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Background
Penetrating abdominal trauma typically involves the violation of the abdominal cavity by a gunshot wound
(GSW) or stab wound. The management of penetrating abdominal trauma has evolved greatly over the last
century.
Before World War I, penetrating trauma was managed expectantly and was nearly uniformly fatal.
Laparotomy became the treatment of choice during World War I, but mortality remained high. By World War
II, early laparotomy resulted in a survival rate close to 50%.
The 1950s afforded availability of antimicrobials, better understanding of fluid replacement, and faster
transport from the scene, which further increased survival rates. By the late 1950s, mandatory laparotomy
was the rule for the management of patients with abdominal penetrating trauma.
In 1960, Shaftan suggested selective management of patients with abdominal stab wounds after observing
an increased rate of laparotomies without identifiable injuries. More recently, expectant management has
also been used in the treatment of specific GSWs to the abdomen…
Anatomy
In evaluating patients with penetrating abdominal trauma, the abdomen is classically divided as follows:
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Anterior abdomen - Anterior costal margins to inguinal creases, between the anterior axillary lines
Intrathoracic abdomen or thoracoabdominal area - Fourth intercostal space anteriorly (nipple) and
seventh intercostal space posteriorly (scapular tip) to inferior costal margins
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Flank - Scapular tip to iliac crest, between anterior and posterior axillary lines
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Back - Scapular tip to iliac crest, between posterior axillary lines.
This anatomic classification is important in guiding the clinician’s suspicion for specific organ injury.
Intraperitoneal abdominal organs include the solid organs (ie, spleen, liver) and the hollow viscus organs
(ie, stomach, ileum, jejunum, transverse colon).
Retroperitoneal organs include the duodenum, pancreas, kidneys, ureters, urinary bladder, ascending and
descending colon, major abdominal vessels, and rectum.
Pathophysiology
A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy
transfer and, consequently, can involve an unpredictable pattern of injuries. Secondary missiles, such as
bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile
velocity than handguns, resulting in even higher energy transfer.
In penetrating abdominal trauma due to gunshot wounds, the most commonly injured organs are as follows:
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Small bowel (50%)
Colon (40%)
Liver (30%)
Abdominal vascular structures (25%)
The severity of shotgun wounds depends on the distance of the victim from the weapon. The mass of a
shot pellet is minimal, and thus its velocity decreases rapidly after the shell leaves the barrel of the gun.
When the distance is less than 3 yd, the injury is considered high velocity; if the distance exceeds 7 yd,
most of the buckshot penetrates only the subcutaneous tissue.
Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound
generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked,
resulting in devastating complications.
In penetrating abdominal trauma due to stab wounds, the most commonly injured organs are as follows:
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Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
The mechanism that underlies the penetrating trauma (eg, gunshot wound, stab wound, impalement)
relates to the mode of injury (eg, accidental or intentional injury, homicide, suicide). Homicide or intentional
injury is the predominant mode of abdominal injury in this patient population. Accidental injury is most
common in pediatric home firearm injuries but is uncommon by comparison to the overall levels of homicide
and intentional injury. Suicide via penetrating abdominal trauma is uncommon.
Etiology
Gunshot wounds, considered high-velocity projectiles, are the most common cause (64%) of penetrating
abdominal trauma, followed by stab wounds (31%) and shotgun wounds (5%).
Penetrating abdominal trauma may result from urban violence. Domestic violence crosses all
socioeconomic barriers and is an important consideration in the evaluation of injuries sustained at home
and those reportedly involving the patient's family or significant other.
From a global perspective, penetrating abdominal trauma in most settings results principally from military
actions and wars.
Penetrating abdominal trauma may be iatrogenically introduced. Documented complications of diagnostic
peritoneal lavage include injuries to the underlying bowel, bladder, or major vessels such as the aorta or
vena cava. Fortunately, the incidence of such complications is relatively small.
Epidemiology
United States statistics
In the United States, suicide and homicide consistently rank in the top 15 causes of death. According to
data published by the National Vital Statistics Reports, 11,406 homicide deaths occurred from firearm
injuries in 2009 and 18,689 deaths from self-inflicted GSWs. Forty percent of homicides and 14% of suicides
by firearm involved injuries to the torso.
