The Management of Penetrating

Abdominal Trauma

Syahbuddin Harahap
Department of Surgery
Adam Malik Hospital
 Penetrating trauma

Injury that occurs primarily by an object piercing the skin or

entering a tissue of the body.

- minimal damage to skin and connective tissue

- though deeper damage to :

-vessels
-nerves
-internal organs

The severity of the injury is determined by velocity of the

object that enters the body.
 Penetrating abdominal trauma
Gunshoot wounds
High-velocity objects bullets from high-powered rifles

Medium-velocity projectiles include those from handguns

High- and medium-velocity projectiles cause a cavitation injury

Stab wounds
Low-velocity items, such as knives,
by a person's hand, and usually do damage only to the area
that is directly contacted by the object.
The most commonly injured organs
In :
Penetrating abdominal are :
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%).

Gunshot wound are :

Small bowel (50%)
Colon (40%)
Liver (30%)
Abdominal vascular structures (25%).
 Penetrative objects
should not be removed
except where definitive
treatment can be provided.
stab wound
small intestine clearly protrudes
Pathophysiology
The major findings:

1. Peritonitis

2. Hemodynamic instability due to hemorrhage

3. Sign visceral hemorrhage

- Hematemesis
- Proctorrhagia
- Hematurie
 Mortality/Morbidity

Depending on the extent of injury

In the first 24 hours death from hemorrhagic shock

Damage control surgery

-improved early survival
-increase in late morbidity wound infection (2-8%)
CLINICAL
History

Include the following:

1. Anatomic location of injury

2. Type of weapon (ie, gun, knife )
3. Blood loss
4. The character of the bleeding
5. The initial level of consciousness
6. Evidence of hypotension in the field should raise
suspicion for intra-abdominal injury.
Lab Studies
Patients with penetrating abdominal trauma generally require
complete laboratory profiles in case of need for emergent
operation.
1. Blood type and crossmatch
2. Complete blood count (CBC)
3. Electrolyte levels
4. BUN level
5. Creatinine level
6. Glucose level
7. Prothrombin time (PT)/activated partial thromboplastin
time (aPTT)
8. Venous or arterial lactate level
9. Calcium, magnesium, and phosphate levels
10. Urinalysis
11. Serum and urine toxicology screen
 Imaging Studies

Stable hemodynamic
Associated injuries.

•Chest radiography
pneumothorax
hemothorax
•Plain radiography
account for bullets
foreign bodies.
intraluminal
Intravascular
potential source of emboli distant from the site of
entrance.
FAST examination:
positive FAST
therapeutic laparotomy

negative FAST
cannot be to rule out injury.
Computed tomography

Triple contrast (CT) computed tomography -

- intravenous
- oral
- rectal contrast
It is useful for evaluation of :
- penetrating flank and back wounds
and is found to be 97% accurate.
Other Tests

Stable patient
Blood at the urethral meatus
- Retrograde urethrogram
- Cystogram.
Proctosigmoidoscopy
suspected rectal or sigmoid injury.

Laparoscopy
In thoracoabdominal stab wounds,
laparoscopy aids in the diagnosis of
diaphragmatic injuries.
 Assessment severity of
gunshot wounds

1. type of weapon used

2. the type of the bullet used
3. the range at which the victim was shot
4. the site of injury.
5. the number of wounds inflicted.
6. all gunshot wounds are medical emergencies
which require immediate hospital treatment.
 Procedures
Gunshot Wounds
 High / medium velocity Cavitation injury
• Anterior Abdomen
- Automatic laparotomy
• Posterior /Back / Flank Abdomen
- Unstable gunshot wounds
- Automatic laparotomy
- Stable gunshot wounds
- CT scan contrast
positive  Exp.laparotomy
negative Observasi
 Low velocity
- Plain abdominal radiography AP / L
- Exp. laporotomy
 Procedures
Stab wounds
Unstable patients or those with clear-cut peritonitis should
undergo exploratory laparotomy.

