eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Abdominal Trauma, Penetrating: Treatment & Medication

Author: Paul A Testa, MD, Resident, Department of Emergency Medicine, New York University Medical Center, Bellevue Hospital
Coauthor(s): Eric Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital, Manhattan; Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine
Contributor Information and Disclosures

Updated: Jul 28, 2008

Treatment

Prehospital Care

• The scope of care that paramedics deliver at the scene of the injury has evolved in parallel with the changing standard of care in the hospital setting.
  • Because most deaths occurred from exsanguination associated with prehospital hypotension, trauma system response is designed to minimize care in the field and expedite transport to the emergency department and to reduce the time to definitive care.
  • Aggressive intravenous fluid administration to maintain or reach normotension is discouraged in patients with penetrating injury unless the patient manifests severe shock or prolonged transport is expected.
• Prehospital personnel must be well trained in properly assessing patients and in transporting them to the closest appropriate facility or trauma center. The receiving hospital should be notified as soon as possible by radio or ground line to give the ED time to prepare and to alert the appropriate staff. The mode of transportation also must be considered. In an urban setting with multiple appropriate facilities, the best transport is probably by ground. In the rural setting, where the closest facility is 25 minutes or more away, trauma patients' best chance for survival may be transport by air ambulance.

Emergency Department Care

Missed intra-abdominal injuries are among the most frequent causes of potentially preventable trauma deaths. The evaluation and management of abdominal trauma is dependent on mechanism and location of injury, hemodynamic and neurologic status of the patient, associated injuries, and institutional resources. A team leader should direct resuscitation and coordinate all care. Depending on the institution, it may be an emergency physician, trauma surgeon, or one of their supervised residents. Given the potential for significant injury, a junior level physician should not lead care without direct oversight.

• ED care of the patient with penetrating trauma revolves around several important concepts. On arrival, as the ABCDE's are being assessed, a few brief interventions should be performed. The patient should be placed on a cardiac monitor, pulse oximeter, and 100% nonrebreather oxygen mask. Intravenous access should be established.
  • Assessment and treatment of the basics of trauma life support
    • Airway: Patients with severe shock or loss of ability to control their airway should be intubated to ensure appropriate oxygenation or ventilation. In general, occult cervical spine injury in penetrating trauma is highly unlikely. Unless there are clear deficits or associated blunt injury, cervical collars are rarely necessary and may hinder resuscitation.
    • Breathing: Tube thoracostomy or needle decompression should be undertaken immediately for patients with obvious pneumothorax. If the patient is otherwise stable, he or she should have a chest radiograph performed in the trauma room. An upright positioned radiograph during expiration may provide the best evidence of pneumothorax. Ultrasonography for pneumothorax has been shown to be highly accurate and may be used as the initial test, but it should be followed by a radiograph at some point.
    • Circulation: The route of intravenous access is important. Large-bore peripheral intravenous catheters in the upper extremities are the resuscitation lines of choice. These allow for rapid volume/blood infusion versus a central line where the infusion rate is slower. Still, extensive debate exists in the literature on the amount and end points for resuscitation prior to definitive control of hemorrhage. Both animal data and several studies in humans are looking at "permissive hypotension," that is, actively or passively allowing the blood pressure to remain in the hypotensive ranges less than 90 mm Hg. The theory is that this will prevent disruption of clot and dilution of clotting factors while maintaining adequate blood viscosity. While no definite consensus exists, prevailing thought seems to promote limited resuscitation with avoidance of attempting to raise blood pressure to normal or near-normal levels until hemorrhage is definitively controlled.
    • Deficits: A rapid and brief evaluation for neurologic deficits should be conducted.
    • Exposure: All patients with penetrating trauma should be fully undressed. Complete exposure and head-to-toe visualization of the patient is mandatory in a patient with penetrating abdominal trauma. This includes the buttocks, posterior part of the legs, scalp, posterior part of the neck, and perineum. There is little to be gained by practicing spinal immobilization unless spinal injury is obvious.
    • Depending on the initial assessment, and in all seriously injured patients, a Foley catheter should be placed if possible to monitor urine output and to check for hematuria. In addition, a nasogastric tube (NGT) or orogastric tube (OGT) should be inserted to evaluate for intragastric blood and to decompress the stomach so as to reduce aspiration risk. Appropriate laboratory specimens should be immediately sent to the laboratory for evaluation.
• After the initial evaluation, further evaluation depends on the hemodynamics and mechanism of wounds. Briefly, options are as follows:
  • Stab wounds
    • Unstable patients or those with clear-cut peritonitis should undergo exploratory laparotomy.
    • If stable, patients may have local wound exploration to ascertain if the peritoneum was violated. If unable to perform or if flank or thoracoabdominal wounds are present, other methods must be used. DPL is still an option, but it is currently being used less frequently. A positive FAST examination result has a high positive predictive value for a therapeutic laparotomy, but a negative FAST examination result cannot be relied upon to rule out injury.
    • If thoracoabdominal, a chest radiograph should be obtained. If no signs of diaphragmatic injury are present, laparoscopy is usually advocated; although some surgeons will elect not too perform this on a right-sided wound given the low likelihood of delayed complications.
    • The use of CT scan is still controversial; some centers use it as a screening test in patients with anterior stab wounds, while others feel the cost-benefit ratio is not justified. A triple contrast CT should be performed on patients with penetrating flank wounds.
    • Essentially all nonoperative patients, except those who have a wound that clearly does not penetrate the abdomen, should be observed for serial examinations. Literature is beginning to support a shortened time frame of 12 hours, but most centers use about 24 hours.
  • Gunshot wounds
    • All unstable gunshot wounds should proceed emergently to the operating room (OR). Abdominal and other radiographs (depending on possible bullet course and number of wounds) should be taken at some point during the patient's care to account for all bullets.
    • In the past, all gunshot wounds that were clearly nontangential were taken to the OR for exploration. An increasing body of literature supports CT imaging, either triple contrast or just intravenous contrast alone to evaluate for intra-abdominal or retroperitoneal injury. This has been shown to significantly decrease the need for laparotomy without a concurrent increase in morbidity. All hollow viscus injuries need emergent laparotomy; however, isolated liver or spleen injuries are sometimes observed or undergo angioembolization.
• Patient disposition relates to the type of facility and to the mechanism of and potential for injury. The most common post-ED disposition for patients with penetrating abdominal trauma is to the OR. Any patient with an obvious reason for laparotomy (eg, evisceration, rigid abdomen, hypotension) should be taken directly to the OR following initial evaluation and resuscitation in the ED. Some facilities do not have a surgical or OR team available 24 hours a day. In this case, these patients must be transferred to an appropriate facility. Similar concerns occur if the patient's injuries overwhelm the available resources at the receiving facility.

