Penetrating Abdominal Trauma

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Continuing Education Activity

Penetrating abdominal trauma is most commonly caused by gunshot or stab wounds. These injuries primarily affect the small bowel, colon, liver, and abdominal vasculature, with severity ranging from localized injuries to life-threatening exsanguination and contamination. Advances in imaging technologies, including computed tomography and ultrasound, have significantly improved the ability to detect and assess the extent of injuries, guiding decisions on whether to pursue surgical intervention or nonoperative management. Additionally, new interventional techniques, such as endovascular embolization, have complemented traditional surgical approaches, reducing the need for open surgery in some instances.

This educational activity reviews the evaluation and management strategies for penetrating abdominal trauma, highlighting the critical role of the interprofessional team in delivering effective care. Participants gain a deeper understanding of injury assessment, treatment algorithms, and the latest innovations and techniques. The activity also emphasizes the importance of early triage, proper imaging, and monitoring to minimize complications and improve patient outcomes. 

Objectives:

  • Identify the common mechanisms and clinical presentations of penetrating abdominal trauma, including the most commonly injured organs and associated risks of morbidity and mortality.

  • Differentiate between the severity of penetrating abdominal trauma, distinguishing between cases requiring urgent surgical intervention and those suitable for nonoperative management.

  • Create and implement individualized treatment plans for patients with penetrating abdominal trauma by collaborating with trauma surgeons, radiologists, anesthesiologists, nurses, and other clinicians.

  • Coordinate post-operative care and monitoring strategies with the interprofessional team, including repeat imaging and patient assessments, to detect complications or missed injuries following initial treatment.

Introduction

Although penetrating trauma is less common than blunt trauma and has declined in recent years, trauma remains a leading cause of death worldwide. Abdominal injury is found in roughly a quarter of all global patients with trauma, and penetrating trauma is associated with high morbidity and mortality in developed and developing countries. (See www.who.int/news-room/fact-sheets.) Penetrating abdominal trauma often takes the form of gunshot or stab wounds, and the most commonly injured organs are the small bowel, colon, liver, and vasculature. Gunshot wounds are associated with high morbidity and mortality due to velocity and potential for kinetic and thermal injury. Stab wounds range from pre-fascial to morbid destruction of large vessels. Missed injuries result in delayed diagnosis and complications that contribute to morbidity and mortality.[1]

Determinants of injury from penetrating trauma include the instrument, the velocity, anatomical location, and the tissue traversed. Lower velocity weapons produce injury in their direct path. Even though most gunshot wounds typically have a linear trajectory, high-energy wounds are associated with unpredictable injuries due to the composition of the ammunition and how the tissue is penetrated, resulting in a range of thermal and mechanical forces and resultant damage. Close-range gunshot generates greater kinetic energy than that fired from a distance. Secondary injuries may occur from bone or bullet fragments.[2] 

Injuries may be categorized into anterior, posterior/flank, and thoracoabdominal locations. Anterior injuries occur anterior to the posterior axillary line, and posterior and flank injuries arise posterior to this landmark. Thoracoabdominal injuries may occur in the upper quadrants of the abdomen and inferior to the fifth intercostal space; they have an increased likelihood of penetrating the diaphragm and causing injury within the thoracic and abdominal cavities.[3]

The severity of penetrating abdominal trauma ranges from superficial injuries that may be treated locally to active exsanguination and widespread intraabdominal contamination (see Image. Evisceration From Penetrating Abdominal Injury).  Algorithms for assessment and treatment drive decision-making, allowing persons who meet criteria to be carefully observed while others undergo emergent lifesaving measures. Recent innovations include using endovascular techniques instead of or in conjunction with traditional surgical interventions, even in damage control situations. The assessment and treatment of penetrating abdominal trauma is subject to continual study and innovation in both prehospital and hospital settings.[4]

Etiology

Penetrating trauma occurs when a foreign object enters the body, either remaining in or passing through the tissue of injury. Penetrating injury can result from any object forced through the skin, often secondary to gunshots or knives, but also from blasts, industrial accidents, or as a consequence of high-velocity blunt trauma. In addition, fragments of bones or bullets can cause additional penetrating trauma. The extent of injury from penetrating trauma is determined by the dispersion of energy of the weapons, the trajectory, and the distance between the weapon and the victim. Injury can be both immediate and delayed and can result in shock and infection.[5] 