Tracking trauma is the purview of the National Center for Injury Prevention and Control (NCICP). Data
collected by this organization suggest that traumatic injury is the third overall leading cause of death and
the number one cause of death in persons aged 1-44 years. Penetrating abdominal trauma affects
approximately 35% of those patients admitted to urban trauma centers and 1-12% of those admitted to
suburban or rural centers.
International statistics
According to age-adjusted rates from 1990 to 1995, firearm mortality rates across the world vary widely,
from 0.05 in Japan to 14.24 in the United States. Firearm-associated homicide mortality was highest in
Mexico at 10.35; firearm associated suicide was highest in the United States at 6.3. The frequency of
penetrating abdominal injury across the globe relates to the industrialization of developing nations, weapons
available, and, significantly, to the presence of military conflicts. Therefore, frequency varies.
Racial differences in incidence
Age-adjusted firearm death rates are 2-7 times higher for non-Hispanic black males than for males of other
ethnicities. For non-Hispanic whites, most firearms deaths are due to suicide.
Sex- and age-related differences in incidence
Males constitute the great majority of patients with penetrating trauma injuries across the United States and
the world. In some areas of the United States, approximately 90% of patients with penetrating trauma are
male. Injuries are the leading cause of death in patients aged 1-44 years.
Prognosis
The death rate from penetrating abdominal trauma spans the entire spectrum (0-100%), depending on the
extent of injury. Patients with violation of anterior abdominal wall fascia without peritoneal injury have a 0%
mortality rate and minimal morbidity rate, while those with multiorgan injury complexes presenting with
hypotension, base deficit less than -15 mEq/L HCO , core temperature less than 35° C, and development
of coagulopathy have a dramatically increased mortality rate mandating "damage control" resuscitation.
3
An average mortality rate for all patients with penetrating abdominal trauma is approximately 5% in most
level 1 trauma centers, but this population is necessarily biased, given the higher acuity seen at such
centers, thus skewing the data.
Survival from penetrating abdominal trauma has not measurably changed in the past decade, largely
because of death within 24 hours resulting from irreversible hemorrhagic shock and exsanguination. More
than 80% of deaths occur within 24 hours of admission, 66.7% at the initial operation associated with
abdominal vascular injury. In contrast, survival from penetrating abdominal injury without vascular injury
remains high.
General factors that predict increased mortality from penetrating abdominal trauma include the following:
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Female sex
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Long interval between injury and operation
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Presence of shock on admission
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Coexisting cranial injury
The death rate is markedly influenced by prehospital hypotension, massive hemorrhage, arrest in the field
or on presentation, acidosis with an initial pH less than 7, lactate level greater than 20 mmol/L, or base
deficit more negative than -15 mEq HCO .
3
In a series by Nicholas and colleagues of 250 patients with penetrating abdominal trauma and positive
laparotomies, the overall survival was 86.8%. Mortality was found to be associated with the number of
organs injured, vascular injury, and the need for damage-control surgery, emergency department
thoracotomy, or operating room thoracotomy.
While damage-control surgery has been used with some success in the management of patients with
extensive abdominal trauma, it is associated with significant morbidity, including sepsis, intra-abdominal
abscess, and gastrointestinal fistula, according to Nicholas et al.
Patients who present to the ED in the early postoperative period with abdominal pain or signs of infection
should be strongly considered for CT scan and surgical consultation.
Injury patterns differ depending on the weapon. Low-velocity stab wounds are generally less destructive
and have a lower degree of morbidity and mortality than gunshot wounds and shotgun blasts. Gunshot
wounds and other projectiles have a higher degree of energy and produce fragmentation and cavitation,
resulting in greater morbidity.
History
The history provides clues to the most likely injury patterns and potential management priorities. Emergency
medical services (EMS) personnel are often essential in providing a history, especially in a critically ill
patient or one with altered mental status.
