Penetrating injury

Question 1

What are the 2 groups that penetrating injury can be broken down into?

Answer 1

high and low velocity

Question 2

What is the difference in the way that high and low velocity penetrating injury cause damage?

Answer 2

• low velcoity: tends to push internal organs out of the way following fascial planes
• high velocity will normally have a shock wave that will cause deceptive damage compared to the entry wound and won’t push organs aside
  
  • these can also ricochet off bones

Question 3

In addition to the velocity of penetrating injury, what is another important factor when considering penetrating injury and its effects?

Answer 3

direction of penetrating injury

Question 4

Why is it important to think about the direction of penetrating injury?

Answer 4

injuries to the abdomen can still hit lungs or heart

Question 5

What is important to remember about penetrating chest wounds?

Answer 5

they are potentially life-threatening, even if innocuous

Question 6

What is the most common cause of penetrating abdominal injry?

Answer 6

stab wounds (still more comon than GSW in the UK)

Question 7

What are 4 mechanisms of penetrating abdominal injury?

Answer 7

1. Stabbing
2. Gunshot wound (GSW)
3. Fragmentation in explosion
4. Impalement

Question 8

What are 4 key aspects of the initial assessment in penetrating abdominal injury?

Answer 8

1. History
2. Examination - fully expose
3. Assess neurological status of limbs to check for spinal cord injury (if patient conscious)
4. Plain X-ray if stable patient

Question 9

What are 6 things to ask about in the history for penetrating abdominal trauma?

Answer 9

1. Time of injury
2. Type of weapon or round
3. Distance from assailant
4. Number of wounds or shots
5. Position of patient when penetration occurred
6. Amount of external bleeding at scene

Question 10

What should the examination involve in penetrating abdominal trauma?

Answer 10

fully expose patient early in primary survey to identify any concealed wounds - including flanks, back, groins, buttocks, perineum, rectal examination

Question 11

What is important to remember about the size of the wound in penetrating abdominal trauma?

Answer 11

size of external wound does not determine the likelihood or severity of intra-abdominal injuries

Question 12

What is the role of plain x-rays in penetrating abdominal trauma?

Answer 12

useful in stable patients to identify location of any retained bullet and allow prediction of the trajectory e.g. has it gone from chest to thigh, passing through the thorax and abdominal cavity

Question 13

What is important to remember about any foreign bodies in penetrating abdominal trauma?

Answer 13

any foreign body or knife must only be removed in theatre at laparotomy under direct vision, to enable control of any potential haemorrhage or contamination

Question 14

What are 3 aspects of wound care for penetrating abdominal trauma?

Answer 14

1. Cover wound with sterile dressing. Any protruding bowel or omentum should be covered with warm saline soaked swabs and not handled or pushed back into the abdomen
2. Check tetanus status and consider need for prophylaxis
3. Give IV antibiotics according to local prescribing guidelines

Question 15

What are 3 additional investigations following initial assessment, for penetrating abdominal injury?

Answer 15

1. Local wound exploration
2. Serial examinations
3. Laparoscopy

Question 16

What does local wound exploration involve for penetrating abdominal injury?

Answer 16

evaluation of stab wound using LA before extending and probing the wound

performed in theatre by surgeon, who will be able to proceed to laparoscopoy or laparotomy if indicated

Question 17

Is local wound exploration performed for gunshot wounds to the abdomen?

Answer 17

no - these should all have a laparotomy

Question 18

What is the benefit of performing serial examinations in penetrating abdominal trauma?

Answer 18

good sensitivity and negative predictive value for evaluating patients with minor penetrating abdominal trauma

Question 19

For how long and how frequently are serial abdominal examinations performed for minor penetrating abdominal trauma?

Answer 19

• patient admitted for observation for at least 24h
• hourly assessment of haemodynamic status
• at leats 4-hourly assessment for clinical abdominal signs

Question 20

What is done if the patient develops any signs of bleeding or peritonism during the 24-hour period of observation for minor penetrating abdominal trauma?

Answer 20

laparotomy performed

Question 21

What should be done for a patient admitted for 24h for a minor penetrating abdominal injury who develops pyrexia/tachycardia/localised tenderness on CT?

Answer 21

laparoscopy, laparotomy or CT scan performed

Question 22

What should be the next step if, after 24h of observation for minor penetrating abdominal trauma, the patient remains well?