Epidemiology

Trauma accounts for 8% of mortalities worldwide and remains the primary cause of mortality in the first several decades of life. In the United States (US), up to 15% of trauma involves the abdomen, and this figure rises to 24% globally.[6] After the head and extremities, the abdomen is the most commonly injured area.[7][8] Up to 38% of penetrating trauma involves the abdomen. Penetrating abdominal trauma affects 35% of those admitted to urban trauma centers in the US and up to 12% of those admitted to suburban or rural centers.[9][10][11] Penetrating abdominal trauma is 5 times as common in men younger than 45 and is a leading cause of morbidity and mortality in developing countries—primarily affecting men younger than 45.[7][12] 

While gunshot wounds are decreasing overall, this mechanism accounts for nearly 90% of the mortality from penetrating abdominal injuries. A high-velocity gunshot wound is associated with an 8-fold greater mortality compared to a stab wound.[13][14] Within a major urban trauma center in the US, recent statistics revealed an annual trauma admission of 3100 persons, 18% of whom presented with penetrating trauma. Of those, 1% underwent resuscitative thoracotomy, and 18% were taken to the operating room within 4 hours of arrival for laparotomy.[15]

Overall, the most commonly injured solid organ in penetrating abdominal trauma is the spleen, followed by the liver.[16] Mortality from penetrating trauma to the abdominal aorta increased from 30.4% in 2002 to 66% in 2014.[17] Except for in children, most duodenal injuries are from penetrating trauma. Over 65% of penetrating duodenal injuries are from gunshot wounds and 25% from stab wounds and are often associated with significant hemorrhage from concurrent injury to major vessels.[18] Up to 17% of abdominal penetrating trauma includes injury to the mesentery and bowel.[19] 

Penetrating inferior vena cava injuries account for about 5% of penetrating abdominal injuries, with high pre and in-hospital mortality. The infra-renal vena cava is the most frequently injured portion of the abdominal vena cava, followed by retrohepatic, suprarenal, para-renal, and suprahepatic. There is a reported 100% mortality for suprahepatic vena cava injury.[20] Penetrating trauma accounts for roughly 15% of abdominal trauma in children, and of these, gunshot wounds predominate, accounting for over 90% of penetrating abdominal trauma in children older than 12, most commonly affecting the gastrointestinal tract, liver, blood vessels, kidney, and spleen.[21]

The most common sites of injury from intraabdominal stab wounds are the great vessels, diaphragm, mesentery, spleen, liver, kidney, pancreas, gallbladder, and adrenals. The left upper quadrant is the most common stab location, followed by the left lower, right upper, and right lower quadrants. Stab wounds to the posterior abdomen and flank pose a greater risk of damage to retroperitoneal structures. Many stabbing victims sustain multiple stab wounds, and up to 30% of direct chest stabbings also penetrate the diaphragm. Stab wounds to the anterior chest lower than the nipple, correlating to the fourth intercostal space, and posteriorly lower than the tip of the scapula, correlating to the seventh intercostal space, mandate evaluation for a diaphragmatic injury.[22][23]

Pathophysiology

Penetrating trauma causes tissue destruction and blood loss. Low-velocity penetrating trauma is contained in areas of direct contact, whereas kinetic and thermal energies extend the trauma sustained from gunshot wounds. Tissue damage activates endothelium, platelets, clotting factors, and cellular and noncellular immunomodulation. Endothelial damage results in the loss of barrier function and causes the adhesion of immune cells. With significant hemorrhage, the reduction of blood volume decreases oxygen delivery to the microcirculation, and depletion of fibrinogen increases the risk for additional vascular bleeding. The consumption of coagulation factors and fibrinolysis leads to acidosis, coagulopathy, and hypothermia, resulting in disseminated intravascular coagulation and organ failure.[24]

As a projectile passes through tissue, it decelerates and transfers kinetic energy to the tissue. Kinetic energy increases with the square of the velocity and causes more damage than a proportionate increase in mass.[1] The space within tissue destroyed by the penetrating object forms a cavity called permanent cavitation. Higher velocity missiles create shock waves and secondary cavitation larger than the primary cavity, affecting distant tissues. This secondary cavitation occurs as the object enters the body, creating a pressure wave that temporarily displaces tissue. The tissues may resume their original position, but the temporary cavitation causes damage, necrosis, bleeding, and pseudoaneurysms. Pressure changes created through rapid compression and decompression of tissues result in tissue destruction. In addition, some bullets tumble and generate a larger cavity, and bullet fragments create additional cavities. Ammunition may also cause lead toxicity and bullet embolisms.[2][25]

