP) also reveals any baseline renal insufficiency or electrolyte abnormalities.
- Coagulation studies (PT/INR + PTT) may suggest development of coagulopathy.
- Arterial blood gas (ABG) provides important information regarding acid-base balance and, thus, the hemodynamic stability of the patient.
- Urine dipstick may reveal occult blood indicative of genitourinary tract injuries. Female patients should have urine pregnancy testing.
Patients who arrive in shock should be typed and crossed for 4-8 units packed red blood cells.
Ethanol and drug screens are also standard practice in trauma patients. Studies have shown that even brief intervention and counseling in patients at the time of admission for trauma injury has positive outcomes.
Imaging Studies
Many imaging modalities can be useful in the evaluation of a patient with PAT.
Plain radiograph
Chest radiograph is obtained on all patients because penetration of the chest cavity cannot be ruled out, even with abdominal stab wounds or even-numbered GSWs. Chest radiograph can reveal hemothoraces/pneumothoraces or irregularities of the cardiac silhouette, which can be a sign of cardiac injury or great vessel injury. Air under the diaphragm indicates peritoneal penetration. Abdominal radiographs in 2 views (ie, AP, lateral) are also obtained on all patients with GSWs to help determine missile trajectory and to account for retained missiles in patients with odd-numbered GSWs.
Ultrasound
The focused assessment with sonography for trauma (FAST) uses 4 views of the chest and the abdomen (ie, pericardial, right upper quadrant, left upper quadrant, pelvis) to evaluate for pericardial fluid indicative of cardiac injury and for free peritoneal fluid. Free fluid in the abdomen can be a sign of hemorrhage secondary to liver or splenic laceration or, less commonly, of spillage secondary to hollow viscus injury.
CT scan
CT scan is used in the evaluation of patients with stab wounds to the flank and the back and in the evaluation of selected patients with abdominal stab wounds and GSWs. Triple contrast (ie, oral, intravenous, rectal) is often used to maximize the sensitivity of this study for peritoneal penetration and intra-abdominal organ injury.
Specific signs of peritoneal penetration include a wound tract outlined by hemorrhage, air, or bullet or bone fragments that clearly extend into the peritoneal cavity; the presence of intraperitoneal free air, free fluid, or bullet fragments; and obvious intraperitoneal organ injury.
Intravenous pyelogram
This study is more often used intraoperatively to assess contralateral renal function in a patient with kidney damage necessitating nephrectomy.
Diagnostic Procedures
In patients with PAT, a limited number of procedures are necessary for diagnosis and/or treatment.
Nasogastric intubation
All patients undergoing endotracheal intubation require decompression of the stomach to decrease the risk of aspiration. Blood in the nasogastric tube can indicate upper gastrointestinal injury.
Foley catheterization
Catheter insertion is required to monitor the fluid resuscitation status of the patient with PAT. The presence of blood in the urine is a sign of genitourinary tract injury.
Diagnostic peritoneal lavage
Diagnostic peritoneal lavage (DPL) can be performed via either a closed method (ie, small skin puncture with blind insertion of catheter over guidewire) or an open method (ie, insertion of catheter under direct vision after exposure of the peritoneum through a small infraumbilical incision).
Aspiration of gross blood is positive for peritoneal penetration and organ injury. If aspiration is negative, 1 liter of sodium chloride is administered through the catheter and then retrieved by gravity siphonage. The fluid is then evaluated for the presence of red blood cells (>10,000/mm3), white blood cells (>500/mm3), bile, fibers, or particles, any of which indicate peritoneal penetration and organ injury.
While very sensitive and specific, DPL requires a fair amount of time to perform, and it has been supplanted in many institution protocols by FAST, CT scan, and/or laparoscopy.
Tube thoracostomy
Patients with penetrating wounds to the thoracoabdominal area may require chest tube placement. Absent or significantly decreased unilateral breath sounds necessitate immediate tube thoracostomy to relieve hemothorax/pneumothorax. In other patients, hemothorax/pneumothorax will be identified on chest radiograph.
A large-bore (38-40F) chest tube should be placed in the midaxillary line at the fifth intercostal space. Time permitting, liberal local anesthesia is preferred in the patient who is awake. The tube is placed to 20-cm wall suction, and, postprocedure, chest radiograph is performed to confirm placement.
Rigid sigmoidoscopy
Patients with blood on rectal examination who are otherwise being managed expectantly (mostly stab wounds) should undergo rigid sigmoidoscopy to rule out rectal injury.
More on Abdominal Trauma, Penetrating |
| Overview: Abdominal Trauma, Penetrating |
 Workup: Abdominal Trauma, Penetrating |
| Treatment: Abdominal Trauma, Penetrating |
| Follow-up: Abdominal Trauma, Penetrating |
| Multimedia: Abdominal Trauma, Penetrating |
| References |
| Further Reading |
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References
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Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma. Aug 2002;53(2):297-302; discussion 302. [Medline].
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Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol. Dec 2001;177(6):1247-56. [Medline].
Feliciano DV, Burch JM, Spjut-Patrinely V, Mattox KL, Jordan GL Jr. Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients. Ann Surg. Sep 1988;208(3):362-70. [Medline].
Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg. Feb 1997;132(2):178-83. [Medline].
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Udobi KF, Rodriguez A, Chiu WC, Scalea TM. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. Mar 2001;50(3):475-9. [Medline].
Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma. Aug 2001;51(2):320-5. [Medline].
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Jacobs LM, et al. Advanced Trauma Operative Management: Surgical Strategies for Penetrating Trauma. Connecticut: Cine-Med Inc; 2004.
Mattox KL, Feliciano DV, Moore EE. Trauma. 4th ed. New York: McGraw-Hill; 1999.
Morris JA Jr, Eddy VA, Rutherford EJ. The trauma celiotomy: the evolving concepts of damage control. Curr Probl Surg. Aug 1996;33(8):611-700. [Medline].
Murphy SH. National Vital Statistics Reports. Deaths, final data for 1998. 2000;Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf. [Full Text].
Pourmoghadam KK, Fogler RJ, Shaftan GW. Ligation: an alternative for control of exsanguination in major vascular injuries. J Trauma. Jul 1997;43(1):126-30. [Medline].
Thal ER. Operative exposure of abdominal injuries and closure of the abdomen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, eds. Scientific American Surgery. New York: Scientific American; 1996: revised 1997.
Weigelt JA, Thal ER, Carrico JC, eds. Operative Trauma Management Atlas. Stamford, Conn: Appleton & Lange; 1997.
Further Reading
Lawson R, Goosen J. Abdominal Stab Wound Exploration. eMedicine from WebMD. Updated May 31, 2007. Available at: http://www.emedicine.com/proc/topic82869.htm.
Keywords
gunshot wound, GSW, gut shot, stab wound, missile injury, celiotomy, diagnostic peritoneal lavage, DPL, diagnostic laparoscopy, intra-abdominal injuries, intraabdominal injuries, advanced trauma life support, ATLS
