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Home , Abdominal trauma, Stabbing, Stab wound

Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from Postgraduate Medical Journal (1986) 62, 155-158

Review Article

Assessment and management ofthe injured

T.G. Parks Department ofSurgery, The Queen's University ofBelfast, Belfast, UK.

In many countries trauma remains the major cause of incipient paralytic ileus, significant should be in patients under 40 years of age. Severe blunt strongly suspected. occurs most often as a result of In patients with multiple , abdominal road traffic accidents but it is not uncommon in trauma may represent a major challenge in diagnosis industrial injuries, civil or participation in and treatment. In other instances there may be no sport. The death toll in the European Economic significant injury to the abdomen but this may be Community from road traffic accidents alone totals difficult to substantiate with certainty initially. 50,000 per year. Furthermore, for every fatality there Altered level of consciousness due to , are 20 cases ofserious injury. With improved transport presence of concurrent chest or skeletal injuries, services and vigorous resuscitative measures more of hypovolaemia and may add to the problems of these critically ill patients are surviving long enough to diagnosis in cases of abdominal trauma. reach the operating theatre for emergency . A diagrammatic representation of a suggested The wearing of automobile seat belts has not only scheme for the clinical management of patients with reduced the mortality but also the frequency and penetrating and non-penetrating injuries is given in copyright. severity of injuries. However, the belt itself may cause Figure 1. intra-abdominal injury, particular if misplaced pres- sure acts directly on the abdomen rather than on the chest and iliac bones. The commonest intra- Blunt abdominal trauma abdominal injury is to the small bowel or its mesentery but other intra-abdominal organs are also at risk. Inaccuracy of clinical evaluation Patients with seat belt marks should be admitted for If observation. there is persistent or On the initial clinical assessment the diagnosis will in http://pmj.bmj.com/ all probability be accurate in only 70-80% ofcases. In ABDOMINAL INJURY those patients who have concomitant head injury, multiple trauma or are shocked on admission, the INITIAL ASSESSMENT correct clinical diagnosis may be made in less than 60% (Bivins et al., 1978). In patients with blunt abdominal trauma in whom PENETRATING NON-PENETRATING physical signs are absent or apparently trivial initially, GUNSHOT STAB CLINICAL EVALUATION significant lesions become manifest in up to one-third on September 25, 2021 by guest. Protected WOUNDS of cases (Bagwell & Ferguson, 1980). Thus, close BLAST GY PERITONEAL LAVAGE observation and repeated physical examinations are of LOCA CONTRAST STUDIES paramount importance. Aids to diagnosis LAPAROTOMY OBSERVE OBSERVE LAPAROTOMY Table I lists various investigations which may aid in Figure 1 Suggested scheme for the clinical management of the diagnosis of non-penetrating abdominal trauma. patients with abdominal trauma. In some instances none ofthese will be feasible because of the necessity to provide immediate resuscitation Correspondence: T.G. Parks, M.Ch., F.R.C.S., Department and proceed to urgent laparotomy. of Surgery, Institute of Clinical Science, Grosvenor Road, X-ray of the abdomen and chest may demonstrate Belfast BT12 6BJ free intra-peritoneal gas from a ruptured hollow Accepted: 9 October 1985. viscus. Retroperitoneal rupture ofthe duodenum may A) The Fellowship of Postgraduate Medicine, 1986 Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from 156 T.G. PARKS