The severity of injury from a gunshot wound depends on the firing distance and the characteristics of the injured tissue. The closer the range, the more severe the injury, and the denser the tissue, the greater the transmitted energy. Tissue with greater elasticity, such as the bowel, can absorb more trauma than denser tissue, such as the liver or spleen, which are subject to greater crushing and pulverizing forces.[2] Close-range high-velocity wounds are usually fatal, and tissues with higher specific gravity, such as organs, muscle, and bone, sustain more damage. In children, damage to the abdomen from gunshots is more severe than in adults due to the smaller surface area and dissipation of force within structures with closer proximity to one another and of relatively larger size contained within a thinner abdominal wall.[21]

History and Physical

A detailed history, including the type of weaponry and the time interval of physiologic decompensation, allows for more effective decision-making and administration of life-saving care as the mechanism of injury guides rapid physical evaluation and intervention. Quickly assess for penetrating objects and all wounds while attending to the critical steps of airway, breathing, and circulation and impeding any areas of active hemorrhage.[1] The advanced trauma life support guidelines govern the primary and secondary surveys.

Resuscitation takes precedence, including securing the airway and addressing findings such as hemodynamic instability, hemorrhage, evisceration, or impalement while monitoring physiologic parameters. Physical exam includes full exposure and assessment. The examiner may find irregular bowel sounds, peritonitis, hyperresonance, or dullness to percussion and bruits. A rectal exam is an important component of an initial survey, and bloody nasogastric drainage provides additional information. Any bilious or feculent drainage within a wound indicates critical damage.[11][26]

Resuscitation is integrated into the initial assessment and can include intravenous fluids or blood products. Local wound exploration may be feasible for some wounds in stable persons without evidence of physiologic derangement or intraabdominal injury. Impaled objects are secured in place for later removal in an operating room. Physiologic deterioration, findings such as evisceration, exsanguination, hematemesis, and gross blood per rectum may mandate urgent intervention.[19]

Evaluation

Mechanisms of injury and available technology guide the evaluation of a person with penetrating abdominal trauma, including the need for urgent intervention. The Focused Assessment with Sonography for Trauma (FAST), with a reported sensitivity of 90% and specificity of 95% for the detection of intraperitoneal free fluid, has replaced diagnostic peritoneal lavage to assess for intraperitoneal blood but is not sensitive for solid organ or mesenteric vascular injuries. Extended view sonography (eFAST) includes the pericardium, pelvis, subphrenic, subhepatic, and paracolic gutters and has become the standard of care.[11] Results from a study comparing conventional ultrasound versus contrast-enhanced ultrasound for blunt and penetrating abdominal trauma demonstrated that the contrast study had higher sensitivity and specificity, particularly for active bleeding and injuries to solid organs.[27][28][29]

Computed tomography (CT) has a sensitivity of 94% and a specificity of 95% for injury detection.[27] Injuries to the mesentery and bowel are the most frequently missed injuries on CT and are often found intraoperatively. CT is noted to have only moderate sensitivity for injuries to the bowel and mesentery, and thin axial images in CT with intravenous contrast in arterial and portal venous phases are recommended to better evaluate the bowel walls and vascular structures within the mesentery. Fluid within mesenteric folds, bowel loops, or a mesenteric hematoma is concerning for injury. A linear jet near the mesentery can be indicative of vascular injury. Bullet elements within the bowel wall or lumen are specific for a full-thickness injury.[19] 

Results from a single-center study demonstrated the superiority of multidetector computed tomography in detecting bowel injury in penetrating trauma.[30] The high resolution of multidetector CT helps to diagnose diaphragm injuries.[31] Multidetector CT can rapidly scan an area during the moment of breath-holding to render high-quality thin sliced imaging used in conjunction with software that reconstructs images into multiple planes to allow for greater resolution, increasing sensitivity and specificity in the identification of small diaphragmatic injuries in penetrating trauma.[31] A study comparing the utilization of CT with enteric contrast versus no enteric contrast to evaluate the abdomen in penetrating trauma provided results that found no benefit to the addition of enteric contrast, although there remains anecdotal utility for enteric contrast.[32][33] 

Identifying entry and exit sites and the trajectory of a penetrating object before a CT scan is important. Wounds can be marked with a radiopaque object.[19] CT tractography has been used on occasion when higher resolution CT is not available or feasible for penetrating torso wounds to detect incursion into the abdominal cavity. In a tractography study, the contrast is injected through a catheter just before imaging. Tractography has been shown to decrease hospitalization time. Disadvantages include decreased accuracy, increased body mass index, wound tract infiltration by contrast, and procedural pain.[34]

