Management of Penetrating Wounds: GSW to the Abdomen

1. Management of Penetrating Wounds: GSW to the Abdomen Jowhara Al-Qahtani PGY-1, General Surgery 4/21/2014

2. 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)

3. Anatomic zones:

4. Mechanism of injury: • Force • Velocity • Energy • Projectile • Distance (most lethal GSW occu at close range <2.7m

5. 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

6. 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

7. Diagnostic Modalities • Plain radiographs: pneumoperitonium. Not great

8. 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

9. 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%) Rosen’s Emergency Medicine, 7th ed. 2009 Trauma.org

10. FAST • hepato-renal space) Rosen’s Emergency Medicine, 7th ed. 2009

11. FAST • Perisplenic view Rosen’s Emergency Medicine, 7th ed. 2009

12. Retrovesicle (Pouch of Douglas) Pericardium (subxiphoid)

13. 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

14. 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

15. Management • ABC • Full physical examination, potential wounds in skin folds areas like axilla.

16. Management:

17. Management of penetrating abdominal trauma • Mandatory laparotomy vs • Selective nonoperative management

18. 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

19. 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 !

20. Antibiotics • All receive 1 dose upon presentation • Only to those GSW which require surgical intervention. • No prophylactic role in other GSWs

21. 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

22. Thank you

23. 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