Evisceration has historically been a clear indication for

operative management

stable patients
Anterior abdomen can be explored locally to determine
whether they penetrate the peritoneum.
Local wound exploration
penetrate the peritoneum  DPL
Positive  Exl .Laparotomy
Negative  Admit & observe
No penetrate  Debride suture & Consider discharge
 Stab wounds

On the flank area and back area

Unstable patients  exploratory laparotomy.

stable patients
exploration is more difficult and less reliable ,
are not explored
1. DPL
2. CT scann
Positive  Exp.Laparotomy
Negative Observe
TREATMENT

Prehospital Care
Aggressive intravenous fluid administration
to maintain or reach normotension
 Emergency Department Care

Assessment and treatment of the basics of trauma life

support
1. Airway:
severe shock should be intubated.
cervical collars are rarely necessary

2. Breathing:

Pneumothorax.
Tube thoracostomy
needle decompression should be undertaken
immediately for patients with obvious

Chest radiograph stable, in the trauma room.

An upright positioned -> pneumothorax.
3. Circulation:
Patient's mental status
Skin color
Skin temperature.
The traditional vital signs of :
- heart rate
- blood pressure
- respiratory rate
are not sensitive or specific for hemorrhagic shock.
Large-bore peripheral intravenous catheters

Permissive hypotension
- hypotensive ranges less than 90 mm Hg.
- prevent disruption of clot
4. Deficits: Glasgow coma scale

5. Exposure: undressed.
head-to-toe visualization
Buttocks
posterior part of the legs
Scalp
posterior part of the neck
perineum.
Foley catheter
monitor urine output
hematuria.

nasogastric tube (NGT)

orogastric tube (OGT)
- intragastric blood
- decompress the stomach so as to reduce
aspiration risk.

Appropriate laboratory specimens should be

immediately sent to the laboratory for evaluation.
 Indication for operative management.
1. Gunshoot wounds

2. Eviscerated omentum /visceral organ

2. Sign of peritonits

2. Free gas on radiography

3. Stab wounds Hemodynamically Unstable

4. Stab wounds Hemodynamically Stable

Explored under local anesthesia
Is peritoneum intact?
No  DPL  possistive  Explorasi laparotomy
DPL  negative  Observed
Yes  Debridement and suture Consider discharge
 Penetrating Injury

Gun shot? Explore wound

Evisceration? No under local
Rigid silent abdomen? anesthesia
Free gas on radiography?

Is peritoneum
intact?

Yes Positive

DPL No Yes

Negative
Laparotomy Debride suture
Consider discharge
Admit, observe
 Trauma scoring
Trauma scoring has emerged as a means of describing
injury severity and has become an essential component of
quality improvement.

Physiologic scores
-Glasgow Coma Scale [GCS] score
-Revised Trauma Score

Anatomic injury
-Abbreviated Injury Score
-Injury Severity Score
 REVISED TRAUMA SCORE
( RTS )

• Value of the :
1.GCS
2. SBP
3. RR

• coded value 0 – 4.
 The Glasgow coma scale.

Parameter Response Score

Eye opening Nil 1
To pain 2
To speech 3
Spontaneously 4
Motor response Nil 1
Extensor 2
Flexor 3
Withdrawal 4
Localising 5
Obeys 6
command
Verbal response Nil 1
Groans 2
Words 3
Confused 4
Orientated 5
Revised Trauma Score (RTS).

Clinical Category Score x weight

Parameter
Respiratory rate 10-29 4 0.2908
(Breaths per
>29 3
minute)
6-9 2
1-5 1
0 0
Systolic blood >89 4 0.7326
Pressure
76-89 3
50-75 2
1-49 1
0 0
Glasgow Coma 13-15 4 0.9368
Scale
9-12 3
6-8 2
4-5 1
3 0
 Glasgow Systolic Respira Coded
Coma Blood tory Value
Scale Pressure Rate
(GCS) (SBP) (RR)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0

RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR

Values of the RTS 0 – 7.84

 REVISED TRAUMA SCORE
( RTS )
GCS 10 value - 3
SBP 90 - 4
RR 40 - 3

RTS = 0,9368.3 + 0,7326.4 + 0,2908.3

= 2,8104 + 2,9304 + 0,8724
= 6,6132