In pregnancy, CT remains the preferred radiographic modality for suspected severe trauma, but magnetic resonance imaging (MRI) can be used to image more stable persons or as a follow-up to known injuries and is superior in the detection of placental abruption. MRI is also used to assess great vessels when iodinated contrast is contraindicated and may be superior in detecting ureteral, hepatobiliary, and pancreatic injuries. Missed pancreatic duct injuries lead to poor outcomes, and magnetic resonance cholangiopancreatography with contrast can assess the pancreatic duct and biliary tree, pinpointing leaks and guiding intervention. Magnetic resonance can discriminate between pancreatic trauma and pre-existing pathology.[35]

Guidelines have been established to identify those persons who require urgent intervention. The World Society of Emergency Surgery defines hemodynamic instability as a systolic blood pressure less than 90 mm Hg, transfusion of more than 4 units of product within the first 8 hours, when using vasopressors, or a base excess greater than 5 mmol/L.[36] The American Association for the Surgery of Trauma Injury Scoring Scale (www.aast.org/resources-detail/injury-scoring-scale) provides a scale of organ injury for blunt and penetrating trauma. The scale incorporates free fluid, isolated fat stranding, free air, bleeding, wound tract, hemoperitoneum, extraluminal contrast, and bowel wall defect and enhancement. The Bowel Injury Prediction Score identifies more subtle signs suggesting injury in the absence of definitive CT findings, including degree of tenderness and white blood cell count.[19]

Evaluation must continue following intervention for penetrating abdominal trauma for any change, such as a decrease in hemoglobin or an increase in oxygen requirement, that may indicate a missed injury. Imaging following damage control surgery is key in identifying missed injuries.[4] Some injuries may only be evident over time as structures impacted by thermal and mechanical stress may proceed to perforation or ischemia days following the initial injury. Some findings, such as a hematoma or serosal tear that might be observed nonoperatively in blunt trauma may require operative intervention in the context of penetrating trauma. Trauma to the abdominal wall, such as fat-stranding, hematoma, muscle tear, or herniation, can be used to estimate intra-abdominal injuries.[19]

Treatment / Management

Quickly triaging those with penetrating abdominal trauma using Advanced Trauma Life Support as designed by the American College of Surgeons is highly important. The objectives are to address bleeding and contamination, correct temperature, acidosis, and coagulopathy.[21][37] Trauma injury scales assist with triage, and initial measures include rewarming, resuscitation that includes electrolyte repletion and transfusion, and use of permissive hypotension.[37][38] 

Courses of action in penetrating abdominal trauma include immediate intervention versus resuscitation and imaging or a trial of nonoperative management. Several national and international guidelines have been established in the setting of penetrating trauma. Please refer to the Eastern Association for the Surgery of Trauma Practice Management Guidelines for comprehensive algorithms for penetrating abdominal trauma, use of antibiotics, management of the open abdomen, selective nonoperative management, and pregnancy in trauma. Please refer to the Western Trauma Association algorithm for additional details regarding the evaluation and management of abdominal gunshot and stab wounds: Journal of Trauma and Acute Care Surgery.[13][39] 

Improved imaging technology and increased use of diagnostic laparoscopy have led to a decrease in non-therapeutic laparotomy, and conversion rates from laparoscopy to laparotomy are lower than in the previous decade. In contrast, the missed injury rate is comparable between laparotomy and laparoscopy.[40][41] All full-thickness injuries to bowel or mesentery, ischemia, contrast extravasation, vessel or organ avulsion, air in peritoneum or retroperitoneum, or mesentery require surgery—whereas free fluid, intramural hematoma, abnormal bowel wall enhancement, bowel wall thickening, mesenteric fat stranding, hematoma in mesentery may be observed in stable persons.[19] 

An injury grading system such as that of the American Association for the Surgery of Trauma is used with hemodynamic monitoring to determine the need for operative intervention. Injury to organs is graded on a scale from I to IV depending on the severity of the injury, and repair or resection is recommended. For example, a splenic laceration graded I-III may resolve with conservative management, but a higher-grade injury may require splenectomy. Injuries to the retroperitoneum and pelvis often require operative intervention due to damage to vascular structures, but flank injuries may be observed in the absence of extensive hemorrhage.[3][42] The paradigm of nonoperative management for trauma has been well studied. Results from a multicenter study in northern Europe concluded that selective observation remains a viable option even in those centers that treat relatively fewer numbers of such injuries.[43] A meta-analysis evaluated 53 studies involving a total of 60,291 persons who sustained abdominal gunshot wounds and were sorted to either immediate surgery or observation. Among the 27% selected for nonoperative management, 10% ultimately required surgery, and of the 73% selected for immediate laparotomy, 10% had no injury requiring operation.[14]

If surgery is indicated, laparoscopy is feasible in a hemodynamically stable cohort, and this approach is associated with lower odds of mortality, fewer complications, and shorter hospital stays than those undergoing laparotomy.[44] Laparoscopy may often be considered in the event of failed nonoperative management of penetrating abdominal trauma. When initially used for trauma, laparoscopy was associated with a high rate of missed injuries, but this is now below 1%.[45] Such is the case for the increasing number of laparoscopic splenectomies or splenic preservation for splenic injury following failure of nonoperative management.[46] Laparoscopy can also be used to screen for any breach of the peritoneum following abdominal trauma. 