Table I Blunt abdominal trauma radioisotopic or ultrasonic techniques as aids to diagnosis. It should be stressed however that it is only Aids to diagnosis: in a relatively small percentage of cases of abdominal trauma that these latter are indicated. Abdominal and chest X-rays techniques Serum amylase Paracentesis Peritoneal lavage Penetrating wounds Urinalysis Urinary tract radiography Penetrating wounds are most often due to or Radioisotope scans of and spleen gunfire. The size of the external bears little Ultrasonography relationship to the depth of the penetration and the Computerized axial tomography severity ofinternal injury. Since the diaphragm rises as studies high as the fourth intercostal space during expiration, Biliary tract studies any patient with a penetrating wound below this level anteriorly or the fifth intercostal space laterally or the sixth intercostal space posteriorly should be con- give rise to air bubbles around the right psoas and sidered potentially at risk for a subdiaphragmatic , obliteration of the psoas margin, scoliosis or injury. With gunshot wounds the bullet entering the segmental ileus. Rupture of the diaphragm, more chest at any level may pass in an oblique or vertical common on the left than the right, may be demon- rather than a horizontal plane through the chest and strated by gas filled organs in the chest. hence enter the abdomen. Four quadrant peritoneal aspiration using a fine Plain X-rays of the abdomen may yield useful needle is helpful when positive but negative results information following penetrating abdominal should not be allowed to cloud the clinical acumen of wounds. However, sinography in which a radio- the or lead to complacency. Although the opaque medium is used to outline the tract is unrelia- method is simpler than diagnostic peritoneal lavage it ble in determining whether or not the has is much less accurate as a diagnostic procedure and in been penetrated in stab injuries (Aragon & Eiseman, copyright. many centres has been abandoned. The recent 1976). Furthermore, probing is inaccurate in deter- modification whereby the is tapped mining the depth of the and may open up in the paracolic gutter with the patient inclined to the false tracts or introduce (Petersen & Sheldon, side may lead to improved accuracy of the method. 1979). Peritoneal lavage if expertly carried out is now Exploration is mandatory in all gunshot wounds of accepted as a relatively safe diagnostic procedure and the lower chest and abdomen. When the missile has is accurate in up to 98% of cases in determining the entered the peritoneal cavity, significant lesions are presence or absence ofintra-abdominal injury follow- present in 92-98% of cases. Serious intraperitoneal ing (Fischer et al., 1978). However, in injury due to shock waves may occur without penetra- http://pmj.bmj.com/ cases of injury of the retroperitoneal portion of the tion of the peritoneal cavity, especially in abdominal colon, duodenum or , the technique is trauma caused by high velocity weapons. notoriously inaccurate. Likewise, isolated bladder and The management of abdominal stab wounds is a may yield misleading results. more controversial topic. For many years most sur- Potential complications of lavage include perforation geons routinely explored stab wounds ofthe abdomen of the and colon, injury to the mesen- but in recent years many have adopted what or or teric iliac vessels, to the bladder. In a prospective they consider to be a more rational approach to on September 25, 2021 by guest. Protected randomized trial undertaken by Pachter & Hofstetter management of such injuries. (1981), the open method in which the catheter is When a distinct policy of selective exploration of inserted through the peritoneum under direct vision abdominal stab wounds was adopted by Nance et al. was shown to be safer and more accurate than the (1974), their negative exploration rate fell from 53% to percutaneous method. 11% and complication rate fell from 14% to 8%. In a In patients with a suspected urinary tract injury, large series of 403 cases of abdominal stab wounds urinalysis and intravenous urography may reveal the reported by Wilder & Kudchadkar (1980), 216 type and degree of injury. The absence ofexcretion of patients were observed and only 16 of these sub- the contrast by one ofthe kidneys may indicate a renal sequently came to surgery (all within 24 hours) with no pedicle injury, warranting arteriography for confirma- obvious detrimental effects due to this period ofdelay. tion. These authors relied very much on careful and re- In difficult cases, particularly those presenting with peated clinical examinations and only occasionally less acute signs, useful information may be obtained undertook peritoneal aspiration or lavage. by employing more sophisticated radiological, Surgery is clearly indicated if there is evidence of Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from THE INJURED ABDOMEN 157

