anterior abdominal stab wounds (aasw’s) · 2019-05-22 · anterior abdominal stab wounds: a...
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Anterior Abdominal Stab Wounds (AASW’s)
Jose Baez PGY-4KCHCJune 3 2010
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Case Presentation
• CC: Pain to epigastrium
• HPI: 47 year-old female who presented to KCHC on 4/10/10 after sustaining a stab wound to the epigastrium
• PMHx: asthma
• PSHx: C-section
• Meds: albuterol inhaler
• NKDA
• Shx: etoh, drug use, + tobacco
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Case Presentation
• Physical Exam:
– V/S: 102/70, HR: 92, RR: 22, T: 97.7
– GCS: 15
– CHEST: clear bilaterally
– ABD: 1.5 cm SW to epigastric region, + local tenderness, no bleeding or hematoma. No omental or intestinal evisceration
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Case Presentation
• Labs/Diagnostic Modalities– Vbg: 7.33/42/39/70/21/-3.1
– Lactate 3.6, 1.2
– CBC: 19/14/44/370
– LFT’s-wnl, amylase/lipase-wnl
– UCG: negative
– Utox: cocaine
– Etoh: 40
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Case Presentation
• Upright CXR: negative for free air, no acute cardiopulmonary disease
• FAST: negative
• Local wound exploration (LWE): + Fascial Defect
• Management:– Admitted to SICU for serial abd exams and serial labs
– Serial exams indicated persistent/worsening local peritonitis, rising leukocytosis ( 19 to 22), no hemodynamic instability (stable hct)
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Operative Intervention
• Procedure: Exploratory laparotomy with repair of CBD injury
• Findings: pelvic adhesions, Grade I liver lac(segment 2) anterior surface, bile staining in area of portal triad and pylorus, 1-2mm CBD serosalinjury
• Drains: JP x 1
• Methylene blue given via NGT-no dye seen in upper GI tract
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Hospital Course
• POD# 1: Extubated
• POD#2: Tolerated clears, JP output 30cc SSF
• POD#3:Regular diet
• POD#5: Discharged with JP
• LFT’s- wnl throughout hospital stay
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AASW’s
• Abdomen is a diagnostic black box• In ED: need to identify if the fascia/peritoneum
has been violated– Positive: need further eval for intrabdominal organ
injury ~ with 50% need for laparotomy
• Anterior abdomen (boundaries): from costal margins to inguinal ligaments and bilateral ant axillary lines
• 1/3 of AASWs violate the peritoneal cavity; 1/3 of these cause injury requiring operative repair.
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AASWs (Diagnositic Modalities)
• OR for laparotomy– Hemodynamic instability– Peritonitis– Omental or intestinal evisceration– Peritoneal or fascial penetration
• Non-operative approach – In pts with none of the above mentioned findings– Serial exams, LWE, DPL, DL, CT, US
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Serial exams
• Serial exams with observation – According to a prospective study where 651 pts
with AASWs where followed: laparotomy vsobservation rate (53% vs 47%)
– Of the 47% only 2.9% required subsequent surgery, therefore it’s a safe modality
– Problems: need for experienced and frequent evals of pt; possibility of delayed dx of injury
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Local wound exploration
• LWE– Need to ID violation of peritoneal cavity
– If negative: no risk for intrabdominal injury therefore discharge from ED
– If positive: OR for exploration
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Diagnostic Peritoneal Lavage (DPL)
• Why? It quickly determines presence of intraperitoneal injury/need for exploration
• Reduces number of negative laparotomieswithout increasing morbidity/mortality related to delays
• Useful if unable to perform serial exams• Accuracy 89-95%• Sensitivity varies depending on criteria for a
postive test
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DPL
• KCHC criteria– RBC > 20k/mm3
– WBC > 500/mm3
– Bile or particulate matter on aspirate
• Absolute CI– Need for laparotomy
• Relative CI– Prior abd surgeries,
obesity, ascites
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Diagnostic Laparoscopy (DL)
• Why? Detect peritoneal violation
• Proved to be most useful to rule out diaphragmatic injuries
• Associated with high rate of negative laparotomies (~20%)
• Cost-effectiveness is unclear ( OR costs, length of stay)
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Computerized Tomography (CT)
• Poor sensitivity for AASWs due to inability to detect hollow viscus injury
• Better for evaluation of back and retroperitoneal injuries
• CT enema is highly sensitive for evaluating the retroperitoneum
• CT scan offers no advantage over serial exams or DPL for AASWs
• Adjunct to identify the wound tract, solid organs and retroperitoneum
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Ultrasonography
• Identify free intraperitoneal fluid
• More defined role in blunt trauma with a sensitivity of 85-99% and specificity of 97%
• Not as reliable for penetrating with a sensitivity of 45% and specificity of 94%
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Biffl, WL. Kaups KL, et al. Management of Patients With Anterior Abdominal Stab Wounds: A Western Trauma
Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical Care. Volume 66(5), May 2009, pp 1294-1301
• Multicenter prospective study, 2 years, 11 institutions, 359 pts
• Purpose to compare different management strategies of asx AASW’s patients to treat and identify injuries in a safe and cost-effective manner
• Inclusion: Age > 16, AASW
• Exclusion: back, flank, thoracoabdominal stab wound
• Indications for Imed Laparatomy: hypotension, peritonitis, evisceration
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Results/Discussion
• 81/359 pts had indication for immediate laparotomy of which 84% where therapeutic
• Used LWE, DPL and CT to facilitate ED discharge vs laparotomy– ED d/c : 23,21,16% respectively– Negative laparotomies based on abnormal
findings : 57, 24, 31% respectively– 26/359 were selected for SCA of which 12%
underwent laparotomy (33% neg lap)
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Results
• If immediate indication for laparotomy: laparotomy is highly therapeutic 84%
• If other modalities are abnormal, there is a high yield of negative laparotomies
• Propose LWE as best method for facilitating ED discharge
• Bottom line: high yield of negative laparotomies with modalities, if no indication for immediate laparotomy, recommend SCA’s
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References
1. .Hasaniya N, Demetriades D, Stephens A, et al. Early morbidity and mortality of non-therapeutic operations for penetrating trauma. Am Surg, 1994, 60 (10), 744-7
2. Nance FC, Wennar MH, Johnson LW, et al. Surgical judgment in the management of penetrating wounds of the abdomen: experience with 2212 patients. Ann Surg, 1974, 179 (5), 639-46
3. Demetriades D and Rabinowitz B, Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg, 1987, 205 (2), 129-32
4. Biffl, WL. Kaups KL, et al. Management of Patients With Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical Care. Volume 66(5), May 2009, pp 1294-1301
5. Aaron Winnick, MD and Patricia A. O’Neill, MD. Trauma, Surgical Critical Care and Surgical Emergencies
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