Criteria for laparoscopic management of anterior abdominal stab wounds are not well established and remain institution-based, but with increasing skill and technology, the practice is evolving.[26] The German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries 2022 update concludes that diagnostic laparoscopy should be performed in hemodynamically stable persons with penetrating trauma when the need for intervention is unclear. The guidelines also recommended the elimination of the diagnostic peritoneal lavage as alternatives have replaced this practice.[47] The laparoscopic approach for pediatric abdominal trauma is confined mainly to pediatric centers and is relatively understudied, but documented results demonstrate no missed injuries.[48] 

Emergent intervention includes interventional radiology and minimally invasive procedures when applicable. Interventional radiology procedures are commonly used for pelvic arterial bleeding. The use of angioembolization in the setting of active bleeding in pelvic trauma is well-established for relatively stable persons without additional injuries. Deep pelvic vessels are more accessible through an endovascular approach.[49][50] There are contemporary examples of hybrid operative and interventional radiology approaches for the management of massive bleeding and intraabdominal trauma.[25] Endovascular techniques are used with increasing frequency to address vascular injuries, but open surgery remains the standard to address the need for urgent revascularization and prevention of thrombosis.  Options have emerged for conduits beyond autologous vein grafts, including various graft materials, and operative approaches involve the traditional open procedure, endovascular, combined, and staged repair. Further study is needed before protocols are standardized.[17]

Strategies have been developed for addressing penetrating trauma to specific structures. Duodenal injuries are particularly challenging given the anatomy and associated risk of vascular, pancreatic, and ductal injuries, the complexity of reconstruction, the need for drainage, and the high risk of anastomotic breakdown.[18] Trauma pancreaticoduodenectomy (ie, Whipple procedure) is rare but occasionally performed to treat devastating trauma to the pancreatic head, proximal duodenum, and bile duct.[51] In the setting of penetrating trauma to the renal system, it is possible to close certain lacerations or perform a partial nephrectomy; however, total nephrectomy may be required for uncontrolled hemorrhage, total renal pelvis avulsion, or vascular pedicle injury. When the fascia surrounding the kidney is opened, any tamponade effect is eliminated, posing an increased risk of bleeding and urinary extravasation. Attempted nonoperative management of penetrating renal injury is increasingly common and may include embolization. Data show a higher nephrectomy and failure rate of embolization rate per grade of injury for penetrating versus blunt renal trauma.[52]

Liver injury can be mild, requiring observation and serial exams, or can be acutely lethal. In diffuse hepatic bleeding, wrapping and packing the liver allows for the correction of coagulopathy and is typically left for approximately 48 hours. Earlier reexploration is associated with a greater rebleeding risk. Rarely an emergency hepatectomy is performed, but it is associated with a very high mortality. Results from a single-center study examining nonoperative management of hepatic trauma concluded that approximately 20% of penetrating hepatic trauma could be managed nonoperatively. Different techniques such as packing or suturing, or omental patching as initial operative measures were suggested, in combination with embolization as needed for arterial injury, instead of large resections when possible for both blunt and penetrating trauma.[53] 

Angioemolization of hepatic bleeding is associated with the risk of necrosis.[54] For severe hemorrhage, vessel ligation, shunt, hepatic vascular exclusion, or aortic occlusion may be necessary. The aorta may be cross-clamped above the celiac plexus, or an endovascular balloon may be deployed. Ligation of the portal vein is a measure of last recourse due to the risk of hepatic and intestinal ischemia. In the setting of significant hepatic trauma, cholecystectomy is recommended to avoid necrosis of the gallbladder. Additional measures can include balloon occlusion of the vena cava and aorta and veno-venous bypass as a bridge to transplant.[55][56]