evisceration, , haemoperitoneum, For minor contusions ofthe pancreas simple drain- peritoneal irritation or hypovolaemia and circulatory age is adequate. For moderate or severe injuries ofthe inadequacy for which there is no other obvious cause. body of the pancreas involving the main pancreatic Likewise, if blood appears from the , rectum duct, distal pancreatectomy is preferable to more or bladder, exploration must be undertaken. On the conservative options. While many lacerations of the other hand, if peritoneal signs are absent and local duodenum may be adequately dealt with by direct exploration of the wound under local anaesthesia suture in two layers, there are some cases of severe reveals that the peritoneal cavity has not been violated, injuries to the duodenum and pancreatic head, in then laparotomy may be avoided. which repair procedures incorporating the use of a Roux loop ofjejunum are recommended (Campbell & Kennedy, 1980). Other procedures such as duodenal Operative management diverticulisation which involves duodenal exclusion and gastric diversion have their advocates. Pan- Loss of the tamponade effect occurs when muscle creatico-duodenectomy has a limited place in those relaxants are given during induction of anaesthesia patients in whom the head of the pancreas and and more especially when the abdomen is opened. This duodenum have been shattered. Obviously in these may lead to increasing rate ofblood loss and profound circumstances this extensive operation carries a high hypotension. Steps should be taken to combat this mortality of the order of 50%. phenomenon by increasing the rate of intravenous Supplementary procedures such as decompression infusion, aortic compression and, if necessary, direct of the duodenum are beneficial and in some cases a intra-aortic infusion. feeding jejunostomy is desirable. The abdomen is usually opened through a long mid- line incision, especially in blunt trauma although a Hepatic injuries right or left paramedian may be preferred in some penetrating wounds, depending on the site of the By the time laparotomy is undertaken following injury. Rapid assessment is made with a view to abdominal trauma, 50% of cases of hepatic wounds

identifying and controlling any source of acute major have stopped . For these cases adequate copyright. haemorrhage. Sites ofleakage ofintestinal content are drainage of the area is sufficient. Small superficial controlled and then a thorough assessment ofthe total lacerations that are still bleeding are dealt with by local intra-abdominal injury is undertaken. pressure or direct suture. The entrance and exit wounds caused by missiles Deep central lacerations often present a major should be thoroughly debrided and drained, the challenge. Insertion of deep mattress sutures which deeper layers being loosely proximated. The skin is close the laceration externally but convert a deep closed by delayed primary suture. It should be remem- crevice into an intrahepatic cavity is best avoided as bered that following stabbing the wound may have this leads to intrahepatic collection of blood and been heavily contaminated by large bowel organisms with the likelihood of progress of infection, http://pmj.bmj.com/ which are deposited in the abdominal wound during formation and even the development ofhaemobilia. It withdrawal. may be possible to control bleeding by direct ligation but exploration in the depth ofthese wounds may lead Pancreatico-duodenal injuries to torrential haemorrhage. If temporary occlusion of the hepatic or one of its two main branches Injury to the spleen or liver may be obvious; injury to controls the bleeding then ligation of the appropriate the pancreas or retroperitoneal duodenum may be less vessel, as advocated by Aaron et al. (1975) may be a on September 25, 2021 by guest. Protected so. Bile staining of the peritoneum or air bubbles in safer option. relation to the duodenum, ligament of Trietz or Formal lobectomy is seldom warranted but if the transverse mesocolon indicate the need for further lobe is completely shattered, there is no reasonable exploration. Likewise, haematoma over the alternative to excision. Occasionally smaller areas of duodenum, along the base of the mesentery or ad- devitalised liver tissue may have to be removed. This jacent to the greater curvature of the stomach should may be achieved by the 'finger fracture' method which arouse suspicion of a potentially serious injury. If allows exposure and ligation of intact parenchymal penetration of the region by a missile or instrument vessels and bile ducts prior to their division. has occurred, exploration must be carried out with Injuries to the hepatic veins or retrohepatic vena diligence. cava are highly lethal and are particularly difficult to Injuries ofthese organs vary from minor bruising to manage surgically. If direct repair cannot be achieved extensive pancreatico-duodenal disruption. The most on mobilisation ofthe liver, it may be necessary to use significant aspect ofall is whether or not there has been an intracaval shunt introduced via the right atrium a major pancreatic duct involvement. following median sternotomy. Postgrad Med J: first published as 10.1136/pgmj.62.725.155 on 1 March 1986. Downloaded from 158 T.G. PARKS