Consultations

In general, consultation by a general or trauma surgeon should be undertaken for victims of penetrating trauma.

• At some centers, trauma surgeons perform the majority of operative repair, while at others, consultants may be involved as individual injuries are identified. For example, a vascular surgeon may repair major arterial and venous injuries or a urologist may address injuries to the bladder, kidneys, and ureters.
• Trauma surgeons, even if not directly performing care, should oversee the patient's care and postoperative course.

Medication

In general, medications used to treat victims of penetrating abdominal trauma fall into discrete categories. Analgesics, anxiolytics, antimicrobials (skin and enteric flora), immune boosters (tetanus booster), and neuromuscular blockers comprise the major classes of pharmacotherapeutic agents used for these patients.

Analgesics

Pain control is essential to quality patient care. Appropriate and sufficient pain control is important. Concerns still exist regarding pain control in patients undergoing observation. A reasonable protocol should be developed by institutions in consultation with the trauma service or consulting surgeon. Postoperatively, analgesics are essential to ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens.

Morphine sulfate (MS Contin, Oramorph SR, Duramorph)

Drug of choice for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect is obtained.

Fentanyl citrate (Duragesic, Sublimaze)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. Common choice for procedural sedation analgesia. Excellent for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter.
Most patients are controlled with 72-h dosing intervals when using transdermal dosage form, although some patients require 48-h dosing intervals.

Anxiolytics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of GABA, a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Excellent choice when patient must be sedated for longer than 24 h.

Midazolam hydrochloride (Versed)

Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring immediate and/or short-term sedation. Also useful for its amnestic effects. Frequently used for procedural sedation

Antibiotics

Antibiotic prophylaxis is proven to reduce postoperative surgical infections after penetrating abdominal trauma.

The Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group recently published evidence-based consensus guidelines addressing the use and duration of antimicrobial prophylaxis after penetrating abdominal trauma. They recommended, in the absence of hollow viscus injury, patients should receive a single dose of a broad-spectrum antimicrobial agent that provides both aerobic and anaerobic coverage. No specific agent is recommended, but it may be a single agent with beta-lactam coverage or combination therapy with an aminoglycoside and clindamycin or metronidazole. In patients with a hollow viscus injury, antimicrobial prophylaxis should be extended to 24 hours.

While some controversies still exist regarding therapy for seriously injured patients, for the emergency physician, the key point is to start antibiotics in the ED. If the patient requires emergent laparotomy and must be rapidly transported, it may be done upon arrival to the OR.

Cefotetan (Cefotan)

Second-generation cephalosporin with activity against some gram-positive cocci, gram-negative rod infections, and anaerobic bacteria. Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.
Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefotetan.
Antibiotics have proven effective in decreasing rate of postoperative wound infection and improving outcome in patients with intraperitoneal infection and septicemia.

Metronidazole hydrochloride (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Gentamicin sulfate (Garamycin, Gentacidin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with an agent against gram-positive organisms and one that covers anaerobes.
Not the drug of choice. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on creatinine clearance and changes in volume of distribution. May be administered IV/IM.

Vancomycin hydrochloride (Vancocin, Lyphocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin-structure infections. Indicated for patients who cannot receive or who are unresponsive to penicillins and cephalosporins or who have infections with resistant staphylococci. For penetrating abdominal injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures.

Ampicillin sodium-sulbactam sodium (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Neuromuscular blocking agents

Many patients with penetrating abdominal trauma require urgent airway control.

Succinylcholine chloride (Anectine Chloride, Anectine Flo-Pack)

Prototypical depolarizing neuromuscular blocker that is ultra–short-acting and predictable in onset (<1 min) and duration (4-6 min). Highly ionized, relatively fat-insoluble; does not readily cross placenta.
Pediatric patients must be pretreated with atropine to avoid bradycardia and cardiac arrest. May also occur in adults but more commonly is associated with administration of either a higher dose or a second dose.

Vecuronium bromide (Norcuron)

Prototypic, nondepolarizing, neuromuscular blocking agent that reliably results in muscular paralysis. For intubation and maintenance of paralysis, a continuous infusion may be used.
Infants are more sensitive to neuromuscular blockade activity; recovery is prolonged by 50%, although the same dose is used. Not recommended for use in neonates.

Immune enhancement

For penetrating abdominal trauma resulting in wounds contaminated with either dirt or debris or for wounds caused by metallic objects carrying a risk of Clostridium tetani infection. Tetanus results from elaboration of an exotoxin from C tetani. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. Patients who may not have been immunized against C tetani products (eg, immigrants) should receive tetanus immune globulin (Hyper-Tet).

Tetanus toxoid aluminum phosphate

Induces active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.

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