Retrohepatic inferior vena cava penetrating injuries have a 90% mortality rate, are difficult to expose, and treatment often requires access to both the abdomen and thorax.  If clamping vessels at the hepatic hilum fail to control right upper quadrant bleeding, a major venous bleed is suggested. Control of the infra and suprahepatic inferior vena cava is necessary, and control of the hepatic artery and portal vein is recommended before mobilizing an injured liver. Historically, an atriocaval shunt, from the suprarenal vena cava to the right atrial appendage, has been used to treat vena cava hemorrhage. A 36 French catheter is placed from the right atrial appendage to the suprarenal cava, bypassing the liver. This procedure risks abrupt circulatory collapse due to the lack of venous return and is associated with a poor outcome. Recently, veno-venous bypass has been used to decompress the retrohepatic inferior vena cava.[54]

When massive trauma results in hypothermia and coagulopathy, a damage control surgery is performed, with the goals of controlling bleeding and contamination and allowing sufficient time to restore normothermia and correct coagulopathy and acidosis before definitive treatment.[1] Traditional damage control surgery uses 4-quadrant packing and control of contamination, followed by temporary abdominal closure. The newer paradigm includes interventional radiology as an alternative or adjunct to damage control surgery. Endovascular interventionists use balloon occlusion, embolization, and stenting to address hemorrhage. The techniques are as selective as possible but can be used to embolize nonselectively quickly in an unstable individual. The more focal the endovascular intervention, the longer the procedure and the higher the radiation dose.[36] Newer trauma guidelines recommend a shortened response time for the interventional radiology team. Interventional approaches are used with surgical maneuvers, such as for venous and arterial hepatic or splenic bleeding, where packing may control a venous bleed. Still, embolization may be needed to address arterial bleeding. Angioembolization is now included in the Resources for Optimal Care of the Injured Patient from the American College of Surgeons Committee on Trauma, including for the hemodynamically unstable patient who did respond transiently to fluid bolus.[16] 

There are guidelines in the setting of penetrating trauma for those who lose a pulse during transport or treatment. A resuscitative thoracotomy has been used in select cases to cross-clamp the aorta to reduce bleeding and improve proximal perfusion. The guidelines recommend no longer than 10 minutes between loss of pulse and thoracotomy, and the survival estimate for a person with extrathoracic penetrating trauma arriving with a pulse undergoing resuscitative thoracotomy is 2.9%, compared to 0.1% without these measures.[57] 

More recently, endovascular aortic occlusion has supplanted thoracotomy in some circumstances.[58] Designed to control noncompressible bleeding, resuscitative endovascular balloon occlusion of the aorta (REBOA) was initially used for penetrating trauma in a military setting. Without standardized protocols, the practice of REBOA varies among and within trauma centers. Although the Aortic Occlusion for Resuscitation in Trauma registry was established in 2013, studies remain scarce. One observational study includes 17 persons, mostly males, injured by explosives or gunshot wounds, primarily in the abdomen, in whom resuscitative endovascular balloon occlusion of aorta device was deployed. Three-quarters of the devices were placed in an operating room, the remainder in the emergency department. All persons underwent exploratory laparotomy, including repairs to the liver, splenectomy, and small bowel resections. Of the 17, 14 patients survived and were discharged.[58] Results from one comparative study found those with penetrating abdominal trauma treated with REBOA had higher in-hospital mortality compared with those treated with other methods; however, results from a meta-analysis indicate that resuscitative endovascular balloon occlusion of the aorta may result in lower mortality compared with resuscitative thoracotomy.[59][60]

Major trauma centers have established internal REBOA guidelines after reviewing and credentialling their trauma clinicians on the procedure. Using methods extrapolated from emergency department thoracotomy and literature reviews, clinicians developed a protocol based on clinical condition and bleeding source exclusive of chest trauma. The training incorporates endovascular skills for trauma, a construct originally implemented by the Department of Defense for military surgeons but adapted to civilian trauma. The protocol also includes roles for the interdisciplinary team.

Suggested selection criteria for REBOA include hypotension with a lack of or diminishing response to resuscitation measures in the setting of extensive abdominopelvic exsanguination. After the inception of REBOA in 2014, the practice of arterial monitoring in all trauma patients with systolic blood pressure less than 80 mm Hg was standardized using a femoral arterial line with a 5 French sheath that is easily upsized to accommodate the 7 French sheaths used in REBOA. Newer techniques allow for quick placement of the REBOA device using a portable x-ray and external anatomical landmarks for balloon deployment, including the chest, the level of the renal arteries, and the aortic bifurcation.