Decompression of the common bile duct after velocity gunshot injury associated with marked hy- hepatic injury has its advocates and opponents. In potension and multiple intra-abdominal injuries par- isolated hepatic injury it is undertaken less often ticularly the pancreas and the duodenum, is best nowadays. If, however, severe hepatic trauma is treated by resection and delayed anastomosis. associated with injury to the pancreatico-duodenal region, then ductal decompression should be con- Left colon Minor wounds ofthe left colon may also be sidered. closed by simple suture if (i) there is little peritoneal soiling, (ii) if less than 4 hours has elapsed since the Splenic injuries time of injury and (iii) if there are minimal associated injuries. Otherwise, it is wise to establish a concomit- For many years splenectomy has been the standard ant proximal colostomy. More major wounds of the treatment following trauma to this . In 1952, left colon are either exteriorized or resected. When King & Shumacker reported the occurrence ofserious resection with primary anastomosis is undertaken, a and highly lethal post-splenectomy infection in chil- proximal colostomy is advised. Alternatively, follow- dren. The case for conservation of the spleen in the ing excision ofthe damaged segment, the proximal end young patient, where at all feasible, is now widely may be brought out as an end colostomy and the distal accepted. The risk offulminating infection is less in the end as a mucous with a view to restoration of adult and also lower in the hitherto healthy person. If bowel continuity at a later date. injury to the spleen is limited and the hilum is intact, then operative repair should be attempted, especially Rectum If feasible, the wound is closed, a proximal in the child or young adult, but it would be unwise to colostomy is formed, perirectal drainage is established carry this conservation to the extreme in any age and the faecal material is irrigated from the rectum. group. The prognosis following large bowel injuries is enhanced by the use ofmetronidazole together with an Large bowel injuries aminoglycoside or a cephalosporin to help control infection. Nowadays mortality with isolated injury of Right colon Stab wounds and some low velocity the large intestine is relatively low. On the other hand, gunshot injuries of the right colon are suitable for mortality and morbidity are increased with age, severe copyright. closure by simple suture. More extensive gunshot haemorrhagic shock, gross peritoneal contamination, injuries and severe contusion or rupture resulting from multiple visceral injuries and undue delay in treatment blunt injury require resection. Occasionally a high (Parks, 1981).

References

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lavage? American Journal of Surgery, 140, 368. percutaneous paracentesis and lavage for abdominal on September 25, 2021 by guest. Protected BIVINS, B.A., SACHATELLO, C.R., DAUGHERTY, M.E., trauma: a randomised prospective study. Archives of ERNST, C.B.& GRIFFEN, W.O. JR. (1978). Diagnostic Surgery, 116, 318. peritoneal lavage is superior to clinical evaluation in blunt PARKS, T.G. (1981). Surgical treatment ofinjuries ofthe large trauma. American Surgeon, 44, 637. intestine. British Journal of Surgery, 68, 725. CAMPBELL, R. & KENNEDY, T.L. (1980). The management PETERSEN, S.R. & SHELDON, G.F. (1979). Morbidity of a of pancreatic and pancreaticoduodenal injuries. British negative finding at laparotomy in abdominal trauma. Journal of Surgery, 67, 845. Surgery, Gynecology and Obstetrics, 148, 23. FISCHER, R.P., BEVERLIN, B.C., ENGRAV, L.H., BENJAMIN, WILDER, J.R. & KUDCHADKAR, A. (1980). Stab wounds of C.I. & PERRY, J.F. JR. (1978). Diagnostic peritoneal lavage: the abdomen. Observe or explore? Journal ofthe American fourteen years and 2586 patients later. American Journal of Medical Association, 243, 2503. Surgery, 136, 701.