Excerpt from Abdominal Trauma, Penetrating

Synonyms, Key Words, and Related Terms: 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

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History of the Procedure: The management of penetrating abdominal injuries has advanced greatly in the past century. In the era preceding World War I, penetrating trauma was managed expectantly. During World War II, studies showed that early celiotomy improved survival. By the late 1950s, celiotomy was the rule for management of patients with penetrating abdominal trauma. In 1960, Shaftan suggested selective management of patients with abdominal stab wounds after observing an increased rate of negative results from celiotomy.

The introduction of diagnostic peritoneal lavage (DPL) by Root in 1965, the CT scan in 1980, and diagnostic laparoscopy in the 1990s has refined the diagnostic workup. Recently, some authors have reported cases of patients with gunshot wounds (GSWs) managed selectively.

Problem: Penetrating abdominal injury implies that either a GSW or a stab wound has violated the abdominal cavity.

Frequency:

In the United States: In 1998, homicide and legal intervention was the 13th most common cause of death. According to data published by National Vital Statistics Reports for 2000, 30,708 persons died of firearm injuries in the United States. Of the firearm injury deaths in 1998, 61.9% were white males, 21.5% were black males, 11.3% were white females, and 3% were black females. The age-adjusted and age-specific death rates for firearm injuries generally were highest for black males, followed by white males, black females, and white females.

Internationally: The number of firearm deaths in the United States far exceeds reported numbers from all European countries. Among European countries, Norway has the highest firearm death rate, and it is approximately one fifth of that reported in the United States.

Pathophysiology: A GSW is caused by a missile propelled by combustion of powder. It implies high-energy transfer and unpredictability of the extent of intra-abdominal injuries. Not only is the missile track unpredictable, but also, secondary missiles such as bone fragments or fragments of the bullet are capable of inflicting additional injuries. The missile velocity of military firearms and hunting rifles is much higher than that of civilian handguns and therefore has a much higher energy transfer. Shotgun injuries, especially at close range, frequently are associated with massive tissue damage and should be regarded as high-energy transfer injuries.

Stab wounds are caused by a sharp object penetrating the abdominal wall. This type of injury usually is more predictable with regard to injured organs, but a high index of suspicion must be maintained to avoid overlooking occult injuries.

Clinical: History and vital signs at the scene are of importance, and the emergency medical service (EMS) may be the only source of important medical information. Carefully question the EMS team about the scene of the accident and vital signs upon initial presentation. A history of hypotension given by EMS personnel frequently correlates with significant blood loss. Upon arrival of patients at the emergency department, the advanced trauma life support (ATLS) protocol should be followed.

Patients may present in extremis, and only immediate and organized surgical exploration with adequate blood-product resuscitation may change a dismal prognosis. Actively bleeding patients do not benefit from crystalloid resuscitation, and exploration should not be delayed to routinely infuse fluids. Patients presenting with hypotension already are in class III shock (30-40% blood volume loss), and resuscitation with blood products should be considered. Hemodynamically stable patients presenting with peritonitis should not be treated much differently because irreversible shock soon may ensue.

For physical examination, completely undressing the patient for the primary survey and examining the entire body su .....