Penetrating Abdominal Injury (Case 36)

Chapter 53 Penetrating Abdominal Injury (Case 36)



Mark J. Seamon, MD, Brian P. Smith, MD


Case: A 51-year-old male sustains a gunshot wound to the LUQ of the abdomen.



Differential Diagnosis









Hemoperitoneum from major vascular injury or solid organ injury. Peritonitis from hollow viscus injury with peritoneal contamination. Retroperitoneal hematoma



Speaking Intelligently


When I encounter a trauma patient with a head injury, I first ensure that the ABCs have been adequately assessed and managed. A precise and thorough neurological examination is then performed during the secondary survey, noting Glasgow Coma Scale (GCS) score, pupil size and reaction to light, an extremity assessment, and a thorough motor/sensory examination. Once the patient is hemodynamically stable, a head CT should be performed. Patients who are alert and fully oriented generally do not require emergent neurosurgical intervention. Obvious head and facial trauma combined with agitation suggests a possible brain injury. The combination of the patient’s neurological examination and the head CT help the neurosurgeon determine the best course of action, be it close neurological monitoring in the ICU, ventriculostomy, or an emergent trip to the OR.



PATIENT CARE



Clinical Thinking


As for any trauma patient:


• A Does this patient have an adequate airway and the ability to protect it?

• B Is the patient breathing? Is oxygenation and ventilation adequate? Remember, a gunshot wound high in the abdomen may penetrate the diaphragm and cause a significant thoracic injury.

• C Does the patient have adequate blood volume and perfusion? How does the patient respond to resuscitation? Does this 51-year-old male take medications such as beta-blockers that might mask an appropriate tachycardia?

• D Evaluate the patient’s ability to follow commands and respond appropriately. Is neurological disability a central phenomenon from shock, or is there a direct spinal cord injury?

• E The patient must always be adequately exposed to evaluate all injuries. Don’t overlook the axilla, back, gluteal cleft, and perineum.

• Patients with penetrating abdominal injuries are best served by antibiotic therapy prior to operative intervention. Initial therapy should be broad, with coverage of both gram-positive and gram-negative organisms. Current practice guidelines advise broad-spectrum antibiotics prior to incision and throughout operation.

• Tetanus toxoid upon admission

• The care of the trauma patient does not end with intraoperative repair of injuries. The hypothermic, coagulopathic laparotomy patient is prone to numerous postoperative complications:
• Expect to encounter significant postoperative hypovolemia, often requiring massive volume resuscitation.

• Anticipate (life-threatening) abdominal compartment syndrome: look for a decrease in urinary output, increasing airway pressures, decreased venous return, and increasing abdominal pressure.


History



• Ascertain mechanism of the injury: the damage inflicted by a low-velocity handgun is far different from the cavitating blast effect exerted by a high-velocity hunting projectile.

• AMPLE (Allergies; Medications; Past medical hx; Last meal; Events leading to presentation)

• Past medical hx provided by the patient or family may provide insight to observed physiology: for example, beta-blockade may mask the tachycardia of stage II shock.


Physical Examination


Editor’s note: Though there may be exceptions, A GUNSHOT WOUND TO THE ABDOMEN GETS EXPLORED; END OF STORY. Keep this in mind as subtleties of the physical examination are discussed.


• Pay careful attention to the obvious signs of abdominal penetration and try to reconstruct the path of injury.

• Be skeptical of apparent injuries. Two holes aligned on a patient do not necessarily indicate entrance and exit wounds.

• Does the patient have abdominal pain? Is the patient tachycardic and hypotensive because of peritoneal hemorrhage? Are respirations labored because of a distended abdomen and limitation to diaphragmatic excursions or because of a missed pneumothorax?

• Check the NG tube after insertion: bloody nasogastric effluent?

• Rectal examination may reveal blood within the bowel lumen.

• Is the Foley catheter draining blood-tinged urine?

• Whereas all of these findings may corroborate the need for laparotomy, hemodynamic instability, distention, and peritoneal signs are nearly absolute indications for operative exploration.


Tests for Consideration











• Blood typing and screening: Assume that all patients will require operative intervention.
 $65

• Obtain uncrossmatched blood, if clinically indicated.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Penetrating Abdominal Injury (Case 36)

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