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

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

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