A common acronym describing important information to gather when taking the history is AMPLE, as
follows:
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Allergies
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Medications
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Prior illnesses and operations
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Last meal
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Events and environment surrounding injury
The anatomic location of injury and type of weapon (ie, gun, knife) direct the diagnostic process. Information
such as the number of gunshots heard or the number of times the patient was stabbed, and the patient’s
position at the time of injury help describe the trajectory and path of the injuring object.
Close-range injuries transfer more kinetic energy than those sustained at a distance, although range is
often difficult to ascertain when assessing gunshot wounds.
Blood loss at the scene should be quantified as accurately as possible from EMS personnel. However,
research has shown that this assessment is very difficult and rarely reliable. The character of the bleeding
(eg, arterial pumping, venous flow) may assist in determining whether major vascular injury has occurred.
The initial level of consciousness or, for moribund patients, the presence of any signs of life at the scene
(ie, pupillary response, respiratory efforts, heart rate or tones) is vital to determine the prognosis and to
guide resuscitative efforts. Particularly important is the patient's response to therapy en route to the ED.
Evidence of hypotension in the field should raise suspicion for intra-abdominal injury.
Physical Examination
Assessment of the patient begins at the scene of the incident by EMS personnel. Upon arrival at the
emergency department (ED), communication of the incident history and the patient’s vital signs to the
emergency or trauma team is of paramount importance.
The initial physical examination begins with visual assessment of the patient during transport into the ED,
with particular focus on the ABCs. Rapid determinations regarding respiratory effort, perfusion, external
hemorrhage, and consciousness level are usually easily made. Confounding injuries or medical problems,
such as tension pneumothorax or acute myocardial infarction, need be excluded.
Initial vital signs assist in determining injury severity and need for operative intervention. Hypotension,
narrow pulse pressure, tachycardia, high or low respiratory rate, or signs of inadequate end organ perfusion
in the setting of penetrating abdominal trauma provide evidence of significant intra-abdominal injury,
especially vascular trauma, and warrant immediate surgical exploration.
Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and
guarding and rebound tenderness. Hemodynamically stable patients with penetrating abdominal trauma
and peritonitis can be assumed to have a hollow visceral perforation and may have significant intraabdominal hemorrhage. Thus, peritonitis on physical examination is a trigger for emergent intervention
regardless of vital signs.
Peritoneal signs develop when the peritoneal envelope and the posterior aspect of the anterior abdominal
wall are both inflamed. The peritoneal or retroperitoneal blood and organ contents inflame deeper nerve
endings (visceral afferent pain fibers) and result in poorly defined pain. Irritation of the parietal peritoneum
leads to somatic pain, which tends to be more localized; however, the diffuse nature of intra-abdominal
spillage often leads to diffuse findings.
Referred pain may provide a clue to organ damage. For example, left shoulder pain may result from a
damaged spleen with subphrenic blood.
Abdominal distention in an unresponsive patient may indicate active internal bleeding. In hypotensive
patients, this may be an indication for immediate exploration. Focused Assessment With Sonography for
Trauma (FAST) examination can be useful in this situation to detect massive hemoperitoneum.
Rectal examination is performed on all patients with penetrating abdominal trauma, because blood per
rectum and, in males, high-riding prostate can indicate bowel injury and genitourinary tract injury,
respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.
Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds.
Multiple wounds may represent either entrance or exit wounds and must not be labeled as such, since
multiple missiles or foreign objects may be retained within the body.
Wounds located on the anterior abdomen can be explored locally to determine whether they penetrate the
peritoneum. On the flank area and back area, exploration is more difficult and less reliable. Therefore, flank
and back wounds are not explored and are considered penetrating unless obviously superficial.
When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing
and diagnostic and imaging studies.
Patients without recordable cardiac activity upon presentation should not be further resuscitated.
Primary survey
The primary survey is defined by the mnemonic ABCDE: Airway, Breathing, Circulation, Disability, and
Exposure/Environment. Although described sequentially, much of this evaluation may be performed
simultaneously and problems identified are managed immediately.
The airway is assessed immediately for patency, protective reflexes, foreign body, secretions, and injury.
Breathing is assessed by determining the patient's respiratory rate and by subjectively quantifying the depth
and effort of inspiration.
