02.05 Penetrating Abdominal Trauma

When we talk about penetrating trauma it's important to try to figure out what did the penetrating.

Gun shot wounds...We want to try to find out about the ballistics...the type of gun, size of the bullet, flight path if possible. All of these things are important in helping us diagnose the injuries and in turn, treat them. There is a big difference in how we approach a single wound from a 22 caliber pistol shot from 50 yards away as opposed to a shotgun blast at close range.

Stabbing and piercing. I kind of put these in a similar category as they usually involve a handheld object inserted into our patient. With stabbings, it's usually a sharpened blade but with piercings, we are usually referring to something that's not a blade, like a pencil, or a spear, or if your an olympian, maybe a javelin...but i guess that's still kind of a spear, right. Anyway, the most important thing for us, and anyone who comes into contact with these patients...if the object is still in them, like if the knife is sticking out of the belly...DO NOT REMOVE IT!!!. Pack it and secure it until it can be fully evaluated. Im namy patients the fact that he has not bled out yet may be due to the knife pressing against the bleeding spot and tamponading the inevitable hemorrhage.

Our assessments for our penetrating abdominal trauma are similar to any of our other trauma assessments. We worry about our ABC’s. In some cases, we may work with CABC, that means we try to control any life threatening hemorrhage before we establish the airway. This is a quick process. Basically we have someone apply direct presure while another is checking airway. The fact here is that if they bleed out, the airway won't matter. 

Our abdominal assessments are the same as alway, inspection, auscultation, palpation and percussion. We may have to alter this depending on the injury but the basic idea is the same.

We want to watch the trends in the vitals and specifically the BP. The more hypotensive they get, the more we can assume they are losing too much blood.

And as always, our wonderful radiology friends will help us go look inside our guy and try to get a better idea of injuries. In our abdominal traumas, there are some pretty ominous signs we want to look out for.

Cullen sign is bruising around the umbilicus and is indicative of an intraperitoneal hemorrhage. It can also lead us to injuries of the pancreas or in females, the fallopian tubes. 

Grey-Turner sign is bruising to the flanks and is a sign of retroperitoneal bleeding.

And Kehr’s sign is pain to the tip of the shoulder. When it comes to abdominal trauma, pain in the left shoulder is usually a sign of a ruptured spleen,. I know it seems weird to have an injury so low causing pain so high but it is due to the irritation of the diaphragm and the phrenic nerve which causes that shoulder pain.

We can also have a condition called an acute abdomen. This is a sign that the belly is filling with fluid and the peritoneal space is getting inflamed. These patients are ones who have that distended, rigid abdomen, which is a direct result of the fluid building up. That peritoneal irritation is going to cause them to have diffuse tenderness throughout the abdomen. These patients are quickly becoming immediate surgical candidates. 

Now...what do we do. Well most likely our patient is bleeding….so….stop the bleeding. We can take this back to our basic first aid. If we see bleeding from a hole, get a gloved hand on that hole. Apply direct pressure. Now if the injury goes deep enough, there is only so much that your hand is going to do. Direct pressure on the perforated colon is not the easiest thing to maintain. 

We want to do our best to figure out how much bleeding has occurred and where it may be coming from. Now in the ED locating the exact source of the blood may not be easy, or even possible. But it may also may not be necessary. We are going to use our tools to help us here. Our eyes and ears are going to show us those signs and symptoms of internal bleeding and our friends from the world of radiology are going to help us get a picture of what's going on inside. While radiology may be able to narrow down the location of an injury, they may not be able to clearly identify the exact spot until they can get the patient to the OR and the surgeon can get actual direct visualization of the injury. 

You guys know about X-rays and cat scans. One other diagnostic tool, that used to be a standard but has fallen out of favor is the DPL, or diagnostic peritoneal lavage. This involves cutting a hole in the belly and inserting a catheter. When you get the draining of fluids, it helps to determine severity of bleeding. If there is no drainage, in an effort to determine how much blood is still contained in the belly, they will instill fluids into the belly and drain those fluids out. Depending on the color of that drainage will help to diagnose a degree of severity. Many facilities no longer do this as the FAST exam has taken its place. I mean what sounds better, dripping blood tinged normal saline all over the ED floor or just taking a quick picture of the belly right at the bedside. Exactly, and the results from FAST exams have been proven to be just as diagnostically sound as PL if not better. 

OK so once we know there is bleeding, we have an idea of how much, and we kind of know where its coming from...what do we do.

Well, if our guys is losing blood…..give him blood. lots of it!

There may be some procedures such as basic packing and ligations that trauma surgeons may do in the ER but the definitive treatment for any of these patients is going to be a trip to the OR. 

Like we have said in all our trauma lessons, it is imperative that you know your anatomy in order to anticipate how many injuries can result from the specific trauma. 

And with the possibilities for severe hemorrhage and organ lacerations  as well as the perforation of abdominal organs, the alterations in fluid and electrolyte balance can be lethal. 

It goes without saying that any sort of penetrating trauma is going to cause issues with tissue and skin integrity especially if there are concurrent injuries. 

A few key points

Mechanism of injury… we want to try to figure out what happened, and really, what cause the injuries

We spoke about some specific warning signs in abdominal trauma, Cullen, Kehr, remember what they are and what they mean

Use your tools… the FAST exam is a wonderful tool and is in most Trauma Bays for a reason. lt your residents do what they do.

Concurrent injuries. If you know the patient was shot from the front, don't forget to check his back. If the bullet was small, did it bounce around inside, or go right through. If it bounced, how many things did it hit or destroy before it stopped. 

Tunnel vision. I know its kinda hard to take your eyes off of the 12 inch kitchen knife sticking out of our guys belly, but maybe we check to see if he is breathing before we get into that.