The device's tip is aligned with the sternal notch for occlusion above the diaphragm and the xiphoid process for occlusion below. Protocols recommend limiting complete occlusion to between 30 and 60 minutes, and occlusion can also be used partially and intermittently to decrease ischemia.[58][61] The REBOA protocol was implemented in an urban level I trauma center with a supply cart and poster instructions. A professional practice evaluation was conducted on all clinicians, and a review of its application over five years included a total of 97 procedures, 15% of which were for penetrating abdominal trauma; overall survival was 65%.[15]

Differential Diagnosis

The mechanism and trajectory of any penetrating object inform the differential diagnosis. Any organs or vessels within the peritoneum, retroperitoneum, and pelvis may be affected by penetrating abdominal trauma, as well as the diaphragm, thoracic cavity, and limbs. A high index of suspicion and vigilant monitoring is necessary to avoid missed injuries. Diagnoses related to penetrating trauma as a sequela or as unrelated pathology include abdominal compartment syndrome, hemorrhagic shock, and sepsis.

Pertinent Studies and Ongoing Trials

Single-center study results demonstrate that a laparoscopic approach for hemodynamically stable patients is feasible for blunt and penetrating trauma but not for persons with hemodynamic instability.[45][62][63] Results from a meta-analysis that examined 5517 persons enrolled in 23 studies demonstrated no difference in missed injury or mortality in those abdominal trauma patients undergoing laparoscopy versus laparotomy. Findings were similar for intraabdominal abscess, deep vein thrombosis, pulmonary embolus, and ileus, but a reduced risk of wound infection and pneumonia, shorter hospitalizations, and procedure times were found in the laparoscopic group.[6] A meta-analysis on pediatric patients in the setting of blunt and penetrating abdominal trauma found that a laparoscopic approach in stable persons yields comparable results and avoids nontherapeutic laparotomy without increased risk for missed injury.[64]

Results from a single-center study on blunt and penetrating liver trauma noted more associated intra-abdominal injuries with penetrating trauma, particularly to hollow organs. The study also cited a successful 20% nonoperative rate for those with penetrating, compared with a 66% rate for those with blunt hepatic injuries.[53] A study published in the Journal of Trauma and Acute Care Surgery determined that a preoperative CT in those who underwent surgery for abdominal gunshot wounds did not provide any diagnostic advantage, did not alter management, did not change the rate of missed injuries and played a role in non-therapeutic laparotomy.[65] Last, results from a study on penetrating colonic injuries comparing those undergoing diversion versus primary repair focusing on in-hospital mortality and complications, including acute kidney injury, thromboses, and infection, found no statistical difference between groups.[66]

Prognosis

Injury scoring systems predict morbidity and mortality and help drive decision-making. An early cause of death for penetrating abdominal injuries is hemorrhage, while later causes include organ failure. The penetrating abdominal trauma index generates a risk score based on the organs injured and the associated injury severity, using a range of 0-200.[67][68] General predictors of prognosis include coagulopathy, blood loss, hypothermia, and acidosis.[21][54][56] A prothrombin ratio greater than 1.2 and an international normalized ratio greater than 5 are associated with worse outcomes.[24] Treatment within the first hour of significant trauma increases survival.[69] Additional factors affecting prognosis include sustained systolic blood pressure less than 90 mm Hg and extra-abdominal injuries.[12]

Injuries to specific organs impact prognosis. Anastomotic leak following resection for traumatic injury is associated with 46% mortality, and a leak is more likely with delayed fascial closure, need for inotropic support, and distal anastomosis.[1] The more distal the colonic injury, the poorer the expected outcome.[40] The prognosis following hepatic penetrating trauma depends on the grade. Mortality is up to 95% for a grade VI injury and near 100% for retro-hepatic cava and main hepatic vein injuries. Most intraoperative deaths from hepatic trauma are from exsanguination, and most postoperative deaths are from multisystem organ failure.[70] A scoring system developed specifically for trauma involving the liver uses serum bilirubin, prothrombin time, serum creatine, age, and injury severity score to predict mortality.[69]

Results from a meta-analysis demonstrated that persons with obesity sustaining gunshot injuries have a longer hospital stay and intensive care course, more respiratory complications, and a greater risk of mortality. The study's results also concluded that abdominal wall fat is not protective against penetrating trauma.[71] A meta-analysis on the effect of obesity on outcomes from blunt and penetrating trauma demonstrated those with a body mass index greater than 40 had higher odds of in-hospital mortality and longer lengths of stay both in the hospital and in the intensive care unit.[72]

Complications

Complications may arise from specific injuries as a consequence of emergent surgery and interventions or secondary to critical illness and physiologic derangements. Sequelae from extensive bodily injury may include sepsis, abdominal compartment syndrome, respiratory failure, coagulopathies, disseminated intravascular coagulation, transfusion-related lung injury, and other transfusion complications.[24][73] Postoperative complications include wound dehiscence, abscess, arterial and venous thrombosis, direct and indirect injury to blood vessels, and wound infections.[15][74] Pseudoaneurysms can arise from the initial injury or intervention and may develop late.[56][75] Study results demonstrate a correlation between injury severity, the need for lengthy surgery, and the incidence of wound infection.[76] In the setting of diaphragmatic trauma, laparoscopy may cause tension pneumothorax.[45]