The circulation assessment begins with an evaluation of the patient's mental status, skin color, and skin
temperature. Patients in significant hemorrhagic shock will progress from anxiety to agitation and finally
coma if their blood loss continues unabated. The traditional vital signs of heart rate, blood pressure, and
respiratory rate are not sensitive or specific for hemorrhagic shock.
Disability is assessed early to document neurologic deficits before giving sedation or paralytics. The
Glasgow Coma Score and the gross motor and sensory status of all 4 extremities should be determined
and recorded. The physician should recognize the need for cerebroprotection measures in cases of brain
injury. Hypotension and hypoxemia exacerbate secondary brain injury and increase mortality by 50% in
patients with traumatic brain injury.
Exposure is particularly important in the patient with a traumatic mechanism of injury, in whom it may
disclose additional, potentially life-threatening injuries. Complete exposure and head-to-toe visualization is
mandatory in a patient with penetrating abdominal trauma. This includes the buttocks, posterior legs, scalp,
posterior part of the neck, and perineum. There is little to be gained by practicing spinal immobilization
unless spinal injury is obvious.
Once the primary survey is complete, a complete head-to-toe physical examination is performed as an
integral part of the secondary survey, including digital rectal and genital examinations. This detailed
examination may need to be delayed until after operative therapy has corrected obvious life-threatening
injury.
Secondary survey and injury assessment
External inspection for injuries with respect to anatomic landmarks aids identification of possible
intracavitary injury.
Common physical examination recommendations include evaluation for tympany (a bell-like or percussive
note upon gently tapping on the abdomen), dullness to percussion, and bowel sounds. Abdominal
distention, not clearly due to "bagging" or swallowed air, may be an indicator of an intra-abdominal
catastrophe. A vascular injury is often found in combination with hollow or solid viscus penetration or
devitalization.
The physical examination is a more reliable indicator for surgical intervention with penetrating abdominal
trauma than with blunt trauma. At many trauma centers, repeated abdominal examinations are the preferred
approach for managing hemodynamically stable patients with penetrating abdominal stab wounds.
When selective nonoperative management is used, the indications for operative intervention include the
development of hemodynamic instability or the development of increasing pain, peritoneal findings (eg,
point tenderness, involuntary guarding, rebound tenderness), or diffuse and poorly localized pain that fails
to resolve.
Evisceration has historically been a clear indication for operative management. However, some centers
replace eviscerated omentum and serially observe or image these patients.
Impaling objects may tamponade otherwise uncontrolled hemorrhage if the object resides within or crosses
a major vessel or solid organ such as the portal vein or liver. Therefore, penetrating objects should not be
removed except where definitive treatment can be provided.
For patients with abdominal stab wounds, a policy of observation and serial examination with discharge in
10-12 hours of patients with negative findings has been proposed. While studies have shown promising
results, this approach has not been fully validated in multiple centers.
Approach Considerations
The approach to patients with penetrating abdominal trauma depends on whether the injury is a gunshot
wound (GSW) or a stab wound and the patient’s hemodynamic status. GSWs are associated with a high
incidence of intra-abdominal injuries and nearly always mandate laparotomy. Stab wounds are associated
with a significantly lower incidence of intra-abdominal injuries; therefore, expectant management is
indicated in hemodynamically stable patients.
Many protocols have been developed for determination of abdominal wall penetration of stab wounds to
the torso, one of which is shown in the diagram below.
Patients with penetrating abdominal trauma generally require complete laboratory profiles in case of need
for emergent operation. Many imaging modalities can be useful in the evaluation of a patient with
penetrating abdominal trauma. The imaging needs of each patient differ, depending on hemodynamic
stability and associated injuries.
Blood and Urine Studies
In case of need for emergent operation, all patients with penetrating abdominal trauma should undergo
certain basic laboratory testing, as follows:
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Blood type and crossmatch
Complete blood count (CBC)
Electrolyte levels
Blood urea nitrogen (BUN) and serum creatinine level
Glucose level
Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
Venous or arterial lactate level
Calcium, magnesium, and phosphate levels
...
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