Epigastric Stab Wounds

An 11-year old male is brought to the ER 30 minutes after sustaining a stab wound at the epigastric area during a street rumble.

Epigastric Stab Wounds

At the Emergency Room: • He is conversant, conscious, coherent, ambulatory, not in

respiratory distress • VS: BP 100/60, PR 82 bpm, RR 24 cpm, T 36.5 C • Pale palpebral conjunctivae, anicteric sclerae • Chest: symmetrical chest expansion with clear breath sounds • Heart: normal • Abdomen: flat, with a 1.5 x 1.5 cm stab wound at the epigastric

area, hypoactive bowel sounds, soft, direct tenderness at the epigastric area

• Rectal exam is unremarkable

Presentation

• Assessment begins at the scene of the incident and on the way to the emergency department

• ABC’s of primary survey should be followed• Upon arrival at the emergency department, incident

history and the patient’s vital is important• Patients who present with hypotension are already in

class III shock (30-40% blood volume loss), and they should receive blood products as soon as possible

• Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds

Presentation

• In the examination of the abdomen, if there is peritoneal signs, such as pain and guarding and rebound tenderness, exploration without delay is a necessity

• Presence of abdominal rigidity or gross abdominal distention is an indication for prompt surgical exploration

• Rectal examination, as blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively

• Notation of blood at the urethral meatus is also a sign of genitourinary tract injury

Management of penetrating abdominal trauma. CT = computed tomography; DPL = diagnostic peritoneal lavage; RBC = red blood cells.

Laboratory Studies

• Complete blood count (CBC)• Basic chemistry profile (BMP)• Coagulation studies (PT/INR + PTT)• Arterial blood gas (ABG)• Urine dipstick• Blood Typing and Crossmatching• Ethanol and drug screens

Imaging Studies

• Plain radiograph• Ultrasound• CT Scan

Diagnosis

Nasogastric intubation - All patients undergoing endotracheal intubation require decompression of the stomach to decrease the risk of aspiration. Blood in the nasogastric tube can indicate upper gastrointestinal injury.

Diagnosis

Foley catheterization - required to monitor the fluid resuscitation status of the patient with penetrating abdominal trauma. The presence of blood in the urine is a sign of genitourinary tract injury

Diagnosis

Diagnostic peritoneal lavage- DPL sensitivity for detecting intraabdominal injury exceeds 95 %- Results of DPL:– grossly (+) – if >10 mL of free blood can be aspirated– if < 10 mL – a liter of normal saline is instilled and the

effluent is sent to the laboratory for RBC count, amylase alkaline phosphatase, and bilirubin levels and red blood cell count greater than 100,000/μL is considered positive

Diagnosis

CT Scan – specificity for hepatic, splenic, and renal injuries– indicated primarily for hemodynamically stable

patients who are candidates for nonoperative therapy