Management of Penetrating Wounds: GSW to the Abdomen

Jowhara Al-QahtaniPGY-1, General Surgery4/21/2014

Epidemiology: High mortality, due to force and

extensive injury and cavitation created by missile tract

Account for 90%mortality associated with penetrating abdominal injuries

In USA, Africans Americans 14-34 yrs old have greatest death rate followed hispanics ( homocides)

Anatomic zones:

Mechanism of injury: Force Velocity Energy Projectile Distance (most lethal GSW occu at close

range <2.7m

Types of GSW Based on Distance Type 1 (>6.4m) subcutaneous tissue

and deep fascial layers Type 2 (2.7-6.4m) abdominal cavity Type 3 (<2.7 m) massive tissue loss

and destruction, contaminants from debris

Diagnostic Modalities Generally unreliable due to distracting injury, AMS, spinal

cord injury Look for signs of intraperitoneal injury

abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension

entrance and exit wounds to determine path of injury. Distention - pneumoperitoneum, gastric dilation, or ileus Ecchymosis of flanks (Gray-Turner sign) or umbilicus

(Cullen's sign) - retroperitoneal hemorrhage Abdominal contusions – eg lap belts DRE: blood or subcutaneous emphysema

Rosen’s Emergency Medicine, 7th ed. 2009

Diagnostic Modalities Plain radiographs: pneumoperitonium.

Not great

Diagnostic Modalities CT scan, best for stable patients: triple contrast to

r/o colorectal injuries DPL: mostly for stab wounds, not GSW

high sensitive test, variable thresholds. Aspiration of 10cc of blood 5000-10000 RBC/HPF. 100000 RBC/HPF+500WBC, bile or amylase Not widely used anymore due to time needed to

analyze, lack of specificity for organ injuries, and it is invasive nature.

FAST : very valuable in low chest and upper abdomen GSW

FAST Focused assessment with sonography for trauma (FAST)

To diagnose free intraperitoneal blood after blunt trauma 4 areas:

Perihepatic & hepato-renal space (Morrison’s pouch) Perisplenic Pelvis (Pouch of Douglas/rectovesical pouch) Pericardium (subxiphoid)

sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid Extended FAST (E-FAST):

Add thoracic windows to look for pneumothorax. Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)

Trauma.orgRosen’s Emergency Medicine, 7th ed. 2009

FAST hepato-renal space)

Rosen’s Emergency Medicine, 7th ed. 2009

FAST Perisplenic view

Rosen’s Emergency Medicine, 7th ed. 2009

Retrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)

FAST Advantages:

Portable, fast (<5 min), No radiation or contrast Less expensive

Disadvantages Not as good for solid parenchymal damage,

retroperitoneum, or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air. Can’t distinguish blood from ascites. high (31%) false-negative rate in detecting

hemoperitoneum in the presence of pelvic fracture

Laparoscopy Most useful to eval penetrating wounds to thoracoabdominal

region in stable pt esp for diaphragm injury: Sens 87.5%, specificity 100%

Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel.

Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation

Rosen’s Emergency Medicine, 7th ed. 2009

Management

ABC

Full physical examination, potential wounds in skin folds areas like axilla.

Management:

Management of penetrating abdominal trauma Mandatory laparotomy vs Selective nonoperative management

Mandatory laparotomy

standard of care for abdominal stab wounds until 1960s, for GSWs until recently

Now thought unnecessary in 70% of abdominal stab wounds

Increased complication rates, length of stay, costs

Immediate laparotomy indicated for shock, evisceration, and peritonitis

None operative Management Started in 1960 for all penetrating wounds Reserved for stable patients with no intra-

abdominal (esp hollow viscous injuries) Observation for 12-24 hrs Laparotomy is higher in GSW than Stab

wounds (SW) Extra-peritoneal wounds are more common

nowadays due to obesity !

Antibiotics All receive 1 dose upon presentation Only to those GSW which require

surgical intervention. No prophylactic role in other GSWs

Damage control Patients with major exsanguinating injuries

may not survive complex procedures Control hemorrhage and contamination with

abbreviated laparotomy followed by resuscitation prior to definitive repair 0. initial resuscitation 1. Control of hemorrhage and contamination

Control injured vasculature, bleeding solid organs Abdominal packing

2. back to the ICU for resuscitation Correction of hypothermia, acidosis, coagulopathy

3. Definitive repair of injuries 4. Definitive closure of the abdomen Complications: abdominal compartment syndrome.

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Thank you

References Puskarich, M. Initial evaluation and management of

abdominal gunshot wounds in adults. Uptodate.Nov 2012 Ball, G. current Management of penetrating torso

trauma: nontheraputic is not good enough anymore. Jcan Chiv.april 2014

Kumar, S, kumar A, Joshi.M, and Rathi.V. comparison of diagnositc peritoneal laage and ofcused assessment by sonography in trauma as adjunct to primary survey intorso trama: prospective randomized clinic trial. Ulus Trama Acil Cerr Derg,March 2014, Vol 20 No 20.

Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Marx: Rosen’s Emergency Medicine, 7th ed. 2009 Mosby