Penetrating Abdominal Trauma Flashcards
Indications for Laparotomy After Penetrating Abdominal Trauma
-Hypotension in absence of other site of potential hemorrhage
-Peritonitis
-Evisceration of bowel and omentum (controversial)
-Bleeding from stomach (hematemesis or bloody return from nasogastric tube) or rectum (bright red blood or hematochezia on finger examination or proctoscopy)
-Bleeding from genitourinary tract (exception would be flank wound in stable patient and CT evidence of isolated nonhilar renal injury amenable to observation or angioembolization)
-Contrast-enhanced CT demonstrates perforation of gastrointestinal tract, intraperitoneal bladder, or solid organ injury
How is the thoracoabdomen anatomically defined?
The thoracoabdomen extends from the nipple to the costal margin, from the midline to the anterior axillary line
What type of CT scan is performed for a wound in the right thoracoabdomen, and what organs does it evaluate?
A triple-contrast CT (intravenous, oral, rectal) is performed to evaluate the liver, right kidney, duodenum, and colon
What is the management approach for a nonbleeding wound to the liver or right kidney without contrast extravasation?
managed nonoperatively with serial physical examinations for 24 to 36 hours and may have a follow-up CT in 5 to 7 days.
What organs are evaluated in a triple-contrast CT after a wound to the left thoracoabdomen?
The liver, spleen, left kidney, stomach, and colon are evaluated
Why must a wound to the left hemidiaphragm be repaired, even without active bleeding?
To prevent omental herniation into the left hemithorax due to the negative intrapleural pressure of respiration.
What should be the next step if a triple-contrast CT is equivocal after a wound to either the right or left thoracoabdomen?
It should be followed by a diagnostic laparoscopy.
What is the minimum diagnostic goal of a local wound exploration?
To document whether the anterior aponeurosis of the muscular abdominal wall has been penetrated.
What is the typical next step in many centers after documenting penetration of the anterior aponeurosis in a trauma patient?
The exploration is often terminated, and the patient is admitted for serial physical examinations or further diagnostic testing
What additional step might other centers take during a local wound exploration?
They may continue the exploration through the muscular layers to determine whether the posterior aponeurosis, peritoneum, or both have been perforated.
What is the first diagnostic maneuver in evaluating a trauma wound in the abdominal wall?
A local wound exploration under semisterile conditions and local anesthesia in the trauma room
What are the contraindications for performing a local wound exploration in a trauma patient?
Contraindications include an agitated or uncooperative patient or one who is morbidly obese
What is the typical management for an asymptomatic or mildly symptomatic patient with penetration of the anterior aponeurosis or peritoneum?
The patient will undergo serial physical examinations every 6 to 8 hours for 24 hours
Another option is to perform a triple-contrast helical CT examination
What should evisceration of a large piece of omentum or any bowel prompt in a trauma patient?
It should prompt an emergency laparotomy.
What approach do some centers take when managing small omental evisceration?
They will ligate the base of the eviscerated omentum, excise it, return the remainder to the peritoneal cavity, close the abdominal wall defect, and perform serial physical examinations for 24 hours.