Answer 22

can start normal diet and discharge can be considered

Question 23

What is the usefulness of laparoscopy in penetrating abdominal trauma?

Answer 23

diagnostic laparoscopy (under GA in theatre) may be useful for identifying peritoneal penetration following abdominal stab wounds or diaphragmatic injury

Question 24

What are 2 things that diagnostic laparoscopy may miss in penetrating abdominal injury?

Answer 24

1. Bowel injury
2. Retroperitoneal injury

Question 25

What are 7 indications for laparotomy following penetrating abdominal trauma?

Answer 25

1. Stab wound with **peritoneal penetration** 2. Any **gunshot** **wound** to the abdomen 3. **Evisceration** (organ removal from body) 4. Retained **foreign** **bodies** 5. **Peritonitis** 6. **Haemodynamically** **unstable** with penetrating abdominal injury 7. Haemodynamically stable with **positive CT scan**

Question 26

What are 3 areas where penetrating injuries to the abdomen are likely to be missed?

Answer 26

1. Buttocks 2. Groin 3. Back

Question 27

What must be done regarding forensics for a patient with penetrating abdominal injury?

Answer 27

* ensure a member of staff informs the police that you have **'a patient' in the department with a stab wound or GSW** * if patient has arrived by ambulance, usually accompanied by a police officer

Question 28

When is it justifiable to break patient confidentiality for patients with penetrating abdominal injury?

Answer 28

if there are issues of public interest, and to protect the safety of your department and staff

Question 29

What must you make sure that is done regarding future forensic requirements for patients with penetrating abdominal trauma?

Answer 29

ensure all patient's clothes, belongings and any weapons are kept secure to be given to an identified police officer for forensic examination

Question 30

What are 5 structures that may be damaged by penetrating objects that traverse the mediastinum?

Answer 30

1. Heart 2. Great vessels 3. Tracheobronchial tree 4. Oesophagus 5. Lungs

Question 31

What is the mortality of mediastinal penetrating injury?

Answer 31

20%

Question 32

What are 4 mechanisms which may lead to penetrating mediastinal injury?

Answer 32

1. Stabbing 2. Gunshot wond 3. Impalement on an object 4. Blast fragmentation

Question 33

What are 5 possible clinical features of mediastinal penetrating injury?

Answer 33

1. Entry and/or exit wounds 2. Signs of tension pneumothorax 3. Open pneumothorax 4. Massive haemothorax 5. Cardiac tamponade

Question 34

What are 4 examples of investigations to perform for mediastinal penetrating injury?

Answer 34

1. **CXR**: pneumothorax, foreign body, widened mediastinum 2. **FAST USS:** free fluid in the pericardial sac 3. **CT** for stable patients, with contrast vascular and GI studies 4. **12-lead** **ECG** and **echocardiogram** if suspected cardiac injury

Question 35

What are 7 aspects of immediate management of mediastinal penetrating injury?

Answer 35

1. Oxygen, monitoring, IV access with crossmatch 2. Treat any life-threatening airway or chest injury 3. IV fluid boluses to maintain a **SBP 90 mmHg** 4. Remove all patient clothing (avoiding cutting through ballistic holes) and keep for police evidence 5. Search for wounds including log roll to look at back, and checking groin, buttocks, perineum and axilla 6. Seek urgent surgical opinion 7. **Analgesia** e.g. titrated IV morphine 8. Treat wounds by **cleaning**, application of sterile dressing, check need for tetanus prophylaxis and IV antibiotics according to hospital policy

Question 36

What is meant by ballistic holes in cloting?

Answer 36

bullet entry holes in the fabric

Question 37

What should the aim for blood pressure be when treating mediastinal penetrating injury?

Answer 37

SBP 90mmHg

Question 38

What analgesia may be used for mediastinal penetrating injuries?

Answer 38

titrated IV morphine

Question 39

How should wounds of penetrating mediastinal injury be treated? 4 aspects

Answer 39

1. **cleaning** 2. application of sterile **dressing** 3. check need for **tetanus** prophylaxis 4. IV **antibiotics** according to hospital policy

Question 40

What is one of the key pitfalls with penetrating mediastinal injury?

Answer 40

under-estimating small external wounds which have no correlation with the degree of internal injury