Injury to intra-abdominal organs may result in fistulas to adjacent organs or body walls, and resection of nonviable bowel can cause short bowel syndrome. An anastomotic leak in the setting of trauma is a common complication, and the duodenum is particularly susceptible to anastomotic leaks. Damage to the biliary system may produce a biloma.[18] Overwhelming post-splenectomy infection is a rapidly progressive sepsis that can occur following the removal of the spleen and has a 50% mortality rate.[46]

Consultations

Treatment of penetrating abdominal trauma requires a collaborative and interdisciplinary effort that often involves multiple specialties, including an assortment of surgical specialists, interventional radiologists, transfusion specialists, intensivists, pharmacists, nutritionists, and therapists.

Deterrence and Patient Education

A component of healthcare is a discussion of safety in general and pertaining to firearms and other weaponry.

Pearls and Other Issues

Evaluating for diaphragmatic injury, including evidence of herniation, compromise to continuity of the diaphragm, and associated injuries to the thorax, such as pneumo or hemothorax, is important; if not promptly diagnosed, these injuries can lead to additional and severe complications. A right-sided injury may be more difficult to diagnose due to the bulk of the liver.[31] A study on the timing of pharmaceutical deep vein thrombosis prophylaxis in blunt and penetrating abdominal trauma in adults provided results showing that earlier prophylaxis was not linked to increased bleeding and that prophylaxis implemented following 48 hours was associated with a higher incidence of thromboembolism.[77] 

Antibiotic administration in penetrating trauma is important to prevent and treat related infections. Guidelines recommend preoperative antibiotic prophylaxis before trauma surgery and 24 hours of antimicrobial therapy for a hollow viscus injury, using a broad-spectrum antimicrobial that provides aerobic and anaerobic coverage. The ideal duration of antibiotics in penetrating trauma is not established, but the Surgical Care Improvement Project guidelines are often used.[78][79]

In the event of penetrating trauma causing circulatory collapse in a pregnant person with a viable fetus, an emergency cesarean section may improve outcomes for both mother and child. Pregnancy-related complications such as uterine rupture and placental abruption require obstetric management, ideally in the setting of a tertiary care center.[80] Clinical practice guidelines regarding trauma in pregnancy vary in their definition of fetal viability, ranging from 20 to 24 weeks gestation, recommended duration and frequency of fetal monitoring, necessity for tetanus vaccination, and administration of anti-D immunoglobulin.[81][82] A standardized ratio and timing of administration for transfusion products have not been universally adopted. Some experts advocate for an equal ratio of red blood cells to plasma to platelets, believing this decreases mortality, especially if used early, but others disagree.[24]

Enhancing Healthcare Team Outcomes

Penetrating abdominal trauma accounts for roughly one-third of penetrating trauma in the US and elsewhere, and most of the mortality stems from firearm injuries. The interprofessional team plays a crucial role in both mitigating the risk of and treating these injuries. Preventative measures are an important component of healthcare. All healthcare professionals should have an understanding of factors that may influence susceptibility to violence and the long-term personal, social, and economic consequences of these injuries.[83][84]

Managing penetrating abdominal trauma requires a cohesive and interprofessional healthcare team, including advanced clinicians, nurses, pharmacists, laboratory staff, transfusion specialists, and therapists, to provide patient-centered care. A collaborative approach improves outcomes. The injuries caused by penetrating abdominal trauma require careful monitoring, and care of these patients entails frequent communication. Clinical changes can occur quickly, and patient outcomes rely on expertise and teamwork to make rapid diagnoses and treatment decisions.[85][86]

Education and training are critical to best practices. Ongoing professional development ensures that healthcare professionals are equipped to respond effectively to penetrating abdominal trauma. Patient preference is central to optimal care, and shared decision-making is implemented when feasible in the setting of penetrating trauma.  A patient-centered approach places the patient's well-being and preferences at the forefront of all decisions, and an interprofessional healthcare team ensures a comprehensive response, minimizes complications, and prioritizes patient safety.[87][88]



(Click Image to Enlarge)
<p>Evisceration From Penetrating Abdominal Injury

Evisceration From Penetrating Abdominal Injury. This image shows the internal organs protruding from a wound due to a penetrating abdominal injury.

Contributed by S Munakomi, MD

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